Pancreatic Tumors: Diagnosis, Treatment Options, and Risks

Pancreatic tumor

Dear Dr.
Lin,
In July, my husband underwent a low-dose computed tomography (LDCT) scan originally intended to monitor his lungs, but it unexpectedly revealed a pancreatic tumor approximately 3.2 cm in size with low density.
We promptly returned to the thoracic specialist for a referral, where he had a CA 19-9 blood test, liver function tests, and other blood tests, all of which returned normal results (though his fasting blood glucose and cholesterol were slightly elevated).
An abdominal ultrasound did not show anything, but a subsequent CT scan confirmed the tumor size of about 3 cm.
He then underwent endoscopic ultrasound (EUS) and magnetic resonance imaging (MRI).
After these examinations, we followed up with both the gastroenterology and surgical gastroenterology departments.
The doctors suggested it was likely a serous cystic neoplasm (SCN).
However, during the follow-up, I noticed the screens displayed English terms, and I researched some abbreviations like SCN, intraductal papillary mucinous neoplasm (IPMN), and others.
The surgical gastroenterologist reviewed the imaging and examination data and indicated that it should be benign, so we were advised to discuss further management with the internal medicine physician.
The gastroenterologist suggested that since my husband is still young (55 years old) and the tumor is over 3 cm (if it were under 3 cm, he would recommend observation), there is concern about potential changes, and whether we should proceed with surgery.
We mentioned the possibility of performing an EUS-guided fine needle aspiration (EUS-FNA) for sampling, and he said that could be done first, but if we decide on surgery, it would not be necessary.
He referred us to the gastroenterologist who performed the EUS.
During the consultation, the doctor explained that the tumor is located in the body of the pancreas, and there is no thickening or abnormality in the bile duct imaging.
The tumor does not appear to be connected to the bile duct, and no nodules were seen within the cyst, leaning towards a diagnosis of SCN.
She scheduled an EUS-FNA to obtain samples for further evaluation.
We are currently conflicted because another internal medicine physician previously suggested that due to my husband's age and the tumor size exceeding 3 cm (if it were under 3 cm, he would recommend observation), we should consider surgical removal.
If we proceed with surgery, we would not need to schedule the EUS-FNA.
Given the current situation, what is your recommendation? What are the risks and considerations associated with EUS-FNA? What should we be aware of after the procedure? Is there a risk of tumor dissemination during the aspiration if it is malignant? If surgery is necessary, what are the risks associated with removing a tumor located in the body of the pancreas, and how might it affect his daily life and potential long-term complications? (The previous physician suggested that the spleen might also need to be removed.) If the EUS shows the tumor as SCN and the pancreatic duct is not dilated or connected, can the spleen be preserved during surgery, or could laparoscopic surgery be an option for tumor removal?
Thank you for your patience and understanding regarding this lengthy explanation.
I appreciate your help!
Thank you!

Vicky, 50~59 year old female. Ask Date: 2023/09/04

Dr. Lin Minghui reply Gastroenterology and Hepatology

A cyst in the body of the pancreas larger than three centimeters may sometimes be difficult to identify on imaging.
An endoscopic ultrasound (EUS) has been arranged, and it does not communicate with the bile duct.
There are no nodules within the tumor, leaning towards a serous cyst.
EUS-guided fine-needle aspiration (FNA) can be performed to examine cytology and biochemistry (CEA and blood glucose) to assist in differentiating between mucinous and non-mucinous cysts.
The opinions of both physicians are valid.
EUS-FNA is generally safe and precise, as it only penetrates a thin layer of the gastric or duodenal wall for aspiration, allowing for biochemical and cytological examination.
However, this technique is still invasive and carries risks of bleeding, infection, and pancreatitis.
If malignant, there is also a risk of tumor dissemination.
Regarding surgical considerations, please discuss with a surgeon whether surgery is necessary, what type of surgery is indicated, and if the spleen can be preserved under certain conditions.
Is laparoscopic surgery feasible? Wishing you good health!

Reply Date: 2023/09/04

More Info

When it comes to pancreatic tumors, the decision regarding whether to proceed with surgical intervention is complex and requires careful consideration of various factors, including the tumor's characteristics, the patient's overall health, and the potential risks associated with surgery. Based on the information provided, your husband has been diagnosed with a pancreatic tumor approximately 3.2 cm in size, which has raised concerns among healthcare providers regarding its nature and the appropriate course of action.

Diagnosis and Imaging
The initial imaging studies, including LDCT, ultrasound, and MRI, have suggested that the tumor may be a serous cystic neoplasm (SCN). SCNs are generally considered benign and have a low risk of malignant transformation. However, the size of the tumor (greater than 3 cm) raises the concern that it could potentially change over time, which is why some physicians recommend surgical removal as a precautionary measure.

EUS-FNA Procedure
The endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a minimally invasive procedure that can help determine the nature of the tumor by obtaining a tissue sample. This can provide valuable information regarding whether the tumor is indeed benign or if there are malignant cells present. The risks associated with EUS-FNA include bleeding, infection, and, in rare cases, the potential for tumor seeding, which is the spread of cancer cells along the needle track. However, the risk of seeding is generally low, especially if the tumor is benign.

Surgical Considerations
If the decision is made to proceed with surgery, the type of procedure will depend on the tumor's location and characteristics. In the case of a tumor located in the body of the pancreas, a distal pancreatectomy may be performed, which involves removing the tail and body of the pancreas. The spleen may also be removed during this procedure, as the spleen is often closely associated with the tail of the pancreas. However, in some cases, it may be possible to preserve the spleen, depending on the tumor's exact location and the surgeon's approach.

Risks and Recovery
Surgical intervention for pancreatic tumors carries inherent risks, including complications such as bleeding, infection, and pancreatic fistula formation. The recovery period can vary, but patients typically require a hospital stay followed by a gradual return to normal activities. Post-surgery, patients may experience changes in digestion and may need to adjust their diet or take enzyme supplements to aid in digestion.

Conclusion
In summary, the decision to proceed with surgery versus EUS-FNA should be made collaboratively with your healthcare team, considering the tumor's characteristics, the potential risks and benefits of each approach, and your husband's overall health. If the tumor is confirmed to be benign through EUS-FNA, a conservative approach may be warranted, while a malignant diagnosis would necessitate surgical intervention. It is crucial to maintain open communication with the medical team and to ask any questions or express concerns during consultations to ensure that you are comfortable with the chosen course of action.

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