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Incidence and clinical findings of benign, inflammatory disease in patient resected forpresumed pancreatic head cancervan Gulik, T.M.; Reeders, J.W.A.J.; Bosma, A.; Moojen, T.M.; Smits, N.J.; Allema, J.H.;Rauws, E.A.J.; Offerhaus, G.J.A.; Obertop, H.; Gouma, D.J.Published in:Gastrointestinal endoscopy

DOI:10.1016/S0016-5107(97)70034-8

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Citation for published version (APA):van Gulik, T. M., Reeders, J. W. A. J., Bosma, A., Moojen, T. M., Smits, N. J., Allema, J. H., ... Gouma, D. J.(1997). Incidence and clinical findings of benign, inflammatory disease in patient resected for presumedpancreatic head cancer. Gastrointestinal endoscopy, 46(5), 417-423. DOI: 10.1016/S0016-5107(97)70034-8

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Incidence and clinical findings of benign, inflammatory disease in patients resected for presumed pancreatic head cancer Thomas M. van Gulik, MD, Jacques W. A. J. Reeders, MD, Anne Bosma, MD, Thybout M. Moojen Nico J. Smits, MD, Jan Hein Allema, MD, Eric A. J. Rauws, MD, G. Johan A. Offerhaus, MD Huug Obertop, MD, Dirk J. Gouma, MD

Amsterdam, The Netherlands

Background: The differentiation between cancer and benign disease in the pancreatic head is difficult. The aim of this study was to examine common features in a group of patients that had undergone pancreatoduodenectomy for a benign, inflammatory lesion misdiagnosed as pancreatic head cancer. Methods: Among 220 pancreatoduodenectomies performed on the suspicion of pancreatic head cancer, an inflammatory lesion in the pancreas or distal common bile duct was diagnosed in 14 patients (6%). Of these patients, all preoperative clinical information and radiologic images (ultrasound, endoscopic retrograde cholangio-pancreaticography [ERCP]) were critically reassessed. For each examination, the suspicion of cancer was scored on a 0 / + / + + scale. Results: Clinical presentation (pain, weight loss, jaundice) raised a suspicion of cancer in 12 patients. On ultrasound, a tumor (mean size: 2.8 cm) was found in the pancreatic head in 13 patients; 12 of 14 ultrasound examinations raised a suspicion of cancer. ERCP showed a distal common bile duct stenosis (length: 1 to 4 cm), stenosis of the pancreatic duct (length: 1 to 5 cm), or a "double duct" stenosis, suspicious for cancer in 13 evaluable patients. The overall index of suspicion was + in seven patients and + + in seven patients, confirming the initial interpretation of preoperative data. Conclusion: When undertaking pancreatoduodenectomy for a suspicious lesion in the pancreatic head, it is necessary to expect at least a 5% chance of resecting a benign, inflammatory lesion masquerading as cancer. (Gas- trointest Endosc 1997;46:417-23.)

Resection offers the only chance of cure for patients with a carcinoma in the pancreatic head region. Despite the fact that mortal i ty of subtotal pancreatoduodenectomy has decreased significantly in the past decade, postoperative morbidity is still considerable and can approach 50%. 1-3 Under taking pancreatoduodenectomy for a pancreatic head tumor becomes even more a subject of discussion when

Received Sept. 16, 1996. For revision March 10, 1997. Accepted June 23, 1997.

From the Departments of Surgery, Radiology, Pathology, and Gastroenterology, Academic Medical Center, University of Am- sterdam, The Netherlands.

Reprint requests: T. M. van Gulik, MD, Dept. of Surgery, Aca- demic Medical Cente5 9 Meibergdreef, 1105 AZ Amsterdam, The Netherlands.

Copyright © 1997 by the American Society for Gastrointestinal Endoscopy 0016-5107/97/$5.00 + 0 37/1/84372

histopathologic examination of the resected specimen may show benign disease, contrary to the preoperative diagnosis. A variety of lesions in the pancreatic head region can mimic a malignancy. 46 Particularly inflammatory lesions, such as in chronic pancreatitis, may display all the typical features of a carcinoma in preoperative imaging studies of the pancreas.

Of 220 consecutive pancreatoduodenectomies performed on the clinical suspicion of a pancreatic head carcinoma, 14 patients (6%) had, on histopathologic examination of the surgical specimen, a benign, inflammatory lesion of the pancreas or of the distal common bile duct (CBD). This subset of patients was analyzed for symptoms and diagnostic discriminat- ing signs of chronic pancreatitis, gallstone disease, and pancreatic cancer. All clinical information and all radiographic images were critically reevaluated

VOLUME 46, NO. 5, 1997 GASTROINTESTINAL ENDOSCOPY 417

T van Gulik, J Reeders, A Bosma, et al. Benign, inflammatory disease in patients resected for pancreatic head cancer

to de t e r mine an index of suspicion for cancer in each case. The defini t ion of common fea tu res in th is group of pa t i en t s was t h o u g h t to help us ident i fy these pancrea t ic i n f l ammato ry lesions and, possibly, avoid u n n e c e s s a r y pancrea toduodenec tomies .

PATIENTS AND METHODS

Preoperative diagnostic work-up of all patients presenting in our institution with a pancreatic head tumor routinely consists of abdominal ultrasound (US) with (color) Doppler flow assessment of the portal venous system and endoscopic retrograde cholangiopancreaticography (ERCP). Computed tomography (CT) has recently become a standard procedure in the preoperative workup of these patients but, in this study, was performed only in selected cases when US and ERCP were indeterminate. Visceral angiography and endoscopic ultrasonography (EUS) are only performed when there is reason for further investigation of vascular involvement or infiltration of the tumor into adjacent structures. When, by this staging procedure, no evidence is found for distant metastases or local tumor infiltration, patients are considered eligible for laparotomy and resection of the tumor with curative intent. In patients with jaundice, a biliary endoprosthesis for preoperative drainage of the biliary system is inserted at the time of diagnostic ERCP.

Between 1983 and 1993, 220 patients (median age 62 years) underwent a subtotal pancreatoduodenectomy (Whipple's resection, n = 188) or a total pancreatectomy (n = 32) on the suspicion of a pancreatic head cancer, based on clinical presentation and imaging studies. In 14 of these patients (seven men and seven women, median age 53 years), histopathologic analysis of the specimen showed a benign, inflammatory lesion diagnosed as chronic pancreatitis of varying severity or as chronic inflammation of the distal CBD. The medical files and radiographic material of these 14 patients were reassessed. The clinical history was reevaluated with spe- cial attention to features specific for benign or malignant pancreatic disease1: previous chronic pancreatitis, alcohol abuse, pain symptoms, weight loss, endocrine and exocrine pancreatic function, jaundice, and gallstone disease.

All radiographic films were reexamined by a blinded panel consisting of a surgeon, gastroenterologist, and radiologists, all of whom are experienced in hepato- pancreatobiliary disorders. Criteria were defined for signs on US and ERCP which, either alone or in combination, are characteristic of malignancy or chronic pancreatitis. 7-1° The suspicion for malignancy resulting from each investigation was graded on a 0/+/++ scale: no suspicion = 0, suspicious = +, highly suspicious = + +. On the basis of reassessment of all clinical and radiographic data, an overall index of suspicion for malignancy was determined for each case by weighing the suspicion scores of all investigations in one patient. Thus, the final suspicion score in each patient was not derived from the exact mean or sum of scores of the individual tests but was based on the investigations giving the highest suspicion. Histopathologic analysis of the resected specimens re-

ported as benign was reconfirmed by an experienced histopathologist.

RESULTS

Clinical presentation

Pain, usua l ly vague u p p e r abdomina l pa in of recent onset , was p re sen t in 11 of 14 pa t ients . None of the pa t i en t s h ad severe, pe r s i s t en t pa in t h a t requ i red narcot ic analgesics. In only one pa t ien t , a diagnosis of chronic pancrea t i t i s associa ted wi th alcohol abuse h ad been m ad e previously. This pa- t i en t was free of symptoms for m a n y years a f te r cessa t ion of dr inking. Ano the r pa t i en t h ad a h i s to ry of increased alcohol consumpt ion. Weigh t loss, ranging f rom 2 to 20 kg, was no ted in 9 of 14 pa t i en t s. Seven of fou r t een pa t i en t s were clinically j aund iced at f irst p resen ta t ion . The du ra t ion of symptoms was shor t (1 to 3 months ) in all bu t one pa t i en t wi th a h i s to ry of 6 months . Two pa t i en t s had diabetes mel l i tus , one requ i r ing insu l in the rapy . None of the pa t i en t s h ad s t e a t o r r h e a or needed pancrea t ic en- zymes. The recen t onse t and type of symptoms were cons idered suspicious for m a l i g n a n t disease in 12 of 14 pa t i en t s (+ in five pa t i en t s and + + in seven pat ients) .

US

US findings inc luded four pa t i en t s wi th a di la ted CBD (> 7 mm) as well as pancrea t ic duct (PD, > 2 mm), whe reas in the r em a in in g 10 pa t ien ts , e i the r the CBD or the PD was dilated. A soli tary, hypoechogenic mass lesion was defined in the pancrea t ic h ead in 12 pa t i en t s (mean t u m o r size: 2.8 cm). In two pa t i en t s who h ad no de tec table t u m o r on US, a t u m o r (1.5 cm and 2 cm in d iameter , respect ively) was pa lpa t ed in the pancrea t ic h ead dur ing surgery. A Doppler shif t was found a t (color) Doppler flow a s se s smen t of the por ta l venous sys tem in one pa t i en t a t some dis tance f rom the t u m o r site. Signs of chronic pancrea t i t i s (calcifications f ea tu r ing acoustic shadowing) were no ted in 4 of 14 pa t ients . Wi th the use of US, 12 cases were found to be suspicious of ma l ignancy (+ in four pa t i en t s and + + in e ight pat ients) ; in one pa t ien t , f indings were compat ib le wi th chronic pancrea t i t i s and in one pa t ien t , no abnormal i t i e s of the panc reas were noted. In the l a t t e r two cases, the decision to perform resec t ion was based on clinical p r e sen t a t i on and the suspicion ra i sed by the ERCP images.

ERCP

The ERCP findings are s u m m a r i z e d in Table 1. In one pa t i en t (case No. 6), r e t rog rade cannu la t ion of the papi l la of Va te r failed, and no images of the CBD

418 GASTROINTESTINAL ENDOSCOPY VOLUME 46, NO. 5, 1997

Benign, inflammatory disease in patients resected for pancreatic head cancer T van Gulik, J Reeders, A Bosma, et al.

Table 1. ERCP findings in 14 patients with a lesion in the pancreatic head, preoperatively diagnosed as cancer

D o u b l e D i l a t a t i o n L e n g t h C B D D i l a t a t i o n L e n g t h P D B i l i a r y S u s p i c i o n

P a t i e n t d u c t s i g n C B D s t e n o s i s (cm) P D s t e n o s i s (cm) d r a i n a g e score

1 - - Y e s 2 N E No f i l l i n g E n d o p r o s t h e s i s + +

2 - - - - 0 Y e s 2 - - +

3 Y e s Y e s 1 Yes 1 S p h i n c t e r o t o m y + +

4 - - - - 0 Yes 1 -- +

5 Y e s Yes 2.5 Y e s 3 E n d o p r o s t h e s i s + +

6 N E N E N E N E N E - - N E

7 - - - - 0 Y e s 4 - - + +

8 Yes Yes 3.5 N E C o m p l e t e s t o p E n d o p r o s t h e s i s + +

9 - - Y e s 1.5 - - - - E n d o p r o s t h e s i s +

10 - - - - 4 Yes 1.5 - - +

II -- -- 0 N E C o m p l e t e s top - - +

12 Y e s Yes 1 Y e s 5 E n d o p r o s t h e s i s + +

13 Y e s Yes 1 N E C o m p l e t e s t o p E n d o p r o s t h e s i s + +

14 - - Y e s 1 N E No f i l l i n g E n d o p r o s t h e s i s + +

NE, N o t e v a l u a b l e .

or the PD were obtained. In two patients (case Nos. 1 and 14), the PD was not adequately visualized because of incomplete filling of the duct. Of 11 patients, five had a typical "double duct" sign, that is, a distal stenosis of both the CBD and PD (Fig. 1). In 9 of 13 patients, a distal CBD stenosis was present ~4th a length ranging from i to 4 cm (mean: 1.9 cm) and with one or more features suggestive of malignancy (irregular narrowing, shouldering sign, eccentric configuration) (Fig. 2). In one patient (case No. 10), stenosis of the CBD did not result in proximal dilatation of the biliary tree. A stenosis (length 1 to 5 cm) or complete obstruction of the PD was shown in 10 of 11 patients in which the PD was successfully opacified. The PD distal to the lesion did not show any accompanying radiographic signs of chronic pancreati t is in these patients. In all but one patient presenting with a CBD stenosis, the biliary tract was drained during the ERCP procedure, either by positioning of an endoprosthesis (seven patients) or by sphincterotomy only (one patient). Of the 13 patients who had undergone ERCP, five patients were considered suspicious (+) and eight patients highly suspicious (+ +) of having a cancer in the pancreatic head.

Overall index of suspicion, intraoperative findings, and pathology results

Taking together the reassessments of clinical presentation and of the US and ERCP images, we determined the overall index of suspicion for cancer for each patient, as shown in Table 2. Agreement was unanimous among surgeon, gastroenterologist, and radiologists with respect to seven cases being classified as suspicious (+) and seven cases as highly suspicious (+ +) for cancer. Although at the outset of

this s tudy criteria were set for suspicious clinical and radiologic features, it proved to be difficult to achieve a final suspicion score based on calculation of the separate scores of each case. Suspicion clearly was based on objective criteria and interpretat ion of a whole set of results.

At laparotomy, a frank tumor measuring 1.5 to 4 cm was identified in the pancreatic head in nine patients, whereas in the other four patients, the pancreatic head was noted to be diffusely enlarged (in one patient, pancreatic head size was not speci- fled). No a t tempt was made to obtain a biopsy sample from the lesion in any of the patients during operation, following the policy in our department. Pancreatoduodenectomy was performed in all 14 patients without mortali ty (30-day mortali ty and hospital mortal i ty in all 220 patients was 2.3% and 6.4%, respectively). Major postoperative complications were noted in 3 of the 14 patients: acute pancreatit is of the pancreas remnant requiring re- laparotomy and two intraabdominal abscesses, one of which was managed percutaneously. At follow-up, 3 to 6.5 years after the pr imary operation, none of the patients showed signs of a malignant process in the previous operative field.

Full histopathologic review of the surgical specimens showed varying degrees of a chronic fibrosing pancreatit is in 12 patients and chronic fibrosing inflammation of the distal CBD in two patients (Table 2). Focal epithelial dysplasia of ducts was noted in only one of the 14 patients.

DISCUSSION

Pancreatic carcinoma and benign, inflammatory lesions of the pancreas, notably in chronic pancreatitis, may present with the same symptoms and

VOLUME 46; NO. 5, 1997 GASTROINTESTINAL ENDOSCOPY 4 1 9


Figure 1. Chronic focally active pancreatitis mimicking pancreatic head cancer (case No. 5). ERCP showed a "double duct" sign, that is, a distal stenosis of both the CBD (arrows) and PD (arrowheads). Open arrow points at opaci- fled Santorini duct draining the ductal system. On US, a 1 cm, hypoechogenic tumor was detected in the pancreatic head.

signs. Furthermore, the differential diagnosis of both conditions is complex because pancreatic cancer is frequently associated with secondary inflammatory changes caused by obstruction of the PD, 5' 11 whereas chronic pancreatitis may develop into pancreatic carcinoma. 12-14 A combination of different imaging modalities is usually applied in the diagnosis of pancreatic head lesions to improve diagnostic accuracy. ~5 Of all imaging techniques, however, there is not one single investigation tha t can reliably discriminate between chronic pancreatitis and pancreatic cancer.

Pancreatic head cancer encompasses mainly carcinomas of the pancreatic duct, the distal bile duct, and ampullary carcinomas. 1' 1G The "double duct" lesion, tha t is, a stenosis of the CBD and the PD, is a characteristic, radiologic finding in pancreatic head cancer. 7-1° However, depending on the site of

Figure 2. Active chronic fibrosing inflammation of the CBD mimicking pancreatic head cancer (case No. 14). ERCP showed a short, irregular, eccentric stenosis of the CBD (arrows). On US, no abnormalities of the pancreas were found.

origin in the pancreatic head, a distal bile duct carcinoma may also present as a single stenosis of the CBD and a PD carcinoma as a single stenosis of the PD. Hence, in the absence of previous pancreatic or biliary tract surgery, any stenosis of the CBD or PD, being single or double, carries a risk of harboring a cancer. In this series, 5 of 12 evaluable patients had a typical "double duct" sign. The other patients had either a single stenosis of the CBD or of the PD.

Chronic pancreatitis usually causes stricturing of the pancreatic ductal system and may present either as a single stenosis or as multiple stenoses of the PD. 17 An irregular stenosis of the PD > 10 mm, is considered highly suspicious of cancer. 13 Ten of eleven patients in this study had at ERCP, a stenosis of 1 to 5 cm in length (seven patients) or a complete obstruction of the PD (three patients). In- flammatory conditions involving the pancreatic head



Table 2. Overall, preoperative suspicion on malignancy,* intraoperative findings and pathology results of 14 patients who had undergone pancreatoduodenectomy for a lesion in the pancreatic head

Preoperative suspicion

ER Intraoperative Patient Clin. US CP Overall findings Pathology result

1 + + + + + + + + 2 cm tumor

2 + + + + + 4 cm tumor

3 + + + + + + + + 1.5 cm tumor

4 + ++ + + 3.5 cm tumor

5 + + + + + + + + Head enlarged

6 + + NE + 5 cm tumor

7 0 + + + + + + 3 cm tumor

8 ++ ++ ++ ++ 2.5 cm tumor

9 + + + + Head enlarged

10 + 0 + + Head enlarged

11 0 + + + 3 cm tumor 12 + + + + + + + Not specified

13 + + + + + + + + Head enlarged

14 + + 0 + + + 2 cm tumor

Active chronic proliferative fibrosing pancreatitis; no epithelial dysplasia

Active (purulent) chronic fibrosing pancreatitis; no epithelial dysplasia

Chronic focally active fibrosing pancreatitis; focal epithelial dysplasia

Active (necrotizing) chronic pancreatitis; no epithelial dysplasia

Chronic focally active (purulent) proliferative fibrosing pancreatitis; no epithelial dysplasia

Chronic active (necrotizing) fibrosing pancreatitis (with cyst formation); no epithelial dysplasia; hyperptasia of neuroendocrine (Langerhans island) cells

Mild chronic fibrosing pancreatitis; no epithelial dysplasia

Chronic focally active fibrosing pancreatitis; squamous metaplasia, no epithelial dysplasia

Active focally necrotizing chronic proliferative, fibrosing pancreatitis; no epithelial dysplasia

Chronic fibrosing (sclerosing) pancreatitis; focal epithelial dysplasia

Proliferative fibrosing (sclerosing) pancreatitis Normal pancreas; mild chronic inflammation of

distal CBD Autoimmune chronic fibrosing pancreatitis; no

epithelial dysplasia Normal pancreas; active (ulcerative) chronic

fibrosing inflammation of distal CBD

NE, Not evaluable. *Index of suspicion was graded as: not suspicious (0), suspicious (+), highly suspicious (+ +).

c a n a lso g ive r i s e to s t r i c t u r i n g of t h e CBD. 7, ls-2o

B i l i a r y s t r i c t u r e s h a v e b e e n r e p o r t e d to o c c u r i n 25% u p to a s h i g h a s 69% of p a t i e n t s w i t h c h r o n i c p a n c r e a t i t i s . T h e s e b i l e d u c t s t e n o s e s u s u a l l y a r e i n c o m p l e t e , l o n g e r (1 to 7 cm), t a p e r e d , a n d s m o o t h l y d e l i n e a t e d i n c o m p a r i s o n w i t h s t e n o s e s c a u s e d b y p a n c r e a t i c c a n c e r . I n t h e p r e s e n t s e r i e s , 9 o f 13 e v a l u a b l e p a t i e n t s h a d a s t e n o s i s o f t h e d i s t a l CBD, w i t h a m e a n l e n g t h o f 1.9 cm.

A l t h o u g h C T i m a g i n g h a s r e c e n t l y b e e n a d d e d to t h e s t a n d a r d p r e o p e r a t i v e w o r k u p o f p a t i e n t s w i t h p a n c r e a t i c t u m o r s in o u r i n s t i t u t i o n , C T w a s p e r - f o r m e d o n l y i n s e l e c t e d c a s e s d u r i n g t h e p e r i o d of t h i s s t u d y . E v a l u a t i o n of CT d a t a in a r e c e n t s e r i e s o f p a t i e n t s w i t h p a n c r e a t i c t u m o r s , h o w e v e r , d i d n o t a p p e a r to a d d m u c h to t h e c o n c l u s i o n s d e r i v e d f r o m U S i n v e s t i g a t i o n s ( s t u d y i n p r o g r e s s ) . A n i m p o r t a n t p o i n t i n t h i s r e g a r d i s t h e q u a l i t y o f u l t r a s o u n d i n v e s t i g a t i o n s , w h i c h o b v i o u s l y i s op- e r a t o r d e p e n d e n t a n d r e q u i r e s e x p e r t i s e , e s p e -

c i a l l y i n t h e a s s e s s m e n t o f b i l i a r y a n d p a n c r e a t i c d i s o r d e r s . A l t h o u g h C T c a n b e h i g h l y a c c u r a t e in p r e d i c t i n g r e s e c t a b l e o r u n r e s e c t a b l e d i s e a s e i n p a n c r e a t i c c a n c e r , 21 t h e t e c h n i q u e i s l e s s r e l i a b l e i n t h e d i f f e r e n t i a l d i a g n o s i s o f p a n c r e a t i c c a n c e r a n d c h r o n i c p a n c r e a t i t i s . 22 D i f f e r e n t i a t i o n o f

c h r o n i c p a n c r e a t i t i s a n d p a n c r e a t i c c a n c e r b y C T m a y e v e n b e i m p o s s i b l e b e c a u s e p a n c r e a t i c c a r c i - n o m a c a n b e a s s o c i a t e d w i t h i n f l a m m a t o r y d i s - e a s e . 2~ T h e a c c u r a c y r a t e o f C T w a s 77% i n a p r o s p e c t i v e s t u d y b y D e l M a s c h i o e t a l . , 24 i n w h i c h t h e v a l u e o f C T w a s a s s e s s e d i n 81 c o n s e c u t i v e p a t i e n t s w i t h s u s p e c t e d p a n c r e a t i c c a n c e r o r c h r o n i c p a n c r e a t i t i s . A n a l y z i n g t h e c o l l e c t i v e p u b - l i s h e d d a t a , R S s c h a n d C l a s s e n 25 f o u n d t h e a c c u - r a c y o f C T to b e 53% i n t h e d i f f e r e n t i a l d i a g n o s i s o f m a l i g n a n c y a n d f o c a l c h r o n i c p a n c r e a t i t i s .

E U S is n o t r o u t i n e l y a p p l i e d in t h e d i a g n o s i s o f b e n i g n a n d m a l i g n a n t d i s o r d e r s o f t h e p a n c r e a s in o u r i n s t i t u t i o n b e c a u s e i t w a s n o t f o u n d to p r o v i d e

VOLUME 46, NO, 5, 1997 GASTROINTESTINAL ENDOSCOPY 421


more information than obtained with conventional, t ransabdominal US. In an analysis of collective published data, the accuracy of EUS in the differential diagnosis between malignancy and focal chronic pancreat i t i s was 61%. 25 Recent innovat ions in magnet ic resonance imaging (MRI) have permitted improved depiction of the pancreas. Non- enhanced FLASH (fast, low-angle shot) imaging and gadol in ium-enhanced FSSE (fa t -suppressed spin-echo) imaging seem to be promising techniques to dis t inguish inf lammatory disease from pancreat ic cancer and may be useful in s i tuat ions in which CT findings are indeterminate . 26 Serum CA 19~9, a l though claimed to be a sensi t ive and specific tumor marke r for pancreat ic cancer, may be influenced by ext rahepat ic cholestasis and active pancreat i t is , l imiting its use as a discrimina- tive t e s t . 24' 27, 28

Obviously, excision of the lesion is the only way to rule out malignancy at the price of performing pancreatoduodenectomy for a benign condition. Pre- operative, fine-needle aspiration biopsy may provide evidence of malignancy but carries a potential risk of implantat ion metastases. 2~-31 In addition, false negative results caused by sampling errors, as high as 60%, should be taken into account when performing fine-needle aspiration biopsy. 32' 33 Even if sampling of the neoplastic sites in the tumor can be improved by advanced techniques, the histopathologic differentiation between inflammatory lesions and malignant disease can be difficult, particularly in well-differentiated pancreatic cancers. Molecular markers as K-ras mutat ions and p53 could potentially increase the diagnostic yield of cytologic aspiration biopsies, but, clinical application awaits further assessments. 34 For these reasons, we do not routinely obtain a biopsy sample from an otherwise resectable pancreatic lesion, but proceed with resection.

Pancreatoduodenectomy is the s tandard operation for pancreatic head cancer and, in addition, has been successfully performed for a variety of diseases including advanced chronic pancreatit is localized in the pancreatic h e a d y Pancreatoduodenectomy performed for a benign lesion that was suspected to be a carcinoma has sporadically been reported in the literature, as reviewed by Cohen et al. 4 They found 52 cases of pancreatoduodenectomies inadvertently performed for benign conditions including cystade- noma and a myoblastoma of the pancreas. With respect to larger series of pancreatoduodenectomies, the incidence of resect ing a lesion tha t tu rned out to be benign was 3% to 5%. 4-6 The present repor t focuses on benign, inf lammatory lesions in the pancreat ic head tha t were misdiagnosed as pan-

creatic cancer. In this series, the incidence of finding such a benign lesion was 6%. Careful review of all preoperat ive information and radiographic images confirmed the suspicious presen- ta t ion of these benign cases. The decision to under take resect ion at the t ime of initial evaluation, therefore, was not an error in judgement , bu t reflects a consis tent policy in the m a n a g e m e n t of pancreat ic head tumors.

Pancreati t is and biliary tract disease account for most inflammatory lesions in the pancreatic head. In this series, 12 patients were diagnosed, his- topathologically, as active chronic pancreatit is of varying severity, whereas two patients had a normal pancreas but had inflammatory changes of the distal CBD. Although the lat ter two patients had no history of gallstone disease or evidence of gallstones in the preoperative investigations, stone passage through the distal CBD and papilla is the most likely cause of the observed inflammatory lesions. Epithelial dysplasia of pancreatic ducts was not present except for one patient (Table 2, case No. 3), in which focal epithelial dysplasia was found in conjunction with chronic, locally active fibrosing pancreatitis.

In conclusion, considering the improved results of pancreatoduodenectomy, resection of any lesion suspicious of pancreatic head cancer is justified in specialized centers, lest a potentially curable cancer be missed. However, a consequence of this policy is that, in at least 5% of cases, a benign, inflammatory lesion masquerading as pancreatic cancer may be diagnosed by histopathologic analysis of the surgical specimen.

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