Preoperative malignancy risk assessment in pancreatic cystic neoplasms using clinical and laboratory parameters

Abstract

BACKGROUND

Pancreatic cystic neoplasms (PCNs) are increasingly detected due to advancements in radiographic techniques, with a prevalence of approximately 15% in the general population. These lesions range from benign to premalignant and malignant, posing a diagnostic challenge. Accurate differentiation is critical, as premalignant and malignant PCNs often require surgical intervention, while benign cysts may only need monitoring unless symptomatic. Current diagnostic methods, including cross-sectional imaging, endoscopic ultrasonography, and endoscopic ultrasonography-guided fine-needle aspiration/biopsy, are specialized, not universally available, and have variable accuracy. Clinical and laboratory parameters such as carbohydrate antigen 19-9 (CA 19-9), neutrophil-lymphocyte ratio, platelet-lymphocyte ratio, and red cell distribution width (RDW) have been associated with malignancy risk, though only CA 19-9 is guideline-supported.

AIM

To assess the malignancy risk of PCNs using preoperative clinical and routine laboratory parameters.

METHODS

A retrospective cohort study analyzed 70 patients who underwent surgery for PCNs at Ankara Bilkent City Hospital between February 2019 and March 2023. Patients were categorized into group A (benign or low-grade dysplasia, n = 40) and group B (malignancy or high-grade dysplasia, n = 30) based on postoperative pathology. Preoperative demographic and laboratory parameters, including age, RDW, albumin, and CA 19-9, were compared. Univariate and multivariate logistic regression analyses identified independent predictors of malignancy. Receiver operating characteristic curve analysis evaluated predictive performance, with internal validation using bootstrapping.

RESULTS

Group B patients were older (69.86 ± 9.58 years vs 52.74 ± 16.85 years, P < 0.001) and had a higher incidence of diabetes mellitus (57.1% vs 21.4%, P = 0.002). RDW (16.2% vs 13.7%, P < 0.001), platelet-lymphocyte ratio (178 vs 126, P = 0.008), and CA 19-9 (21.7 U/mL vs 9.3 U/mL, P = 0.009) were significantly higher in group B, while albumin was lower (41 g/L vs 45 g/L, P = 0.008). Multivariate analysis identified age [odds ratio = 1.067, 95% confidence interval (CI): 1.014-1.122, P = 0.012] and RDW (odds ratio = 1.784, 95%CI: 1.172-2.715, P = 0.007) as independent predictors. The area under the curve for age, RDW, and their combination was 0.798 (95%CI: 0.695-0.900), 0.801 (95%CI: 0.692-0.911), and 0.858 (95%CI: 0.771-0.944), respectively, with bootstrapped validation confirming stability. Cut-off values of age ≥ 60 years and RDW ≥ 15.5% balanced sensitivity and specificity, increasing malignancy risk 15.3-fold and 22.6-fold, respectively.

CONCLUSION

Age and RDW are independent predictors of malignancy in PCNs, aiding in patient selection for advanced diagnostics and surgery. Larger, multicenter studies are needed to validate these findings.

Keywords: Pancreatic cystic neoplasms; Malignancy risk; Red cell distribution width; Age; Preoperative assessment

Core Tip: This study highlights the utility of simple preoperative parameters - age and red cell distribution width - in predicting malignancy in pancreatic cystic neoplasms. With area under the curve values of 0.798 and 0.801, respectively, and a combined area under the curve of 0.858, these markers can guide patient selection for endoscopic ultrasonography and cytological evaluation, potentially improving surgical decision-making for pancreatic cystic neoplasms.