Drs. Zyromski, Nakeeb, and Lillemoe have presented a very excellent and complete review of all aspects of pancreatic neoplasia based not only on extensive literature review but also on their own very extensive and impressive personal experience. This commentary is basically planned to emphasize some of their points by comparison and/or contrast or, at times, play the devil's advocate to stimulate additional thinking, perhaps in a new or different direction.

The major concern in pancreatic carcinoma is its basic biologic behavior. Article after article over many decades has shown that survival has not improved significantly, independent of progress in surgical and medical management. The majority of patients with pancreatic cancer are not resectable, and even among those patients who have their tumors resected only 10% to 20 % enjoy a 5-year survival. There is no substantial proof in any scientific report that earlier diagnosis, any type of screening, or more aggressive operations have produced any significant survivor benefit.

The review of pathology by the authors is quite extensive and complete. I will address only the diagnosis of mucinous cystic neoplasms (MCNs). If there is unilocular cystic mass in the tail of the pancreas with no history of prior pancreatitis and a patient has no contraindications for surgery, then a presumptive diagnosis of MCN can be made and a distal pancreatectomy can be performed. However, with cystic mass present in the head, because of the increased morbidity and mortality associated with pancreaticoduodenectomy, a ...