Cystic neoplasms of the pancreas

Genetics and biology of pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer death in the United States with a median survival of <6 mo and a dismal 5-yr survival rate of 3%-5%. The cancer's lethal nature stems from its propensity to rapidly disseminate to the lymphatic system and distant organs. This aggressive biology and resistance to conventional and targeted therapeutic agents leads to a typical clinical presentation of incurable disease at the time of diagnosis. The well-defined serial histopathologic picture and accompanying molecular profiles of PDAC and its precursor lesions have provided the framework for emerging basic and translational research. Recent advances include insights into the cancer's cellular origins, high-resolution genomic profiles pointing to potential new therapeutic targets, and refined mouse models reflecting both the genetics and histopathologic evolution of human PDAC. This confluence of developments offers the opportunity for accelerated discovery and the future promise of improved treatment.

Preinvasive duct-derived neoplasms in pancreas of keratin 5-promoter cyclooxygenase-2 transgenic mice

BACKGROUND & AIMS

Basic research aimed at a better understanding of pancreatic carcinogenesis and improving the treatment of this disease is crucial because the majority of pancreatic cancers are highly aggressive and therapeutically nonaccessible. Cyclooxygenase (COX)-2, which is a key enzyme of prostaglandin (PG) biosynthesis, is overexpressed in around 75% of human carcinomas including those of the pancreas.

METHODS

The pathologic changes of transgenic mouse pancreas with keratin 5-promoter-driven expression and activity of COX-2 were characterized.

RESULTS

Aberrant expression of COX-2 in a few ductal cells and COX-2-mediated PG synthesis in the transgenic mice resulted in keratin 19- and mucin-positive intraductal papillary mucinous neoplasm- and pancreatic intraepithelial neoplasia-like structures, characterized by an increased proliferation index and serous cystadenomas. Moreover, Ras activation was enhanced and the HER-2/Neu receptor was overexpressed. Loss of acini, fibrosis, and inflammation were pronounced. Feeding a COX-2-selective inhibitor to the transgenic mice suppressed the accumulation of PG and the phenotype. The changes resemble the human disease in which COX-2 was overexpressed consistently.

CONCLUSIONS

We present strong evidence for a causal relationship between aberrant COX-2 overexpression and COX-2-mediated PG synthesis and the development of serous cystadenoma, intraductal papillary mucinous, and pancreatic intraepithelial neoplasms. This model offers the unique possibility of identifying molecular pathways leading to the formation and malignant progression of the various types of preinvasive lesions of pancreatic adenocarcinomas that show different dismal outcomes.

Less common neoplasms of the pancreas

Recently, there has been an increased recognition of neoplasms of the pancreas other than ductal adenocarcinoma. Although not as well studied or characterized as pancreatic adenocarcinoma there are many distinct lesions which exhibit diverse biological behaviors and varying degrees of malignancy. These lesions include: endocrine neoplasms, cystic tumors, solid pseudopapillary tumors, acinar cell carcinoma, squamous cell carcinoma, primary lymphoma of the pancreas, and metastatic lesions to the pancreas. These less common neoplasms are being diagnosed more frequently as the number and sensitivity of diagnostic imaging studies increase. This review article discusses the clinical course, diagnosis, and treatment of these less common, but quite relevant, neoplasms of the pancreas.

A prospective control study of the safety and cellular yield of EUS-guided FNA or Trucut biopsy in patients taking aspirin, nonsteroidal anti-inflammatory drugs, or prophylactic low molecular weight heparin

BACKGROUND

Although the ASGE recommends that high-risk endoscopic procedures can safely be performed on patients taking aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) in standard doses, there is a paucity of data on EUS-FNA per se in this setting.

OBJECTIVE

We studied the safety and cellular yield of EUS-FNA and/or Trucut biopsy (TCB) in patients taking aspirin, NSAIDS, or prophylactic low molecular weight heparins (LMWH).

DESIGN

Prospective control study.

PATIENTS

Consecutive patients undergoing EUS-FNA and/or TCB were recruited over an 18-month period. The usage of aspirin, NSAIDS, or LMWH were recorded and patients who were not taking these medications served as controls.

MAIN OUTCOME MEASUREMENTS

The bleeding events (endosonographic findings of extraluminal bleeding, intraluminal bleeding requiring hemostatic procedures, hematemesis, or melena) and cellular yield were compared between patients and controls.

RESULTS

Two hundred fourteen patients (8 had repeat procedures) underwent EUS-FNA and/or TCB on 241 lesions. Bleeding events occurred in none (0 of 26), 33.3% (2 of 6), and 3.7% (7 of 190) of the patients in the aspirin/NSAIDS, LMWH, and control groups, respectively (p = 0.023). The mean numbers of FNA passes, applications of suction, bloody specimens, and cellular yield were not significantly different between patients who were or were not receiving medications. No significant difference in bleeding events was noted between the FNA and TCB groups.

CONCLUSION

EUS-FNA or TCB is safe in patients taking aspirin or NSAIDS. Consideration should be given to stopping LMWH before the procedure. The cellular yield and blood contamination of the specimen from FNA are similar to those in controls.

Three cases of pancreatic serous cystadenoma and endocrine tumour

AIMS

To report three cases of serous cystadenoma and endocrine tumour in the same pancreas, to review the literature and to evaluate the clinicopathological features of the tumours.

CASES

Three women (71, 57 and 31 years old) were admitted to hospital, two for diseases unrelated to the pancreas and the third for increasing obstructive jaundice in von Hippel-Lindau disease. Preoperative examination showed two distinct lesions in the first patient and only cystic lesions in the other two.

RESULTS

Histological examination of the pancreas showed one serous oligocystic adenoma associated with a benign, well-differentiated endocrine tumour, one serous oligocystic adenoma associated with an endocrine microadenoma, and a von Hippel-Lindau-related cystic neoplasm with a well-differentiated endocrine carcinoma.

CONCLUSIONS

Serous cystadenoma associated with endocrine tumour shows some clinicopathological differences with respect to the two tumours considered separately, and with respect to von Hippel-Lindau-related cases, although there is no convincing evidence at present to justify considering this association as a separate entity.

Clinico-pathological features of cystic pancreatic endocrine neoplasms and a comparison with their solid counterparts

AIM

Pancreatic endocrine neoplasms (PENs) may occasionally manifest as cystic lesions of the pancreas. The aim of this study is to report our experience with cystic PENs and to compare their clinico-pathological features with their solid counterparts.

MATERIALS AND METHODS

From 1990 to 2004, 38 patients with PENs were reviewed. Six of these tumours appeared on radiological imaging as a cystic lesion of the pancreas.

RESULTS

Of the 38 patients with a PEN, 21 of the patients were female and with a median age of 54.5 (range, 33-83) years. Sixteen patients had functional endocrine tumours of which insulinoma was the most common. The six patients with cystic PEN had a median age of 55.5 (range, 41-70) years and half were female. Cystic PENs were significantly larger [48 (range, 25-170) mm vs 19 (range, 3-120) mm, P = 0.013] and were less likely to be benign (0 vs 50%, P = 0.017) compared to their solid counterparts. There was no difference between cystic and solid PENs in terms of age, sex, presence of symptoms, proportion of functioning tumours and location of tumours within the pancreas.

CONCLUSION

Cystic PENs share many clinico-pathological features with solid PENs. These differ only in the cystic appearance and tend to be of a larger size. Hence, these findings suggest that cystic and solid PENs are unlikely to be distinct pathological entities but are likely to be morphological variants of the same entity.

Cystic pancreatic lesions: a simple imaging-based classification system for guiding management

Cystic lesions of the pancreas are increasingly being recognized due to the widespread use of cross-sectional imaging. The initial evaluation of a pancreatic cyst should be directed toward exclusion of a pseudocyst. Patients with pseudocysts generally have a history of acute or chronic pancreatitis, whereas those with cystic tumors most often lack such a history. Several types of cystic lesions are encountered in the pancreas. Because of morphologic overlap at imaging, accurate characterization of these lesions can be difficult. Computed tomography and magnetic resonance imaging are excellent modalities for both initial detection and characterization of cystic pancreatic lesions. An imaging classification system for these lesions has been proposed that is based on the morphologic features of the lesion. This system can be helpful in characterizing lesions, narrowing the differential diagnosis, and making decisions regarding the treatment of affected patients. Endoscopic ultrasonography-guided aspiration and biopsy is useful in cases that are indeterminate at cross-sectional imaging or that require observation.

Cystic pancreatic lesions: a simple imaging-based classification system for guiding management

Cystic lesions of the pancreas are increasingly being recognized due to the widespread use of cross-sectional imaging. The initial evaluation of a pancreatic cyst should be directed toward exclusion of a pseudocyst. Patients with pseudocysts generally have a history of acute or chronic pancreatitis, whereas those with cystic tumors most often lack such a history. Several types of cystic lesions are encountered in the pancreas. Because of morphologic overlap at imaging, accurate characterization of these lesions can be difficult. Computed tomography and magnetic resonance imaging are excellent modalities for both initial detection and characterization of cystic pancreatic lesions. An imaging classification system for these lesions has been proposed that is based on the morphologic features of the lesion. This system can be helpful in characterizing lesions, narrowing the differential diagnosis, and making decisions regarding the treatment of affected patients. Endoscopic ultrasonography-guided aspiration and biopsy is useful in cases that are indeterminate at cross-sectional imaging or that require observation.

Comparison of resected and non-resected intraductal papillary mucinous neoplasms of the pancreas

By comparing the clinicopathological features and survivals between the resected and non-resected intraductal papillary mucinous neoplasms (IPMNs) of the pancreas, this study tried to clarify the natural history of IPMNs, to provide a strategy for treatment, and to determine the justification of not performing resection for some patients. A total of 57 patients with IPMN, including 39 resected and 18 non-resected IPMNs, were recruited for study. Data on demographics, clinical presentations, diagnostic work-up, treatment modality, clinical course, and outcomes were evaluated and compared between the resected and non-resected IPMNs. The most common clinical presentation was abdominal pain (57% in total IPMNs, 67% in resected, 33% in non-resected), followed by body weight loss (32% in total IPMNs, 33% in resected, 28% in non-resected). The sensitivity in the diagnosis of IPMN was highest by magnetic resonance cholangiopancreatography (MRCP) (88%), followed by endoscopic retrograde cholangiopancreatography (ERCP) (68%), and computed tomography scan (CT scan) (42%) and sonography (10%). The median survival was 21.5 months for patients with resected IPMNs, ranging from 2 to 124 months, and 14 months in non-resected IPMN patients, ranging from 5.5 to 70 months. There is no significant survival difference between the resected and non-resected groups, with a 5-year survival of 69.8% in resected IPMNs and 59.8% in non-resected IPMNs, P = 0.347. The survival outcome of the unresectable non-resected IPMNs was much inferior to the resected IPMNs, P = 0.002 and resectable non-resected IPMNs, P = 0.001. Thus, the prime prognostic factor in predicting the survival outcome of IPMNs is resectability, instead of resection itself. Long-term survival could also be expected in resectable IPMNs without resection. No resection for the IPMN may be justified for patients with high surgical risks, especially for those who are asymptomatic and very aged.

Pancreatic juice cytology in the diagnosis of intraductal papillary mucinous neoplasm of the pancreas: significance of sampling by peroral pancreatoscopy

BACKGROUND

The examination of pancreatic juice cytology could hypothetically contribute to the establishment of a definite diagnosis of malignant intraductal papillary mucinous neoplasm of the pancreas (IPMN), but to the authors' knowledge, its significance has not been confirmed to date. The current study was conducted to assess the diagnostic value of pancreatic juice cytology in IPMN and to examine the usefulness of peroral pancreatoscopy (POPS) in sampling pancreatic juice.

METHODS

The study subjects were comprised of 103 patients with IPMN who underwent surgical resection of pancreatic tumors (adenoma in 29 patients, borderline in 17 patients, carcinoma in situ in 25 patients, and invasive carcinoma in 32 patients). Pancreatic juice was collected with a catheter in 71 patients and by POPS in 32 patients. Patients with pancreatic carcinoma (n = 81) and chronic pancreatitis (n = 76) also were investigated.

RESULTS

The cytologic diagnosis was found to be of nondiagnostic value in only one patient with an IPMN, whereas it was of no diagnostic value in 14 of the patients with pancreatic carcinoma (17.3%), a difference that was statically significant (P < 0.001). The location of the IPMN (either in the pancreas or the pancreatic ducts) was not found to significantly affect the diagnostic value of the test. The sensitivity for IPMN was 62.2% when pancreatic juice was collected by POPS, and was 38.2% when it was collected using a catheter. In the case of pancreatic carcinoma, the sensitivity of pancreatic juice cytology was found to be 25.4%, which was significantly lower than that for IPMN when the pancreatic juice was collected by POPS (P < 0.001).

CONCLUSIONS

Pancreatic juice cytology was found to have better diagnostic value in the patients with IPMNs compared with those with pancreatic carcinoma. POPS was found to be useful for the collection of pancreatic juice.

Mucinous cystic neoplasm of the pancreas during pregnancy: the importance of proper management

We describe a case of huge mucinous cystic tumor of the pancreas in a 26-year-old woman during pregnancy. Ultrasonography demonstrated a well-delimited cystic mass in the left upper abdominal quadrant, suggestive of benignity. Magnetic resonance imaging showed a large cystic mass resembling a mucinous cystic tumor of the pancreas. After this assessment the patient underwent surgical exploration and a huge cystic tumor of the pancreas was discovered. The tumor was enucleated and distal pancreatectomy was performed. The resected margin of the specimen was free of tumor. In this case report we discuss the management of mucinous pancreatic tumors during pregnancy and we briefly review the previously reported cases of mucinous pancreatic tumors in pregnant patients. We conclude that surgical resection of these tumors should be strongly considered in pregnancy. Removal of the tumor appears to be a safe procedure without harmful effects to the fetus.

Intraductal papillary mucinous neoplasms of the pancreas: A surgical perspective

Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas represent a relatively "new", but increasingly recognized entity. The emergence of this entity is due primarily to the widespread use of modern imaging methods, but also to a heightened awareness of physicians regarding this cystic neoplasm of the pancreas. No signs or symptoms are pathognomonic of IPMNs, but frequently, patients have a pancreatitis-like abdominal pain. Fully one-third of patients with IPMN are asymptomatic at the time of diagnosis. Cross-sectional imaging (ultrasonography, computed tomography, magnetic resonance cholangiopancreatography), endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography are the diagnostic and staging methods of choice in the evaluation of patients with IPMNs. IPMNs show a wide spectrum of histologic changes, ranging from adenoma to invasive neoplasm, even within the same neoplasm, suggesting a "field defect" predisposing major segments or even the entire ductal epithelium to the development of IPMN. Fine-needle aspiration/cytology and/or analysis of the cystic fluid may be useful diagnostic tools; however, these examinations are associated with high false-negative rates. Complete surgical resection is the therapeutic method of choice. The extent and type of pancreatectomy remain somewhat controversial but should be based on morphologic changes of the pancreas. Even the role of adjuvant therapy remains unclear; however, being "duct-derived" neoplasms of potential malignant character, some form of adjuvant chemo- or ratio-therapy seems indicated in the presence of invasive disease, despite a "curative" resection. In the absence of invasive disease, prognosis after R0 resection is highly favorable with recurrences of 5-10%. However, invasive IPMNs behave quite similar to ductal adenocarcinoma of the pancreas when analyzed stage-by-stage, with a slightly better prognosis; however, even after an R0 resection, recurrence is common.

Clinical and diagnostic aspects of cystic insulinoma

Cystic endocrine tumors of the pancreas rarely occur, and only a few cases of cystic insulinoma have been reported to date. Diagnosis of insulinoma could be difficult if the functional activity is incomplete, possibly leading to blunted symptoms of hypoglycemia and failure in the laboratory to provide evidence of hyperinsulinemia. We report a clinical case of cystic insulinoma confirmed by histological examination after surgery, characterized by a high intracystic insulin concentration despite normal blood basal levels of the hormone. New diagnostic findings from dynamic tests and cystic fluid examination have been carefully focused on.

Preoperative evaluation of pancreatic cystic lesions: cost-benefit analysis and proposed management algorithm

BACKGROUND

This study was performed to develop a management algorithm that accurately predicts the necessity of operative intervention and results in significant cost savings for patients with cystic pancreatic tumors.

METHODS

We reviewed 60 patients treated between 1992 and 2003. Accuracy rates of tests used to differentiate benign from premalignant and malignant cysts were calculated. A management algorithm was generated that incorporated clinical presentation, radiologic findings, and selective use of endoscopic procedures. This algorithm was tested for predictive accuracy, and savings between actual management and proposed management were compared.

RESULTS

There was an average of 3 preoperative tests performed per patient. Endoscopic procedures included endoscopic retrograde cholangiopancreatography in 21 patients and endoscopic ultrasound in 25 patients. A cyst fluid carcinoembryonic antigen (CEA) level of 158 ng/mL or greater had an accuracy rate of 87.5% that was significantly higher than endoscopic retrograde cholangiopancreatography (72%), endoscopic ultrasound morphology (45%), or endoscopic ultrasound cytology (66.7%). There was no combination of tests that provided greater accuracy than cyst fluid CEA level alone (P < .05). The management algorithm had a positive predictive value of 81%. The average actual cost of radiographic and endoscopic procedures was dollar 8,080 per patient. The proposed cost based on the algorithm was dollar 6,677 with a savings of dollar 1,403 per patient (P = .009).

CONCLUSIONS

In patients with clinical symptoms or radiographic findings of mucinous or malignant tumors, further testing is excessive. Of endoscopic tests available, the cystic fluid CEA level most accurately predicts the presence of a mucinous neoplasm. A management algorithm based on presenting symptoms, radiographic findings, and cyst fluid CEA level provides a guideline for the evaluation of cystic lesions in the most cost-efficient manner while ensuring proper care.

Cystic neoplasms of the pancreas; What a clinician should know

Primary cystic neoplasms of the pancreas (serous cystic neoplasms, mucinous serous neoplasms, and intraductal papillary mucinous neoplasms) are lesions of emerging importance. With the wide availability of modern imaging methods, these neoplasms are being recognized with increasing frequency. Due to the improvement of these sophisticated imaging techniques, it is often possible to differentiate preoperatively these primary pancreatic cystic neoplasms not only from other cystic pancreatic disorders (such as pancreatic pseudocysts) but also from one another. This differentiation is very important for the clinician, since these neoplasms have radically different biologic behavior. Serous cystic neoplasms are uniformly benign and usually do not mandate resection unless the lesion is symptomatic. In contrast, mucinous cystic neoplasms and intraductal papillary mucinous neoplasms have a premalignant or overtly malignant tendency, and therefore should be managed aggressively by pancreatic resection. In these mucinous cystic neoplasms, recognition of an underlying malignancy is often not possible without a detailed histopathologic examination of the entire resected specimen. In the absence of invasive disease, prognosis is excellent after appropriate surgery. The presence of invasive malignancy signifies a poor prognosis.

Long-term follow-up of intraductal papillary mucinous neoplasm of the pancreas with ultrasonography

BACKGROUND & AIMS

Most intraductal papillary mucinous neoplasms of the pancreas (IPMNs) have a favorable prognosis. This study was undertaken to clarify the clinical course of IPMNs and to set the criteria for surgical treatment on the basis of long-term follow-up by periodic transabdominal ultrasonography (US).

METHODS

Eighty-one patients with IPMN were periodically subjected to US (>3 years); 27 were reviewed retrospectively (12 with benign neoplasms [adenoma, borderline] and 15 with malignant tumors [carcinoma in situ, invasive cancer]) and 54 prospectively. US examination was focused on the main pancreatic duct (MPD) diameter, cyst diameter, and presence or absence and height of the protruding lesion. Differences between the benign and malignant groups were examined to set the criteria for surgical treatment. Follow-up results of prospective patients were investigated.

RESULTS

The increase of the MPD or the cyst diameter was significantly greater in the malignant group (P < .01). Maximum increases of the MPD diameter by 2.2 mm/year, the cyst diameter by 11.3 mm/year, and emergence or increase of the height of the protruding lesion by 3.3 mm/year were predominantly observed in the malignant group (accuracy, 90.9%, 81.3%, and 81.5%, respectively). The majority of the prospective patients showed no significant changes of these parameters; however, 2 patients (3.7%) were operated on, with the post-surgery histopathologic diagnosis of cancer.

CONCLUSIONS

Periodic imaging follow-up is useful to detect a malignant IPMN. Changes in MPD diameter, cyst diameter, and/or size of the protruding lesion are the practical criteria for selecting surgery.

Serous cystadenoma of the pancreas: tumor growth rates and recommendations for treatment

OBJECTIVE

To define the natural history and optimal management of serous cystadenoma of the pancreas.

SUMMARY BACKGROUND DATA

Serous cystadenoma of the pancreas is the most common benign pancreatic neoplasm. Diagnostic criteria, potential for growth or malignancy, and outcomes are not well defined. As a result, management for patients with serous cystadenomas varies widely in current practice.

METHODS

A total of 106 patients presenting with serous cystadenoma of the pancreas from 1976-2004 were identified. Hospital records were evaluated for patient and tumor characteristics, diagnostic workup, treatment, and outcome. Twenty-four patients with serial radiographic imaging were identified, and tumor growth curves calculated.

RESULTS

Mean age at presentation was 61.5 years and 75% of patients were female. The most common symptoms were abdominal pain (25%), fullness/mass (10%), and jaundice (7%); 47% were asymptomatic. Mean tumor diameter was 4.9 +/- 3.1 cm, which did not vary by location. Tumors <4 cm were less likely to be symptomatic than were tumors > or =4 cm (22% vs. 72%, P < 0.001). The median growth rate in the patients who had serial radiography was 0.60 cm/y. For tumors <4 cm at presentation (n = 15), the rate was 0.12 cm/y, whereas for tumors > or =4 cm (n = 9), the rate was 1.98 cm/y (P = 0.0002). Overall, 86 patients underwent surgery, with one perioperative death.

CONCLUSIONS

Large (>4 cm) serous cystadenomas are more likely to be symptomatic. Although the median growth rate for this neoplasm is only 0.6 cm/y, it is significantly greater in large tumors. Whereas expectant management is reasonable in small asymptomatic tumors, we recommend resection for large serous cystadenomas regardless of the presence or absence of symptoms.

New advances in pancreatic imaging

PURPOSE OF REVIEW

Exciting new developments and applications of imaging techniques in pancreatic diseases have emerged. This review discusses these new advances and how they are improving our ability to diagnose malignancies and inflammatory lesions, to grade severity of pancreatitis, and to stage pancreatic cancer accurately.

RECENT FINDINGS

A new computed tomography severity index shows promise for grading the severity of acute pancreatitis. Magnetic resonance imaging is comparable with computed tomography in staging acute pancreatitis. Analysis of pancreatograms and textural changes of the parenchyma may prove helpful in diagnosing chronic pancreatitis. Contrast enhanced ultrasonography may prove to be a useful way to judge the degree of inflammation and fibrosis in autoimmune pancreatitis and to monitor response to steroid therapy. The debate over the best means of staging pancreatic cancer has focused on endoscopic ultrasound and computed tomography. Preliminary studies with contrast enhanced ultrasonography report improved diagnostic and staging capabilities with pancreatic cystic and solid neoplasms. Improvements in positron emission tomography/computed tomography scans may improve the detection of neuroendocrine tumors.

SUMMARY

These new advances will help refine the diagnosis and staging of pancreatic diseases.

Synchronous pancreatic serous cystic tumor, intraductal papillary mucinous tumor and gastric carcinoma: report of a case

Synchronous cystic tumors of the pancreas are rarely reported in the literature. We report an unusual case of synchronous pancreatic serous cystic tumor (SCT) and intraductal pancreatic mucinous tumor (IPMT) with concomitant gastric carcinoma. This study highlights the importance of careful intra-operative and pathologic examination for concomitant pancreatic neoplasms.

The favorable outcome of human islet transplantation in Korea: experiences of 10 autologous transplantations

BACKGROUND

Cystic neoplasms of the pancreas are an increasingly diagnosed entity, and surgical resection of the pancreas is advocated. Islet autotransplantation is a therapeutic approach used to prevent diabetes in cases of pathologically benign neoplasm after major pancreatectomy.

METHODS

A total of 10 patients underwent pancreatectomy with islet autotransplantation. To evaluate islet transplantation efficiency, the authors compared 23 subjects who did not undergo islet transplantation after partial pancreatectomy with 87 subjects with normal glucose tolerance and with 77 diabetic subjects that did not undergo pancreatectomy.

RESULTS

Ten female patients with nine cystic neoplasms and one patient with pancreatic injury underwent transplantation. Their mean islet equivalents (IEQ) was 3,159 IEQ/kg. During follow-up, two recipients required insulin or oral agents. At the 12-month follow-up, homeostasis model assessment (HOMA)-beta was 77.36+/-17.68, the insulinogenic index (INSindex) was 0.49+/-0.11, and fasting C-peptide and hemoglobin A1c were 1.28+/-0.18 ng/mL and 5.73+/-0.26%, respectively. Islet replacement was found to increase HOMA-beta by approximately 17% compared with distal pancreatectomy in normal glucose tolerance subjects without islet autotransplantation and by 46% compared with distal pancreatectomy diabetes subjects without islet autotransplantation. Factors different in the two insulin and oral hypoglycemic agent (OHA)-requiring recipients and the eight insulin- and OHA-free recipients were pancreatectomy extent, preoperative glucose metabolism insufficiency, age, and underlying cystic neoplasm disease.

CONCLUSIONS

Even partial islet graft function can have a beneficial metabolic effect on the recipient in terms of metabolic parameters such as HOMA-beta and INSindex. This study suggests that islet replacement should be considered for experimental procedures in benign pancreatic conditions.

Approach to cystic pancreatic lesions

Cystic neoplasms of the pancreas represent the best example of a malignant precursor in the pancreas. There are many parallels between pancreatic cystic neoplasms and the colon polyp-cancer sequence. In the past, cystic neoplasms of the pancreas were thought to be relatively rare, composing less than 10% of cancers of the pancreas. With the greater use of cross-sectional imaging, an increasing number of these neoplasms are being seen.

Contrast-enhanced ultrasonography of small solid pseudopapillary tumors of the pancreas: enhancement pattern and pathologic correlation of 2 cases

OBJECTIVE

The purpose of this series is to describe the value of contrast-enhanced ultrasonography (CEUS) in the characterization of small pseudopapillary tumors (SPTs) of the pancreas.

METHODS

Two cases of SPTs found on conventional ultrasonography, both located at the pancreatic body, were studied with spiral computed tomography, magnetic resonance imaging, and CEUS. A final diagnosis was obtained with histologic analysis after distal pancreatectomy. Immunohistochemical analysis of the tumors with the CD34 antigen was performed.

RESULTS

At CEUS, the 2 SPTs had a slight peripheral rim enhancement in the early dynamic phases. The presence of this enhancement pattern at CEUS, not clear at spiral computed tomography or at magnetic resonance imaging, suggested the diagnosis of SPTs with a peripheral pseudocapsule deriving from the compression of the pancreatic parenchyma. The presence of a perilesional pseudocapsule was proved at immunohistochemical analysis of the tumors with the CD34 antigen.

CONCLUSIONS

Contrast-enhanced ultrasonography can improve the characterization of SPTs by showing the typical rim enhancement of these pancreatic tumors.

Ethanol lavage of pancreatic cystic lesions: initial pilot study

BACKGROUND

Ethanol lavage has been used to successfully and safely ablate cystic lesions of the liver, the kidneys, and the thyroid.

METHODS

Asymptomatic patients who undergo EUS examination for a pancreatic cystic lesion were eligible. Patients underwent complete examination with a linear-array echoendoscope, and cyst characteristics were documented. After evacuation of the cyst with needle aspiration, the cyst cavity was lavaged with ethanol for 3 to 5 minutes. The concentration (5%-80%) of ethanol was gradually increased over the course of the study. Patients were monitored for complications during 2 hours after the procedure, and further follow-up was obtained at 72 hours and 1 year after lavage.

OBSERVATIONS

Twenty-five patients were enrolled, 80% were women, and the mean age of all patients was 64.5 years. Cysts had a mean diameter of 19.4 mm and were equally located in the head, the body, and the tail of the pancreas. Cyst-fluid characteristics included high viscosity in 13 (52%) and a mean carcinoembryonic antigen and amylase of 5916 ng/mL and 11,506 U/L, respectively. None of the patients reported any symptoms in short- and long-term follow-up. Of the 23/25 patients with complete follow-up, 8 patients (35%) had complete resolution of their cysts on follow-up imaging. Five patients underwent resection, and histologic evidence of epithelial ablation was seen.

CONCLUSIONS

Ethanol lavage of pancreatic cystic lesions is safe and feasible. A subset of patients undergoing ethanol lavage appears to have long-term resolution on follow-up imaging. Further prospective studies are required to determine if ethanol lavage is an effective treatment for pancreatic cystic lesions.

An endoscopic perspective on pancreatic pseudocysts

Significant advances in endoscopic, radiologic, and surgical techniques have transformed the management of pancreatic pseudocysts. The present review focuses upon advances in the endoscopic management of pseudocysts and incorporation of these techniques into an overall management approach. Findings with endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography often guide the choice of drainage method. Endoscopic drainage can be achieved through the transpapillary or transmural routes. EUS has increasingly become an integral part of transmural pseudocyst drainage.

Cystic neoplasms of the pancreas with mucin-production

AIM

To compare the clinico-pathological features of intraductal papillary mucinous cystic tumours (IPMT) and mucinous cystic tumours (MCT) of the pancreas.

METHODS

Eighteen patients with IPMT and 18 with MCT who underwent surgical resection between 1990 and 2004 were retrospectively reviewed. Their clinico-pathological features were compared using univariate analysis. Statistical analyses of potential predictive factors of malignancy for each of these two groups were also conducted.

RESULTS

Patients with IPMT were found to be older (64+/-10 vs 43+/-18 years, p<0.001) and were predominantly male (male:female ratio, 5:4 vs 1:17, p=0.003) as compared to patients with MCT. MCTs were found in the body-tail region (100%) whereas IPMTs were more evenly distributed (50% in the head) (p=0.001). Pathologically, IPMT was distinct from MCT in terms of size (3.8+/-3.2 vs 9.1+/-4.4 cm, p=0.001), association with secondary pancreatitis (50 vs 0%, p=0.011), communication with the pancreatic duct (94 vs 0%, p<0.001), presence of a dilated main pancreatic duct (61 vs 0%, p<0.001) and the presence of ovarian-type stroma (0 vs 44%, p=0.003).

CONCLUSION

IPMT and MCT are distinct clinico-pathological entities. This distinction is important as management and outcome of these entities may differ.

Technology Insight: current status of endoscopic ultrasonography

Endoscopic ultrasound (EUS) has become the most accurate imaging modality for locoregional cancer staging of the gastrointestinal tract. Fine-needle aspiration (FNA) has added a new level of accuracy for EUS in nodal staging, with reported numbers in the 90% range for luminal and pancreaticobiliary disease. In addition, new non-gastrointestinal applications are being evaluated, such as the role of EUS-FNA for the staging of non-small-cell lung cancer and exploration of the posterior mediastinum. Furthermore, the same techniques that make safe tissue sampling possible are being explored for their use as interventional applications, such as EUS-guided celiac plexus neurolysis, fine-needle injection, EUS-guided pseudocyst drainage, and EUS-guided cholangiography and pancreatography. This review describes the current clinical status of EUS in gastrointestinal oncology, as well as future and novel indications and therapeutic strategies for this technology.

Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study

BACKGROUND & AIMS

Cysts of the pancreas display a wide spectrum of histology, including inflammatory (pseudocysts), benign (serous), premalignant (mucinous), and malignant (mucinous) lesions. Endoscopic ultrasonography (EUS) may offer a diagnostic tool through the combination of imaging and guided, fine-needle aspiration (FNA). The purpose of this investigation was to determine the most accurate test for differentiating mucinous from nonmucinous cystic lesions.

METHODS

The results of EUS imaging, cyst fluid cytology, and cyst fluid tumor markers (CEA, CA 72-4, CA 125, CA 19-9, and CA 15-3) were prospectively collected and compared in a multicenter study using histology as the final diagnostic standard.

RESULTS

Three hundred forty-one (341) patients underwent EUS and FNA of a pancreatic cystic lesion; 112 of these patients underwent surgical resection, providing a histologic diagnosis of the cystic lesion (68 mucinous, 7 serous, 27 inflammatory, 5 endocrine, and 5 other). Receiver operator curve analysis of the tumor markers demonstrated that cyst fluid CEA (optimal cutoff of 192 ng/mL) demonstrated the greatest area under the curve (0.79) for differentiating mucinous vs. nonmucinous cystic lesions. The accuracy of CEA (88 of 111, 79%) was significantly greater than the accuracy of EUS morphology (57 of 112, 51%) or cytology (64 of 109, 59%) (P < 0.05). There was no combination of tests that provided greater accuracy than CEA alone (P < 0.0001).

CONCLUSIONS

Of tested markers, cyst fluid CEA is the most accurate test available for the diagnosis of mucinous cystic lesions of the pancreas.