Pancreatic incidentalomas: high rate of potentially malignant tumors

Molecular analysis of cyst fluid aspiration in the diagnosis and risk assessment of cystic lesions of the pancreas

Pancreatic cyst detection is increasing largely due to increasing use of cross-sectional imaging. The management of pancreatic cysts differs for true cysts, pseudocysts, mucinous cysts, nonmucinous cysts, and malignant lesions. Depending on the setting, diagnostic tests, such as cross-sectional imaging, endoscopic ultrasound, cyst fluid chemistry, and cytology, have moderate accuracy in characterizing the cyst subtype. Molecular analysis of cyst fluid aspirates has shown promise in preliminary studies and may require smaller fluid volumes than is needed for carcinoembryonic antigen level and cytology. This article reviews published studies in which molecular analysis was performed in the evaluation of pancreatic cysts. The molecular studies are compared with the conventional tests. Most studies have had moderate sample sizes (16-124) and have characterized a high proportion of patients with malignant cysts. Evaluation of molecular analysis as a diagnostic tool merits larger prospective trials with long-term follow-up of patients who are not sent to surgery. Larger cysts may meet size criteria for resection, and it is the smaller cysts for which molecular analysis may be of benefit if additional molecular testing results in a change in management.

Solid pseudopapillary tumors of the pancreas. Clinical features, surgical outcomes, and long-term survival in 45 consecutive patients from a single center

BACKGROUND

Solid pseudopapillary tumors of the pancreas (SPT) are rare neoplasms, and the natural history is poorly defined. The aim of this study was to define the natural history and compare patient and tumor factors between patients with malignant and non-malignant disease.

METHODS

Data for all patients with SPT who underwent surgical exploration at MSKCC between 1987 and 2009 were collected and analyzed. Patient, tumor, treatment, and survival variables were examined. Malignant tumors were defined as any tumor that was locally unresectable, metastatic, or recurrent. Differences between groups were analyzed by Fisher's exact, chi-squared, Wilcoxon, and log-rank tests.

RESULTS

Forty-five patients had an SPT during the study period. Median age was 38 years (10-63) and 38 (84%) were women. At the time of diagnosis, 38 were symptomatic, with the most common symptom being abdominal pain (n = 35). The most frequent imaging characteristic was a solid and cystic tumor (n = 29), most commonly located in the tail of the pancreas (n = 23). Resection of the primary tumor (n = 41) (41/2,919 = 1.4% of all resections) included distal pancreatectomy in 26, pancreatoduodenectomy in 11, central pancreatectomy in two, and enucleation in two. Nine patients had malignant disease defined by a locally unresectable tumor in three, liver metastases in three, locally unresectable tumor and liver metastases in one, local recurrence and liver metastases in one, and local recurrence in another. Patients with malignant disease presented with larger tumors (7.8 vs. 4.2 cm) (p < 0.005). After median follow-up of 44 months, 34 patients were without evidence of disease, four patients were alive with disease, three patients died of disease, and four patients died of other causes.

CONCLUSIONS

These results demonstrate that SPT occurs in young women, and the majority of patients will experience long-term survival following resection. The only feature associated with malignant disease was tumor size at presentation. The majority of patients are alive at last follow-up, and a low percentage experienced disease recurrence or death from disease.

Direct intracystic biopsy and pancreatic cystoscopy through a 19-gauge needle EUS (with videos)

BACKGROUND

Histologic diagnosis of cystic pancreatic lesions (CPLs) is often difficult because of the low sensitivity of FNA and brush cytology.

OBJECTIVE

To discover whether obtaining biopsy samples from the cystic wall could increase the diagnostic yield of these lesions.

DESIGN

A pilot study including 2 patients with CPLs.

SETTING

Endoscopy unit in a tertiary-care hospital.

PATIENTS

Two women with CPLs located at the pancreatic head.

INTERVENTIONS

On EUS, biopsy forceps and a SpyGlass fiberoptic were passed through a 19-gauge needle to visualize and obtain samples from the cystic wall.

MAIN OUTCOME MEASUREMENTS

The histologic assessment was based on the obtained biopsy samples.

RESULTS

Both CPLs were considered to be mucinous cystoadenomas, because mucinous-like cylindric epithelium without cellular atypia was observed.

LIMITATIONS

Pilot study.

CONCLUSIONS

Obtaining biopsy samples from the wall of a CPL is now feasible. It represents a significant advantage in the diagnostic yield of this type of lesion.

Intraductal papillary mucinous neoplasm and the pancreatic incidentaloma

Asymptomatic pancreatic lesions (APL) are a commonly encountered problem in today’s pancreatic surgical practices. Current literature regarding etiologies and incidence of APLs, particularly intraductal papillary mucinous neoplasm (IPMN), is presented. APLs constitute a wide spectrum of pathology (solid/cystic, benign/premalignant/malignant) but, overall, IPMN is now the most common diagnosis. The Sendai Guidelines and their function as a basis for risk stratification in branch duct IPMN are presented. The importance of traditionally analyzed cyst characteristics including size, presence of mucin or nodules and cyst fluid aspirate as indicators of malignancy is emphasized, noting also the potential correlation of main duct dilatation, thickened septae and elevated cyst fluid CEA with increased risk of malignancy. Current complication rates after resection of APLs are reviewed and found to be generally equivalent to those for symptomatic resections. A potential multidisciplinary treatment strategy is offered considering the costs of surgery versus repeated imaging or follow up endoscopy for these lesions. The decision for intervention is ultimately based on the Sendai Guidelines in the context of the individual patient.