ACG practice guidelines for the diagnosis and management of neoplastic pancreatic cysts

Surgical resection and outcome of pancreatic cystic neoplasms in China: analysis of a 16-year experience from a single high-volume academic institution

Background

To investigate the clinicopathological features of surgically resected pancreatic cystic neoplasms (PCNs) at a single institution in China.

Methods

The medical charts of patients who operated in the Second Affiliated Hospital, Zhejiang University School of Medicine between 1 January 1997 and 30 June 2013, were pathologically shown to have PCNs.

Results

There was a reliable increase trend not just in the overall number of patients (3 to 75) but additionally in the number of incidentally diagnosed patients across the periods (33.3% to 48.0%). In 83 of 111 cases, preoperative diagnoses matched with pathology, whereas the remaining cases (16/28) were misdiagnosed as pancreatic cancer. The proportion of malignancy in mucin producing neoplasms was 24.3% (9 out of 37). Elevated serum carbohydrate antigen (CA19-9) or carcinoembryonic antigen (CEA) was independently associated with malignancy. The overall survival rate was 96.4%.

Conclusions

The proportion of PCNs within this series differs with that revealed in Western countries. Appropriate preoperative differential diagnosing of PCNs remains challenging. It is strongly recommended that patients with elevated CA19-9 or CEA levels undergo surgical resection.

The role of cytopathology and cyst fluid analysis in the preoperative diagnosis and management of pancreatic cysts >3 cm

BACKGROUND

Pancreatic cyst size >3 cm is a worrisome rather than high-risk feature for malignancy based on the 2012 International Guidelines for the management of mucinous cysts. The value of cytology in preoperative evaluation and surgical triage is unclear.

METHODS

All pancreatic cysts >3 cm resected over a 7-year period were evaluated for clinical, radiologic, and pathologic information. Performance of cytology for the detection of malignancy and surgical triage compared with imaging was assessed.

RESULTS

There were 93 histologically confirmed cysts, 52 of which were mucinous and 41 of which were nonmucinous. Of these, 37% were malignant, including 16 nonmucinous malignancies and 18 mucinous cysts (12 with invasive carcinoma, 6 with high-grade dysplasia). Thirty-nine cysts (41% malignant, 59% benign) were not subject to endoscopic ultrasound-fine needle aspiration (EUS-FNA) prior to resection (average size, 6.0 cm). Fifty-four were evaluated by EUS-FNA, with 35 available for review (average size, 5.4 cm). Cytology/cyst fluid analysis had the highest specificity (88.9%) compared with imaging, whereas magnetic resonance imaging (MRI) showed the highest sensitivity (100%). MRI had the highest predictive value for mucinous (100%) versus nonmucinous cysts (100%). MRI and EUS were able to predict malignancy from the presence of high-risk imaging features in all cases. Some benign cases also showed high-risk imaging features on MRI (28.6%), computed tomography (32.3%), and EUS (45.8%). Cytology correctly classified 5 of 6 benign cysts with high-risk imaging as benign.

CONCLUSIONS

Preoperative evaluation of pancreatic cysts >3 cm is warranted, as many are nonmucinous cysts and not high-grade. Cytology is more specific than imaging for the detection of malignancy in cysts >3 cm.

Quality of life and functional outcome after resection of pancreatic cystic neoplasm

OBJECTIVES

The objectives of this study were to assess the long-term quality of life (QOL) after the resection of a primary pancreatic cyst and to determine predictors of outcome. Secondary outcomes were pancreatic function and survival.

METHODS

One hundred eight consecutive patients, who underwent resection between 1992 and 2007 and had nearly 60 months follow-up, were reviewed. Questionnaires and function tests were collected during scheduled outpatient clinic visits.

RESULTS

At follow-up, 20 patients had died. Five-year overall survival was 94% for benign and 62% for malignant neoplasia. Of 88 living patients, 65 (74%) returned questionnaires. Generic physical and mental QOL scores were equal or better compared with healthy references. None of the disease-specific symptom scales were above mean 50, implicating none to mild complaints. Independent predictors for good generic QOL were young age (P < 0.05) and resected malignancy (P < 0.05); predictors for good gastrointestinal QOL were male sex (P < 0.1), limited resection (P < 0.05), endocrine insufficiency (P < 0.05), and employment (P < 0.05). Endocrine insufficiency prevalence was 40%, and 59% for exocrine insufficiency.

CONCLUSIONS

After cyst resection, long-term QOL is equal to healthy references, pancreatic insufficiency is prevalent but does not impair QOL, and survival relates positive compared with solid pancreatic adenocarcinoma. The excellent long-term outcome justifies proceeding with surgery once a medical indication for resection has been established.

Preoperative GNAS and KRAS testing in the diagnosis of pancreatic mucinous cysts

PURPOSE

Management guidelines for pancreatic intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN) are based on the assumption that mucinous cysts can be accurately distinguished from other pancreatic cystic lesions. Previous studies using surgical material have identified recurrent mutations in GNAS and KRAS in pancreatic mucinous neoplasms. Yet, the diagnostic utility of testing for both genes in pancreatic cyst fluid obtained by endoscopic ultrasound-fine-needle aspiration (EUS-FNA) remains unclear.

EXPERIMENTAL DESIGN

GNAS and KRAS testing was performed on EUS-FNA pancreatic cyst fluid from 91 pancreatic cysts: 41 IPMNs, 9 IPMNs with adenocarcinoma, 16 MCNs, 10 cystic pancreatic neuroendocrine tumors (PanNET), 9 serous cystadenomas (SCA), 3 retention cysts, 2 pseudocysts, and 1 lymphoepithelial cyst.

RESULTS

Mutations in GNAS were detected in 16 (39%) IPMNs and 2 (22%) IPMNs with adenocarcinoma. KRAS mutations were identified in 28 (68%) IPMNs, 7 (78%) IPMNs with adenocarcinoma, and 1 (6%) MCN. Mutations in either gene were present in 34 (83%) IPMNs, 8 (89%) IPMNs with adenocarcinoma, and 1 (6%) MCN. No mutations were found in cystic PanNETs, SCAs, retention cysts, pseudocysts, and a lymphoepithelial cyst. GNAS and KRAS mutations had 100% specificity [95% confidence interval (CI), 0.83-1.00] but 65% sensitivity (95% CI, 0.52-0.76) for mucinous differentiation. Among IPMNs, mutations in either gene had 98% specificity (95% CI, 0.86-1.00) and 84% sensitivity (95% CI, 0.70-0.92).

CONCLUSIONS

The combination of GNAS and KRAS testing was highly specific and sensitive for IPMNs; however, the lack of sensitivity for MCNs highlights the need for additional markers to improve the detection of pancreatic mucinous neoplasms.

Clinical evaluation, imaging studies, indications for cytologic study and preprocedural requirements for duct brushing studies and pancreatic fine-needle aspiration: The Papanicolaou Society of Cytopathology Guidelines

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pancreaticobiliary cytology including indications for endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) biopsy, techniques for EUS-FNA, terminology and nomenclature to be used for pancreaticobiliary disease, ancillary testing and postbiopsy management. All documents are based on expertise of the authors, literature review, discussions of the draft document at national and international meetings and synthesis of online comments of the draft document. This document selectively presents the results of these discussions. This document summarizes recommendations for the clinical and imaging work-up of pancreatic and biliary tract lesions along with indications for cytologic study of these lesions. Prebrushing and FNA requirements are also discussed.

Italian consensus guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms

This report contains clinically oriented guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms in patients fit for treatment. The statements were elaborated by working groups of experts by searching and analysing the literature, and then underwent a consensus process using a modified Delphi procedure. The statements report recommendations regarding the most appropriate use and timing of various imaging techniques and of endoscopic ultrasound, the role of circulating and intracystic markers and the pathologic evaluation for the diagnosis and follow-up of cystic pancreatic neoplasms.

[Surgical aspects of intraductal papillary mucinous neoplasm of the pancreas]

Intraductal papillary mucinous neoplasms (IPMN) have a distinguished role amongst the exocrine pancreatic tumours. Although IPMN is less than 1% of all pancreatic neoplasms, cystic tumours, which has got in the spotlight recently, belong to this histopathological subtype up to 20% to 30%. IPMN originate from the main- and accessory pancreatic ducts. Rate of malignancy, prognosis and, therefore, the operative indications can be quite different. Although the prognosis of ductal carcinoma developed on the basis of IPMN is similar to classic adenocarcinoma - 10% 5-year survival - the overall prognosis of IPMN is much more favourable with over 70% survival rate in case of non-invasive cancers. Hence, it is important the timely diagnosis and surgical resection of IPMN to prevent development of invasive cancer.

Investigation and management of pancreatic tumours

Pancreatic cancer is the 10th most commonly diagnosed cancer in the UK and the fifth most common cause of cancer death. It remains one of the most aggressive cancers with over 95% of patients affected dying of their disease. Often presenting at an advanced stage of disease progression, there is currently no simple screening test available. Therefore a high clinical suspicion and prompt appropriate investigation is required from physicians when dealing with patients with symptoms in keeping with pancreatic cancer. The gastroenterology 2010 curriculum states that trainees should learn the presentation and multidisciplinary management of patients with pancreatic tumours. In this article we discuss the typical clinical presentations of common and less common pancreatic tumours followed by the investigation, staging and management required.

To cease or 'de-cyst'? The evaluation and management of pancreatic cystic lesions

Due to the widespread use of cross-sectional imaging and advances in imaging technology, pancreatic cystic lesions are increasingly being detected. The diagnosis and management of such cysts remains challenging and continues to evolve. Different pancreatic cyst types have varying malignant potential. Thus, accurate cyst characterization is essential to appropriate management; the most clinically important distinction is differentiating mucinous lesions, which have malignant potential and may benefit from surgical resection, from non-mucinous cystic lesions. Endoscopic ultrasound with fine needle aspiration with cytologic, chemical,, and tumor marker analysis appears to be the best currently available method for accurately characterizing a cyst's malignant potential, and therefore impacts the most important management decision for a pancreatic cyst-continued surveillance or surgical resection.

Clinical evaluation, imaging studies, indications for cytologic study, and preprocedural requirements for duct brushing studies and pancreatic FNA: the Papanicolaou Society of Cytopathology recommendations for pancreatic and biliary cytology

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pancreaticobiliary cytology including indications for endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) biopsy, techniques for EUS-FNA, terminology and nomenclature to be used for pancreaticobiliary disease, ancillary testing, and post-biopsy management. All documents are based on expertise of the authors, literature review, discussions of the draft document at national and international meetings, and synthesis of online comments of the draft document. This document selectively presents the results of these discussions. This document summarizes recommendations for the clinical and imaging work-up of pancreatic and biliary tract lesions along with indications for cytologic study of these lesions. Prebrushing and FNA requirements are also discussed.

Multidisciplinary diagnostic and therapeutic approaches to pancreatic cystic lesions

Pancreatic cystic lesions are commonly encountered today with the routine use of cross-sectional imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI). The majority of patients discovered to have a pancreatic cyst are completely asymptomatic; yet the presence of such a finding instills fear in the minds of both patient and physician, as the concern for malignant transformation to pancreatic cancer is great despite the relatively low overall likelihood of cyst progression. Not all cysts in the pancreas represent pancreatic cystic neoplasms (PCNs), and not all PCNs have significant malignant potential. Mucinous PCNs are the most concerning, as these lesions have the greatest potential for cancerous transformation to adenocarcinoma. Within the group of mucinous PCNs, intraductal papillary mucinous neoplasms (IPMNs) involving the main pancreatic duct are the most worrisome, and surgical resection should be pursued if the patient has appropriate operative risks. IPMN lesions involving the branch ducts, and mucinous cystadenomas, have a lower likelihood for malignancy, and they may be closely followed for the development of any worrisome or high-risk features. Surveillance of known PCNs is performed with a combination of CT, MRI and endoscopic ultrasound (EUS). EUS-guided fine-needle aspiration (EUS-FNA) may be used to assess cyst fluid cytology, and also to detect cyst fluid amylase level, carcinoembryonic antigen level, and DNA molecular analysis in certain cases. The presence or absence of specific cyst morphological features, as well as the cyst fluid analysis, is what enables the physician to guide the patient towards continued surveillance, versus the pursuit of surgical resection.

Prediction of malignancy in cystic neoplasms of the pancreas: a population-based cohort study

OBJECTIVES

Pancreatic cystic neoplasms (PCNs) are being detected with increased frequency. The aims of this study were to determine the incidence of malignancy and develop an imaging-based system for prediction of malignancy in PCN.

METHODS

We conducted a retrospective cohort study of patients ≥18 years of age with confirmed PCN from January 2005 to December 2010 in a community-based integrated care setting in Southern California. Patients with history of acute or chronic pancreatitis were excluded. Malignancy diagnosed within 3 months of cyst diagnosis was considered as pre-existing. Subsequent incidence of malignancy during surveillance was calculated based on person-time at risk. Age- and gender-adjusted standardized incidence ratio (SIR) was calculated with the non-cyst reference population. Recursive partitioning was used to develop a risk prediction model based on cyst imaging features.

RESULTS

We identified 1,815 patients with confirmed PCN. A total of 53 (2.9%) of patients were diagnosed with cyst-related malignancy during the study period. The surveillance cohort consisted of 1,735 patients with median follow-up of 23.4 months. Incidence of malignancy was 0.4% per year during surveillance. The overall age- and gender-adjusted SIR for pancreatic malignancy was 35.0 (95% confidence level 26.6, 46.0). Using recursive partitioning, we stratified patients into low (<1%), intermediate (1-5%), and high (9-14%) risk of harboring malignant PCN based on four cross-sectional imaging features: size, pancreatic duct dilatation, septations with calcification as well as growth. Area under the receiver operator characteristic curve for the prediction model was 0.822 (training) and 0.808 (testing).

CONCLUSIONS

Risk of pancreatic malignancy was lower than previous reports from surgical series but was still significantly higher than the reference population. A risk stratification system based on established imaging criteria may help guide future management decisions for patients with PCN.

Treatment of pancreatic cystic neoplasm: surgery or conservative?

Pancreatic cystic neoplasms (PCNs) are a heterogeneous group of tumors with distinct biological features. These neoplasms are now being recognized more frequently owing to advances in cross-sectional imaging and increasing awareness. Guidelines for treatment of the common and clinically important PCNs frequently have been revised in view of the continuing controversies and evolving clinical data. This review summarizes the management approaches of the common and clinically important PCNs based on current evidence and guidelines.

Cyst carcinoembryonic antigen in differentiating pancreatic cysts: a meta-analysis

BACKGROUND

Using carcinoembryonic antigen in discriminating between benign and malignant disease remains controversial.

AIMS

We aim to evaluate the diagnostic accuracy of cyst fluid carcinoembryonic antigen in predicting malignant pancreatic cystic lesions.

METHODS

We performed a literature search of MEDLINE and EMBASE. We included studies that compared the diagnostic accuracy of carcinoembryonic antigen with histology. Pooled estimates of diagnostic precision were calculated using random-effects models.

RESULTS

Eight studies (504 patients) were included. The carcinoembryonic antigen cutoff level for determining a malignant cyst ranged from 109.9 to 6000 ng/mL. Pooled estimates of carcinoembryonic antigen in malignant cysts prediction were poor: pooled sensitivity of 63%, pooled specificity of 63%. The positive likelihood ratio was 1.89 and the negative likelihood ratio was 0.62. The diagnostic odds ratio was 3.84. The area under the summary receiver-operating characteristic curve was 0.70. In subgroup analysis of patients with mucinous cysts (mucinous cystic neoplasm and intraductal papillary mucinous neoplasm; 5 studies, 227 patients), pooled sensitivity was 65%, pooled specificity 66% and diagnostic odds ratio 4.74 respectively.

CONCLUSION

This meta-analysis suggests that the accuracy of carcinoembryonic antigen in differentiating "between benign and malignant" pancreatic cysts was poor. The decision to perform surgical resection for pancreatic cystic lesions should not be based solely on carcinoembryonic antigen level.

A review of pancreatic cyst fluid analysis in the differential diagnosis of pancreatic cyst lesions

Diagnosis and management of pancreatic cyst lesions is challenging as there is currently no investigation that offers both high diagnostic sensitivity and high specificity for the identification of potentially malignant lesions. Accurate classification of these lesions is vital in order to avoid unnecessary treatment of benign lesions and missed opportunities for early treatment of lesions that are malignant/pre-malignant. Pancreatic cyst fluid analysis has an important role in diagnosis, although all currently available investigations based on fluid analysis have significant limitations. Cytological analysis can reveal features that are specific for a certain class of cyst, but offers limited sensitivity in detecting malignant/pre-malignant cysts. Measurement of tumour markers, particularly carcinoembryonic antigen can also be informative. Concentrations of cyst fluid carcinoembryonic antigen tend to be higher in malignant/pre-malignant cysts, although there is a wide overlap between the various classes of cyst. A number of studies have suggested that diagnostic carcinoembryonic antigen cut-offs can be chosen that provide a high degree of specificity but limited sensitivity. Studies of the analytical validity of tumour marker assays in pancreatic cyst fluid analysis have highlighted discrepancies in some fluid specimens, which require further investigation. DNA analysis also has a role. In particular, K-Ras-2 mutational analysis appears to provide high specificity for detection of malignant/pre-malignant lesions. A number of diagnostic algorithms have been published, integrating use of available investigations in order to achieve the optimum discrimination of benign and potentially malignant cysts. Research into new biochemical markers and optimal use of available pancreatic cyst fluid analyses is ongoing.

Immunoprofile of mucinous non-neoplastic cyst of the pancreas

BACKGROUND

A recently described mucinous non-neoplastic cyst (MNNC) of the pancreas is a benign cyst and should be distinguished from mucinous cystic neoplasm (MCN) and intraductal papillary mucinous neoplasm (IPMN) due to different management and prognosis. The immunoprofile of MNNC has not been well studied.

DESIGN

Twenty-three MNNCs diagnosed on surgical resection were retrieved. Immunohistochemical (IHC) staining was performed on surgically resected specimen. Sixteen IPMN and 15 MCN cases were also retrieved for comparison. Cyst fluid carcinoembryonic antigen and amylase concentrations were retrieved.

RESULT

MNNCs were randomly located in the pancreas and were either unilocular or multilocular cysts that were lined by a single layer of bland columnar or cuboidal mucinous cells and supported by paucicellular stroma. The glandular epithelial cells were diffusely positive for CK7 (100%) and PDX-1 (65%); focally positive for CD10 (superficial, 65%), CD99 (basally, 100%), CDX-2 (17%), and CK20 (4%); and negative for MUC2. Only rare stromal cells in the cyst wall were weakly positive for estrogen receptor or progesterone receptor in only 6% of cases and negative for inhibin. These results were also compared with the immunoprofile of IPMN and MCN.

CONCLUSIONS

Although MNNC shares some IHC markers with IPMN or MCN, an IHC panel can help distinguish MNNC from IPMN or MCN. The results suggest that MNNC is different from IPMN and MCN.

European experts consensus statement on cystic tumours of the pancreas

Cystic lesions of the pancreas are increasingly recognized. While some lesions show benign behaviour (serous cystic neoplasm), others have an unequivocal malignant potential (mucinous cystic neoplasm, branch- and main duct intraductal papillary mucinous neoplasm and solid pseudo-papillary neoplasm). European expert pancreatologists provide updated recommendations: diagnostic computerized tomography and/or magnetic resonance imaging are indicated in all patients with cystic lesion of the pancreas. Endoscopic ultrasound with cyst fluid analysis may be used but there is no evidence to suggest this as a routine diagnostic method. The role of pancreatoscopy remains to be established. Resection should be considered in all symptomatic lesions, in mucinous cystic neoplasm, main duct intraductal papillary mucinous neoplasm and solid pseudo-papillary neoplasm as well as in branch duct intraductal papillary mucinous neoplasm with mural nodules, dilated main pancreatic duct >6mm and possibly if rapidly increasing in size. An oncological partial resection should be performed in main duct intraductal papillary mucinous neoplasm and in lesions with a suspicion of malignancy, otherwise organ preserving procedures may be considered. Frozen section of the transection margin in intraductal papillary mucinous neoplasm is suggested. Follow up after resection is recommended for intraductal papillary mucinous neoplasm, solid pseudo-papillary neoplasm and invasive cancer.

Pancreatic cystic neoplasms: a review of preoperative diagnosis and management

Pancreatic cystic neoplasms (PCNs) are a diverse group of neoplasms in the pancreas, and are more increasingly encountered with widespread abdominal screening and improved imaging techniques. The most common types of PCNs are serous cystic neoplasms (SCNs), mucinous cystic neoplasms (MCNs), and intraductal papillary mucinous neoplasms (IPMNs). Clinicians frequently feel bewildered in the differential diagnosis and subsequent management among the various types of lesions in the pancreas, which may lead to overtreatment or delayed treatment. The current review provides recent developments in the understanding of the three most common types of PCNs, the latest modalities used in preoperative diagnosis and differential diagnosis, as well as the most up to date management. Suggestions for diagnosis and differential diagnosis of SCNs, MCNs, and IPMNs are also provided for young surgeons. Better understanding of these neoplasms is essential for clinicians to make accurate diagnosis and to provide the best management for patients.

Imaging of indeterminate pancreatic cystic lesions: a systematic review

BACKGROUND

Pancreatic cystic lesions are an increasing problem and investigation of these cysts can be fraught with difficulty. There is currently no gold standard for diagnosis or surveillance. This review was undertaken to determine the present reliability of the characterisation, assessment of malignant potential and diagnosis of pancreatic cystic lesions using available imaging modalities.

METHODS

A Medline search using the terms 'pancreatic', 'pancreas', 'cyst', 'cystic', 'lesions', 'imaging', 'PET'. 'CT', 'MRI' and 'EUS' was performed. Publications were screened to include studies examining the performance of CT, MRI, MRCP, EUS and 18-FDG PET in the determination of benign or malignant cysts, cyst morphology and specific diagnoses.

RESULTS

Nineteen studies were identified that met the inclusion criteria. 18-FDG PET had a sensitivity and specificity of 57.0-94.0% and 65.0-97.0% and an accuracy of 94% in determining benign versus malignant cysts. CT had a sensitivity and specificity of 36.3-71.4% and 63.9-100% in determining benign disease but had an accuracy of making a specific diagnosis of 39.0-44.7%. MRI had a sensitivity and specificity of 91.4-100.0% and 89.7% in assessing main pancreatic duct communication.

CONCLUSION

CT is a good quality initial investigation to be used in conjunction with clinical data. MRCP can add useful information regarding MPD communication but should be used judiciously. PET may have a role in equivocal cases to determine malignancy. Further examination of CT-PET in this patient group is warranted.

Clinical decision making in the management of pancreatic cystic neoplasms

Pancreatic cystic lesions continue to pose diagnostic and management dilemmas for physicians. This may be related, in part, to the fact that these lesions represent a range of diagnostic possibilities, from inflammatory cysts and nonmucinous cysts to mucinous cysts, which may or may not have foci of invasive malignancy. Adequate characterization of cystic lesions is necessary to help devise a management plan. Moreover, patient-related factors such as comorbid conditions are often essential in deciding whether patients should be managed by a conservative approach of watchful waiting versus surgical resection, if so indicated. This review summarizes the recent advances in the management of pancreatic cystic neoplasms.

Should we do EUS/FNA on patients with pancreatic cysts? The incremental diagnostic yield of EUS over CT/MRI for prediction of cystic neoplasms

OBJECTIVES

To evaluate the performance characteristics of endoscopic ultrasonography (EUS) compared with computed tomography (CT) and magnetic resonance imaging (MRI) and determine the incremental diagnostic yield and accuracy of EUS with or without fine needle aspiration (FNA) over CT and MRI for prediction of neoplastic pancreatic cysts.

METHODS

The EUS database was queried for procedures performed for pancreatic cysts between March 2006 and January 2010. Cystic pancreatic ductal adenocarcinoma, cystic pancreatic neuroendocrine tumor, mucinous cystic neoplasm, intraductal papillary neoplasm, and solid pseudopapillary neoplasm were categorized as neoplastic; pseudocysts and serous cysts were designated as nonneoplastic/low risk.

RESULTS

Final diagnoses were established by surgery in 154 patients (mucinous cystic neoplasm/intraductal papillary neoplasm [69.4%], pancreatic neuroendocrine tumor [10%], pancreatic ductal adenocarcinoma [6.4%], solid pseudopapillary neoplasm [0.6%], nonneoplastic/low risk [13.6%]). Endoscopic ultrasonography with or without FNA was superior to CT and MRI in accurately classifying a cyst as neoplastic (P < 0.0001). After CT and MRI, EUS increased the rate of correctly predicting neoplastic cysts in 43 (36%) and 27 (54%) additional cases, respectively.

CONCLUSIONS

The incremental increase in diagnostic yield of EUS and fluid analysis over CT and MRI for prediction of a neoplastic cyst is 36% and 54%, respectively. The addition of EUS-FNA to abdominal imaging significantly increases overall accuracy for diagnosis of neoplastic pancreatic cysts.

Preoperative classification of pancreatic cystic neoplasms: the clinical significance of diagnostic inaccuracy

BACKGROUND

The potential for malignant transformation varies among pancreatic cystic neoplasms (PCN) subtypes. Imaging and cyst fluid analysis are used to identify premalignant or malignant cases that should undergo operative resection, but the accuracy of operative decision-making process is unclear. The objective of this study was to characterize misdiagnoses of PCN and determine how often operations are undertaken for benign, non-premalignant disease.

METHODS

A retrospective analysis of patients undergoing pancreatic resection for the preoperative diagnosis of PCN was undertaken. Preoperative and pathological diagnoses were compared to measure diagnostic accuracy.

RESULTS

Between 1999 and 2011, 74 patients underwent pancreatic resection for the preoperative diagnosis of PCN. Preoperative classification of mucinous vs. non-mucinous PCN was correct in 74%. The specific preoperative PCN diagnosis was correct in 47%, but half of incorrect preoperative diagnoses were clinically equivalent to the pathological diagnoses. The likelihood that the pathological diagnosis was of higher malignant potential than the preoperative diagnosis was 7%. In 20% of cases, the preoperative diagnosis was premalignant or malignant, but the pathological diagnosis was benign. Diagnostic accuracy and the rate of undercall diagnoses and overcall operations did not change with the use of EUS or during the time period of this analysis.

CONCLUSIONS

Precise, preoperative classification of PCN is frequently incorrect but results in appropriate clinical decision-making in three-quarters of cases. However, one in five pancreatic resections performed for PCN was for benign disease with no malignant potential. An appreciation for the rate of diagnostic inaccuracies should inform our operative management of PCN.

Cystic neoplasms of the pancreas

Pancreatic cysts are being identified with increasing frequency due to a combination of increased awareness and more frequent use of cross sectional imaging. Cystic neoplasms of the pancreas range from completely benign to frankly malignant. Identifying pre-malignant cysts offers the opportunity to prevent the development of pancreatic cancer. This article reviews the presentation, workup, and non-operative and operative management of premalignant and malignant pancreatic cysts.

Association between KRAS mutation, detected in pancreatic cyst fluid, and long-term outcomes of patients

BACKGROUND & AIMS

Endoscopic ultrasound (EUS) with fine-needle aspiration is routinely used to evaluate pancreatic cysts. We investigated the association between results from DNA analysis of cyst fluid and patient outcomes.

METHODS

In a retrospective analysis, we collected data from 113 patients with pancreatic cysts who underwent EUS with fine-needle aspiration at a tertiary care center from June 2004 to June 2007. Detailed follow-up data were obtained through October 2010 (mean, 47 months). Pancreatic cysts were categorized as nonbenign or benign on the basis of pathology analysis of surgical samples and patients' outcomes. We compared the patient characteristics, presenting symptoms, EUS imaging characteristics, and results from analysis of cyst fluid, including cytology results, levels of carcinoembryonic antigen, and DNA sequencing results.

RESULTS

Fifty-one patients underwent pancreatic surgery (10 had malignant, 18 had mucinous, and 16 had benign cysts), 63 patients were followed long-term, and 13 patients died of pancreatic cancer. On the basis of multivariate regression analysis, the presence of cyst solid component, patient symptoms, cyst size >3 cm, and detection of KRAS mutations at codons 12 and 13 in cyst fluid were independently associated with a nonbenign course.

CONCLUSIONS

KRAS mutations, detected in pancreatic cyst fluid, are associated with mucinous cysts and progression and development of malignancy and should be considered in assessing pancreatic cysts. The presence of a cyst solid component, patient symptoms, and cyst size greater than 3 cm were additional high-risk factors for a malignant course of disease.

Dramatic Survival Benefit Related to R0 Resection of Pancreatic Adenocarcinoma in Patients With Tumor ≤25 mm in Size and ≤1 Involved Lymph Nodes

OBJECTIVES:

To evaluate i) the relative importance of R0 resection, tumor size and peripancreatic lymph node (LN) status are significant determinants of survival benefit following upfront surgery for pancreatic adenocarcinoma (PaCa), ii) whether R0 resection confers survival benefit in all patients or a patient subset with certain favorable prognostic factors.

METHODS:

Retrospective analysis of patients (2001–2010) who underwent planned potentially curative surgical resection without neoadjuvant therapy for PaCa.

RESULTS:

Among 154 patients, median survival following R0 (n=105) and R1 resections was 26.8 and 17.7 months, respectively (P=0.010). Tumor size and LN status were significant determinants of survival following R0 resection. There were no differences in survival based on tumor size and LN in patients with R1 resection. Median survival was 17.7 months following R1 resection and was 70.9 months (P<0.001) and 22.2 months (P=0.44) in patients with tumor ≤25 mm in size and ≤1 involved LN and in the remaining patients in the cohort respectively following R0 resection.

CONCLUSIONS:

R0 resection is associated with dramatic survival benefit over R1 resection in a subset of patients with tumor size ≤25 mm and ≤1 involved LN. These findings underscore the importance of R0 resection and careful patient selection for upfront surgery in patients with PaCa.

Cystic and ductal tumors of the pancreas: diagnosis and management

Incidentally discovered cystic tumors of the pancreas (CTP) are an increasingly frequent entity. It is essential to differentiate lesions whose malignant potential is either nil or negligible (pseudocyst, serous cystadenoma, simple cysts) from lesions with intermediate malignant potential (intraductal papillary mucinous tumor of the pancreas [IPMN] involving the secondary ducts, cystic endocrine tumor) or those with high malignant potential (mucinous cystadenoma, solid pseudopapillary tumors and IPMN involving the main pancreatic duct). The approach to defining malignant potential is based on diagnostic CT scan, magnetic resonance imaging (MRI), and endoscopic ultrasound (EUS), often complemented by EUS-guided cyst puncture for biochemical and cytological analysis of cyst fluid. Surgery for diagnostic purposes should be avoided because of its significant morbidity. For pseudocysts, simple cysts and serous cystadenomas, abstention is the general rule. Resection, preserving as much pancreatic parenchyma as possible, is the rule for IPMN involving the main pancreatic duct, mucinous cystadenomas, solid and pseudopapillary tumors, and cystic endocrine tumors. Resection is rarely indicated at the outset for IPMN involving secondary pancreatic ducts; morphologic observation is the general rule and preventive excision may be indicated secondarily. Good collaboration between surgeons, radiologists and endosonographists is necessary for optimal management of CTP.

Pancreatic cystic neoplasms: predictors of malignant behavior and management

BACKGROUND/AIM

Pancreatic cystic neoplasms are being increasingly identified with the widespread use of advanced imaging techniques. In the absence of a good radiologic or pathologic test to preoperatively determine the dianosis, clinical characteristics might be helpful. The objectives of this analysis were to define the incidence and predictors of malignancy in pancreatic cysts.

PATIENTS AND METHODS

Patients with true pancreatic cysts who were treated at our institution were included. Patients with documented pseudocysts were excluded. Demographic data, clinical manifestations, radiological, surgical, and pathological records of those patients were reviewed.

RESULTS

Eighty-one patients had true pancreatic cyst. The mean age was 47 ± 15.5 years. There were 28.4% serous cystadenoma, 21% mucinous cystadenoma, 6.2% intraductal papillary tumors, 8.6% solid pseudopapillary tumors, 1.2% neuroendocrinal tumor, 3.7% ductal adenocarcinoma, and 30.9% mucinous cystadenocarcinoma. Malignancy was significantly associated with men (P = 0.04), older age (0.0001), cysts larger than 3 cm in diameter (P = 0.001), presence of solid component (P = 0.0001), and cyst wall thickening (P = 0.0001). The majority of patients with malignancy were symptomatic (26/28, 92.9%). The symptoms that correlated with malignancy included abdominal pain (P = 0.04) and weight loss (P = 0.0001). Surgical procedures were based on the location and extension of the lesion.

CONCLUSION

The most common pancreatic cysts were serous and mucinous cysts. These tumors were more common in females. Old age, male gender, large tumor, presence of solid component, wall thickness, and presence of symptoms may predict malignancy in the cyst.

Fine needle aspiration cytomorphology of mucinous nonneoplastic cyst of the pancreas

OBJECTIVES

Fine needle aspiration (FNA) cytomorphology of mucinous nonneoplastic cyst (MNNC) of the pancreas has not been described.

METHODS

Nineteen of 24 patients with surgically diagnosed MNNCs had presurgery endoscopic ultrasound (EUS)-FNA biopsy. The FNA cytomorphology was retrospectively evaluated. Cyst fluid carcinoembryonic antigen and amylase concentrations were measured.

RESULTS

Endoscopic US-FNA diagnoses ranged from unsatisfactory to suspicious for adenocarcinoma. Endoscopic US-FNA cytologic findings showed cuboidal or columnar cells arranged in flat 'honeycomb' sheets/nests (100.0%), papillary architecture (10.5%), acini formation (10.5%), 3-dimensional cluster (5.3%), abundant single cell pattern (5.3%), goblet cells (17.4%), and delicate or vacuolated (60.9%) cytoplasm variable in amount. Nuclei were round or oval and small to slightly enlarged with 1 or 2 inconspicuous nucleoli, fine granular chromatin, and smooth nuclear contour (irregular in 1 case). Nuclear grooves (43.5%) and nuclear pseudoinclusions (26.1%) were identified. Most cases showed thin mucin and thick mucin in 4 cases. Stroma was seen in 4 cases (17.4%). Degenerated cells/necrotic material and macrophages were also seen. Carcinoembryonic antigen ranged from 75.2 to 5,488 ng/ml and amylase from 19 to 28,478 U/L.

CONCLUSIONS

Recognition of FNA cytomorphology of MNNC and valuable of carcinoembryonic antigen and amylase levels in cyst fluid is critical in clinical evaluation of pancreatic cysts.

Commercial molecular panels are of limited utility in the classification of pancreatic cystic lesions

The PathfinderTG biomarker panel is useful in the evaluation of pancreatic cysts that have clinical features suspicious for malignancy, but its utility in classifying fine-needle aspiration biopsies from small pancreatic cystic lesions is yet to be proven. We used morphology to classify 20 pancreatic cyst cytology aspirates, all of which met radiographic criteria for close observation. Cases were cytologically classified as consistent with pseudocyst, serous cystadenoma, or mucinous neoplasm with low-grade, intermediate-grade, or high-grade dysplasia and analyzed for carcinoembryonic antigen. Redpath Integrated Pathology Inc. rendered diagnoses of nonmucinous (reactive/indolent or serous) or mucinous (low-risk or at risk) cyst on the basis of results of the PathfinderTG panel (KRAS mutations, DNA content, and loss of heterozygosity at microsatellites linked to tumor suppressor genes). Cytologic and commercial laboratory diagnoses were concordant in only 7 (35%) cases. Seven cysts classified as mucinous with low-grade dysplasia by cytology were interpreted as nonmucinous on the basis of the PathfinderTG panel, 2 of which were resected mucinous cysts. Two pancreatitis-related pseudocysts were misdiagnosed as low-risk mucinous cysts; 1 mucinous cyst with low-grade dysplasia was considered at risk for neoplastic progression using the PathfinderTG panel. Only 1 cyst misclassified as pseudocyst by cytology, but low-risk mucinous cyst by molecular analysis, proved to be a mucinous cystic neoplasm with low-grade dysplasia after surgical resection. We conclude that the PathfinderTG panel may aid the classification of pancreatic lesions, but is often inaccurate and should not replace cytologic evaluation of these lesions.

Duodenum-preserving total pancreatic head resection for benign cystic neoplastic lesions

BACKGROUND

Cystic neoplasms of the pancreas are diagnosed frequently due to early use of abdominal imaging techniques. Intraductal papillary mucinous neoplasm, mucinous cystic neoplasm, and serous pseudopapillary neoplasia are considered pre-cancerous lesions because of frequent transformation to cancer. Complete surgical resection of the benign lesion is a pancreatic cancer preventive treatment.

OBJECTIVES

The application for a limited surgical resection for the benign lesions is increasingly used to reduce the surgical trauma with a short- and long-term benefit compared to major surgical procedures. Duodenum-preserving total pancreatic head resection introduced for inflammatory tumors in the pancreatic head transfers to the patient with a benign cystic lesion located in the pancreatic head, the advantages of a minimalized surgical treatment.

PATIENTS

Based on the experience of 17 patients treated for cystic neoplastic lesions with duodenum-preserving total pancreatic head resection, the surgical technique of total pancreatic head resection for adenoma, borderline tumors, and carcinoma in situ of cystic neoplasm is presented. A segmental resection of the peripapillary duodenum is recommended in case of suspected tissue ischemia of the peripapillary duodenum. In 305 patients, collected from the literature by PubMed search, in about 40% of the patients a segmental resection of the duodenum and 60% a duodenum and common bile duct-preserving total pancreatic head resection has been performed.

RESULTS

Hospital mortality of the 17 patients was 0%. In 305 patients collected, the hospital mortality was 0.65%, 13.2% experienced a delay of gastric emptying and a pancreatic fistula in 18.2%. Recurrence of the disease was 1.5%. Thirty-two of 175 patients had carcinoma in situ.

CONCLUSION

Duodenum-preserving total pancreatic head resection for benign cystic neoplastic lesions is a safe surgical procedure with low post-operative morbidity and mortality.

Interdisciplinary management of cystic neoplasms of the pancreas

Cystic neoplasms of the pancreas are increasingly recognized due to the frequent use of abdominal imaging. It is reported that up to 20% of abdominal cross-sectional scans identify incidental asymptomatic pancreatic cysts. Proper characterization of pancreatic cystic neoplasms is important not only to recognize premalignant lesions that will require surgical resection, but also to allow nonoperative management of many cystic lesions that will not require resection with its inherent morbidity. Though reliable biomarkers are lacking, a wide spectrum of diagnostic modalities are available to evaluate pancreatic cystic neoplasms, including radiologic, endoscopic, laboratory, and pathologic analysis. An interdisciplinary approach to management of these lesions which incorporates recent, specialty-specific advances in the medical literature is herein suggested.

Carcino Embryonic Antigen and long-term follow-up of mucinous pancreatic cysts including intraductal papillary mucinous neoplasm

BACKGROUND AND AIMS

The utility of Carcino Embryonic Antigen (CEA) in differentiating malignant from benign pancreatic cysts is controversial. We sought to examine the role of CEA in differentiating benign from malignant cysts and its utility in progression of cyst size in follow-up.

METHODS

Retrospective chart review of patients who underwent Endoscopic Ultrasound with Fine Needle Aspiration for mucinous cysts between 1998 and 2010. CEA was measured in benign and malignant mucinous cysts. Coefficient of determination (R(2)) was used to measure the association between change in cyst size and CEA. Mann-Whitney test was used to compare the median values of CEA.

RESULTS

143 patients (38.4% males) were included (mean age 68.9 ± 0.8 years). 105 patients had intra-cystic CEA measured. 63 patients underwent surgery while 80 patients were in the follow-up group. In the surgical group, median CEA value for benign and malignant mucinous neoplasms was 796 and 438 ng/ml, respectively (p=0.79). The median follow-up was 21 months. There was no correlation between CEA level and progression in cyst size in patients who had >6 months of follow-up, R(2)=0.0002. Malignant transformation was observed in 5 (5.9%) patients.

CONCLUSION

CEA level was not predictive of malignant cyst nor cyst size progression over follow-up.

Advances in the diagnosis of cystic neoplasms of the pancreas

PURPOSE OF REVIEW

Management of pancreatic cystic neoplasms is challenging due to limitations of current diagnostic tests. There is considerable interest in developing an accurate and cost-effective diagnostic test (or panel of tests) to differentiate cyst types and to identify those which would benefit most from surgical resection.

RECENT FINDINGS

Current multidetector computed tomography scans may have improved accuracy to distinguish between mucinous and nonmucinous cysts. Attempts to generate quantitative criteria from cross-sectional imaging to differentiate cyst types have yielded mixed results. DNA mutations and microRNA show promise in the ability to distinguish between mucinous and nonmucinous cysts. Cyst fluid mucin glycoproteins and cytokines may identify those cysts with high malignant potential. Proteomic analysis may yield other biomarker candidates.

SUMMARY

Analysis of DNA mutations and proteins within pancreatic cyst fluid have identified potential biomarkers to aid with the management of patients with pancreatic cystic neoplasms.

[Radiological evaluation of intraductal papillary mucinous neoplasm]

The intraductal papillary mucinous neoplasm (IPMN) is the most frequent cystic neoplasm of the pancreas. Due to the widespread use of cross-sectional imaging IPMN is being incidentally recognized with increasing frequency. The most common type is branch- duct IPMN which occurs multifocally in about 20-30%. Patients with IPMN may present with symptoms resembling chronic pancreatitis and episodes of acute pancreatitis are increasingly being reported which usually have a mild course. The most important diagnostic technique is contrast-enhanced multidetector computed tomography (MDCT), which most frequently allows the differentiation from other cystic lesions and enables the attribution to branch duct or main duct IPMN. Magnetic resonance imaging (MRI) in combination with magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound are superior in depicting the fine architecture of cystic tumors. Particularly for evaluation of malignant transformation and extent of malignant disease, high resolution imaging is essential. Whereas main duct IPMN is an indication for resection therapy for small and asymptomatic branch duct IPMN periodic surveillance at 6-12 month intervals is recommended.

[Strategy in intraductal papillary mucinous neoplasm of the pancreas]

Intraductal papillary mucinous neoplasm (IPMN) is a premalignant pancreatic entity characterized by papillary growth of the ductal epithelium with rich mucin production and cystic dilatation of the main pancreatic duct and/or its branches. These neoplasms are often multifocal. Preoperative distinction between benign and malignant lesions is important to select the most appropriate treatment and to improve prognosis. Early surgical resection is the treatment of choice to avoid malignant transformation when predictive factors for malignancy are present. These factors include localization, cyst greater than 3cm, nodules in the cystic wall, atypias in the cyst fluid and the presence of symptoms. The extent of resection required for adequate treatment of IPMN of the pancreas is still controversial. Patients who retain a portion of their pancreas following resection of an IPMN need to be followed up with periodic imaging to detect recurrences, signs indicating a risk of malignant transformation, and metachronous lesions. The existence of possible synchronous or metachronous lesions in other organs should also be investigated.

Pancreatic cystic lesions: How endoscopic ultrasound morphology and endoscopic ultrasound fine needle aspiration help unlock the diagnostic puzzle

Cystic lesions of the pancreas are being diagnosed with increasing frequency, covering a vast spectrum from benign to malignant and invasive lesions. Numerous investigations can be done to discriminate between benign and non-evolutive lesions from those that require surgery. At the moment, there is no single test that will allow a correct diagnosis in all cases. Endoscopic ultrasound (EUS) morphology, cyst fluid analysis and cytohistology with EUS-guided fine needle aspiration can aid in this difficult diagnosis.

Inflammatory protein profiling of pancreatic cyst fluid using EUS-FNA in tandem with cytokine microarray differentiates between branch duct IPMN and inflammatory cysts

BACKGROUND

Diagnosis of pancreatic cystic neoplasms remains problematic. We hypothesize that inflammatory mediator proteins in pancreatic cyst fluid can differentiate branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) and pancreatic inflammatory cysts. We aim to 1) detect inflammatory mediator proteins (IMPs) using a multiplexed IMP-targeted microarray in pancreatic cyst fluid obtained during endoscopic ultrasound fine needle aspiration (EUS-FNA) and 2) compare IMP profiles in pancreatic cyst fluid from BD-IPMNs and inflammatory cysts. Pancreatic cyst fluid from ten patients (5 BD-IPMN and 5 inflammatory cysts) was obtained by EUS-FNA and analyzed directly with a multiplexed microarray assay to determine concentrations of 89 IMPs. Statistical analysis was performed using non-parametric methods.

RESULTS

Eighty-three of the 89 assayed IMPs were detected in at least one of the 10 patient samples. Seven IMPs were detected in BD-IPMN but not inflammatory cysts, while eleven IMPs were identified in inflammatory cysts but not BD-IPMN. Notably, granulocyte-macrophage colony-stimulating factor (GM-CSF) expression was present in all five inflammatory cyst samples. Hepatocyte growth factor (HGF) was present in significantly higher concentrations in inflammatory cysts compared to BD-IPMN.

CONCLUSION

Our exploratory analysis reveals that GM-CSF and HGF in EUS-FNA-collected pancreatic cyst fluid can distinguish between BD-IPMN and inflammatory cyst. Coupling microarray molecular techniques to EUS-FNA may represent a major step forward to our understanding complex pancreatic disease.

An unusual cause of dyspareunia

Pancreatic pseudocyst is a complication of acute pancreatitis and it usually manifests with abdominal pain. We report the case of a 45-year-old man with a history of acute pancreatitis who presented with abdominal pain, dyspareunia, and a palpable inguinal mass. Computed tomography scan revealed a large loculated pseudocyst that dissected through the pelvic cavity towards the inguinal canal, compressing pelvic and inguinal structures. When a patient with a history of pancreatitis develops an inguinal mass, a dissecting pancreatic pseudocyst should be suspected.

Diffusion-weighted MRI of focal cystic pancreatic lesions at 3.0-Tesla: preliminary results

PURPOSE

To determine the utility of 3.0-Tesla diffusion-weighted (DW) magnetic resonance imaging (MRI) for focal cystic pancreatic lesion (FCPL) characterization.

MATERIALS AND METHODS

55 FCPL (34 IPMN, 5 serous cystadenoma, and 16 inflammatory) were evaluated. Two radiologists reviewed in consensus DW-MRI images. Reference standard was obtained from patient history, cytological and histopathology data, FCPL fluid analysis, and follow-up imaging results. Signal intensity (SI) and apparent diffusion coefficient values (ADC) of FCPL and normal pancreas were measured. FCPL-to-pancreas SI and ADC ratios were also calculated.

RESULTS

Qualitatively, 11 of 21 non-mucinous vs. 4 of 34 mucinous lesions appeared hyperintense at b value of 1,000 s/mm(2) (P = 0.02). Three FCPL demonstrated restricted diffusion: all inflammatory. Significant differences in mean ADC between neoplastic vs. non-neoplastic (P = 0.009), and mucinous vs. non-mucinous (P = 0.013) lesions were demonstrated. FCPL-to-pancreas ADC and SI ratios demonstrated significant differences between neoplastic vs. non-neoplastic lesions [ADC, (P = 0.019); SI for b values 750 (P = 0.010) and 1,000 s/mm(2) (P = 0.017)] and mucinous vs. non-mucinous lesions [ADC (P = 0.018); SI for b values 750 (P = 0.013) and 1,000 s/mm(2) (P = 0.015)].

CONCLUSION

Although mean ADC values and FCPL-to-pancreas SI and ADC ratios may be helpful in differentiating FCPL, characterization of individual FCPL by means of 3.0-Tesla DW-MRI appears limited.

A giant pancreatic pseudocyst in a patient with HIV infection

This article describes the first case of a giant pancreatic pseudocyst in a 48-year-old man with HIV infection under combination antiretroviral therapy. The patient presented with an abdominal mass involving the epigastrium, left hypochondrium, and left flank. An enhanced abdominal computed tomography (CT) scan showed a well-defined cyst of 21 cm in diameter, with a liquid content that dislocated adjacent viscera. Microbiological and cytological tests on fluid were negative, confirming diagnosis of pancreatic pseudocyst. The CT-guided percutaneous drainage was carried out and the patient's clinical condition gradually improved.

Endoscopic ultrasound-guided pancreatic cyst ablation

Pancreatic cystic neoplasms represent a wide spectrum of invariably benign to precancerous and malignant tumors. Endoscopic ultrasound-guided pancreatic cyst ablation with ethanol and/or paclitaxel offers a nonoperative treatment for patients refusing or not eligible for surgery. Histopathology after resection in these patients has shown variable degrees of cyst epithelial ablation ranging from 0% to 100%. Future research investigating the safety of this procedure, modifications of reported ablation techniques, choice and number of the lavage agents used, and criteria to optimize selection of the appropriate pancreatic cysts for treatment is needed.

Clinical implications of mucinous nonneoplastic cysts of the pancreas

OBJECTIVES

An undercharacterized subclass of pancreatic mucinous cysts without histologic characteristics of neoplasia is emerging. This article aimed to highlight the clinical characteristics and implications of this new subset of pancreatic cystic lesions.

METHODS

The clinical, radiologic, and pathologic features of all cysts that underwent operative resection at a tertiary referral pancreatic disease center from February 2005 to June 2009 were reviewed. Immunohistochemistry for mucinous peptide antigens was selectively performed.

RESULTS

Of 104 operations, a pathologic examination revealed 52 intraductal papillary mucinous neoplasms, 9 mucinous cystadenomas, 17 serous cystadenomas, 9 pseudocysts, 5 solid pseudopapillary tumors, 2 carcinomas, 1 cystic pancreatic endocrine tumor, and 2 other cystic lesions. Seven mucinous cysts without neoplastic features were identified, representing 2% of all pancreatic resections, 6.7% of all resected cysts, and 10.3% of the 68 mucinous cysts. There was no evidence of cytologic atypia, papillary growth, or ovarian-type stroma in any of the cases. MUC1, MUC2, and MUC5AC were expressed in 83%, 0%, and 100%, respectively. There has been no recurrence with a mean follow-up of 44 months.

CONCLUSIONS

This underappreciated entity belongs to the family of mucinous pancreatic cysts. However, unifying clinical characteristics that would prevent unnecessary resections in patients harboring these seemingly benign lesions are currently lacking.

Endoscopic ultrasonography-guided fine-needle aspiration of pancreatic cystic lesions: a practical approach to diagnosis and management

The diagnosis and management of pancreatic cystic lesions remains a challenging area in gastroenterology. Differentiating benign from premalignant or premalignant from malignant cysts is complicated by the large overlap in morphologic, chemical, and clinical characteristics. Imaging alone is insufficient to accurately characterize these lesions. Cyst aspiration and fluid analysis has therefore become a major research focus through which our ability to characterize pancreatic cystic lesions has improved, although accuracy is often still lacking. Future work with molecular analysis of cyst fluid, direct cystoscopy, and confocal laser endomicroscopy will likely further enhance the diagnostic accuracy of these lesions.

Cystic tumors of the pancreas: imaging and management

Cystic tumors of the pancreas are a subset of rare pancreatic tumors that vary from benign to malignant. Many have specific imaging findings that allow them to be differentiated from each other. This article (1) reviews the imaging features of the common cystic pancreatic lesions, including serous microcystic adenoma, mucinous cystic tumor, intraductal papillary mucinous tumor, and solid pseudopapillary tumor, and including the less common lesions such as cystic endocrine tumors, cystic metastases, cystic teratomas, and lymphangiomas; and (2) provides comprehensive algorithms on how to manage the individual lesions, with recommendations on when to reimage patients.

Intraductal papillary mucinous neoplasm of the oesophagus: an unusual case of dysphagia

We report the case of a 58-year-old woman presenting with dysphagia secondary to an intraductal papillary mucinous neoplasm arising from a heterotopic pancreas in the oesophageal wall. This was successfully treated with a laparoscopic/thoracoscopic ivor Lewis oesophagectomy. Dysphagia is the most common symptom of oesophageal tumours regardless of aetiology of the tumour and can be treated successfully with surgical resection. Through an extensive search of the literature, we found that a heterotopic pancreas in the oesophagus is extremely rare with only ten cases being reported. We describe what we believe to be the first case of a heterotopic pancreas in the oesophagus transforming into an intraductal papillary mucinous neoplasm.