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Ohno E, Balduzzi A, Hijioka S, De Pastena M, Marchegiani G, Kato H, Takenaka M, Haba S, Salvia R. Association of high-risk stigmata and worrisome features with advanced neoplasia in intraductal papillary mucinous neoplasms (IPMN): A systematic review. Pancreatology 2024; 24:48-61. [PMID: 38161091 DOI: 10.1016/j.pan.2023.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/24/2023] [Accepted: 12/03/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND This systematic review aimed to assess the diagnostic accuracy of the International Consensus Fukuoka Guidelines (ICG2017) in identifying high-risk lesions of Intraductal Papillary Mucinous Neoplasms (IPMNs). METHODS The ICG2017 revision committee conducted a comprehensive literature review to establish evidence-based statements on IPMNs. The review focused on articles examining the diagnostic value of imaging features (e.g., cyst or main pancreatic duct diameter), clinical symptoms associated with IPMN, and serum biomarkers. Five clinical questions regarding high-risk stigmata (HRS) and worrisome features (WF) in the ICG2017 guidelines were addressed. RESULTS A total of 210 articles were reviewed. The findings revealed a significant association between the presence of mural nodules ≥5 mm in diameter or solid components with contrast enhancement and the diagnosis of high-grade dysplasia or invasive carcinoma. Contrast-enhanced diagnostic tools, such as CT, MRI, or EUS, demonstrated the highest prediction rate and were recommended. Positive cytology was identified as an HRS, while symptoms like acute pancreatitis and cyst diameter growth ≥2.5 mm per year were considered WFs. The use of nomograms and multiple diagnostic factors was recommended for optimal IPMN management. CONCLUSIONS This systematic review provides evidence supporting the improved diagnostic accuracy of ICG2017 in identifying high-risk lesions of IPMN. The multidisciplinary incorporation of HRS and WF based on imaging findings and clinical symptoms is crucial. These findings should inform the revision of ICG2017, enhancing the evaluation and management of IPMN patients. By implementing these recommendations, clinicians can make more informed decisions, leading to better diagnosis and treatment outcomes for high-risk IPMN cases.
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Affiliation(s)
- Eizaburo Ohno
- Fujita Health University, Department of Gastroenterology and Hepatology, Japan; Nagoya University Hospital, Department of Gastroenterology and Hepatology, Japan
| | - Alberto Balduzzi
- The Pancreas Institute Verona, Unit of General and Pancreatic Surgery Department of Surgery, Dentistry, Paediatrics and Gynaecology University of Verona, Italy
| | - Susumu Hijioka
- National Cancer Center Hospital, Department of Hepatobiliary and Pancreatic Oncology, Japan
| | - Matteo De Pastena
- The Pancreas Institute Verona, Unit of General and Pancreatic Surgery Department of Surgery, Dentistry, Paediatrics and Gynaecology University of Verona, Italy
| | - Giovanni Marchegiani
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences (DISCOG), University of Padua, Padua, Italy
| | - Hironari Kato
- Okayama University Hospital, Department of Gastroenterology and Hepatology, Japan
| | - Mamoru Takenaka
- Kindai University, Department of Gastroenterology and Hepatology, Japan
| | - Shin Haba
- Aichi Cancer Center Hospital, Department of Gastroenterology, Japan
| | - Roberto Salvia
- The Pancreas Institute Verona, Unit of General and Pancreatic Surgery Department of Surgery, Dentistry, Paediatrics and Gynaecology University of Verona, Italy.
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2
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Yamashita Y, Shimokawa T, Ashida R, Hirooka Y, Iwashita T, Kato H, Kin T, Masamune A, Miwa H, Ohno E, Shiomi H, Sofuni A, Takenaka M, Kitano M. Protocol for a Multi-Center Confirmatory Trial to Evaluate the Differential Diagnostic Performance of Contrast-Enhanced Ultrasonography Using Perflubutane in Patients with a Pancreatic Mass: A Multicenter Prospective Study. Diagnostics (Basel) 2024; 14:130. [PMID: 38248007 PMCID: PMC10814130 DOI: 10.3390/diagnostics14020130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024] Open
Abstract
For pancreatic masses, an evaluation of their vascularity using contrast-enhanced ultrasonography can help improve their characterization. This study was designed to evaluate the utility and safety of contrast-enhanced transabdominal ultrasonography (CE-TUS) and endoscopic ultrasonography (CE-EUS) in the diagnosis of pancreatic masses including solid or cystic masses. This multi-center comparative open-label superiority study is designed to compare Plain (P)-TUS/EUS alone with P-TUS/P-EUS plus CE-TUS/CE-EUS. Three hundred and one patients with a total of 232 solid pancreatic masses and 69 cystic masses were prospectively enrolled. The primary endpoints are to compare the diagnostic accuracy between P-TUS/P-EUS alone and P-TUS/P-EUS plus CE-TUS/CE-EUS for both the TUS and EUS of solid pancreatic masses, and to compare the diagnostic accuracy between P-EUS alone and P-EUS plus CE-EUS in cystic pancreatic masses. The secondary endpoints are to compare the diagnostic sensitivity and specificity of P-TUS/P-EUS alone and P-TUS/P-EUS plus CE-TUS/CE-EUS for pancreatic solid/cystic masses, and the accuracy of P-TUS alone and P-TUS plus CE-TUS for pancreatic cystic masses. Other secondary endpoints included comparing the diagnostic sensitivity, specificity, and accuracy of CE-TUS, CE-EUS and CE-computed tomography (CT) for solid/cystic pancreatic masses. The safety, degree of effective enhancement, and diagnostic confidence obtained with CE-TUS/CE-EUS will also be assessed.
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Affiliation(s)
- Yasunobu Yamashita
- Second Department of Internal Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-0012, Japan
| | - Toshio Shimokawa
- Clinical Study Support Center, Wakayama Medical University Hospital, Wakayama 641-0012, Japan
| | - Reiko Ashida
- Second Department of Internal Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-0012, Japan
| | - Yoshiki Hirooka
- Department of Gastroenterology and Gastroenterological Oncology, Fujita Health University School of Medicine, Toyoake 470-1192, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu 501-1194, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Okayama 700-8558, Japan
| | - Toshifumi Kin
- Center for Gastroenterology, Teine Keijinkai Hospital, Sapporo 006-8555, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Toyoake 980-8574, Japan
| | - Haruo Miwa
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama 232-0024, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, Nishinomiya 663-8501, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo 160-0023, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka 589-8511, Japan
| | - Masayuki Kitano
- Second Department of Internal Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-0012, Japan
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3
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Lattimore CM, Kane WJ, Subbarao S, Venitti C, Cramer CL, Turkheimer LM, Bauer TW, Turrentine FE, Zaydfudim VM. Long-term surveillance of branch-duct intraductal papillary mucinous neoplasms without worrisome or high-risk features. J Surg Oncol 2023; 128:1087-1094. [PMID: 37530526 PMCID: PMC10592219 DOI: 10.1002/jso.27414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Long-term data evaluating clinical outcomes in patients with branch-duct Intraductal papillary mucinous neoplasms (BD-IPMN) without high-risk stigmata (HRS) or worrisome features (WF) remain limited. METHODS This observational cohort study included all patients diagnosed with BD-IPMN without HRS or WF between 2003 and 2019 who were enrolled in a prospective surveillance program. Time-to-progression analysis was performed using a cumulative incidence function plot and survival analysis was conducted using Kaplan-Meier. RESULTS The median follow-up time for the 267 patient cohort was 44.5 months (interquartile range [IQR]: 24.1-72.2). Radiographic cyst growth was observed in 123 (46.1%) patients; 65 (24.3%) patients progressed to WF/HRS. Twenty-six (9.7%) patients were selected for resection during surveillance: 21 (80.8%) WF, 4 (15.4%) HRS; 1 (3.9%) transformed to mixed-duct. Of all the patients who underwent resection, 5 (19.2%) had adenocarcinoma, and 1 (3.8%) had carcinoma-in-situ. The probability of any radiographic progression was 21.3% (5-year) and 51.3% (10-year). For the entire cohort, there was 1.1% mortality secondary to pancreatic adenocarcinoma and 8.2% all-cause mortality. The 5-year overall survival rate was 91.5%, and at 10 years, 81.5%. CONCLUSION Approximately one in four patients with nonworrisome BD-IPMN have progression to WF/HRS stigmata during surveillance. However, the risk of malignant transformation remains low. Surveillance strategy remains prudent in this patient population.
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Affiliation(s)
- Courtney M. Lattimore
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - William J. Kane
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | | | | | - Christopher L. Cramer
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - Lena M. Turkheimer
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | | | - Florence E. Turrentine
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
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4
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Fong ZV, Hernandez-Barco YG, Castillo CFD. A Clinical Guide to the Management of Intraductal Papillary Mucinous Neoplasms: the Need for a More Graded Approach in Clinical Decision-making. J Gastrointest Surg 2023; 27:1988-1998. [PMID: 37495820 DOI: 10.1007/s11605-022-05536-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/30/2022] [Indexed: 07/28/2023]
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) have become a very common diagnosis and represent a spectrum of disease that ranges from benign to malignant lesions. Presently, clinical and radiographic features are used to predict the presence of high-grade dysplasia and invasive cancer to inform treatment decisions of whether to pursuit surgical resection or continued surveillance. However, the natural history of IPMNs is still not completely understood, with guidelines from different societies providing contradictory recommendations. This underscores the challenge in balancing the risk of missing cancer with long-term surveillance and the morbidity associated with surgical resection. In this review, we aim to reconcile the differences in the guidelines' recommendations and provide a clinical framework to the management of IPMNs with hopes of adding clarity to how treatment decisions should be made. We also highlight recent advances made in the field and future efforts that can minimize rates of missing cancer while also reducing the number of unnecessary operations.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Yasmin G Hernandez-Barco
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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5
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Hashimoto D, Satoi S, Yamamoto T, Yamaki S, Ishida M, Hirooka S, Shibata N, Boku S, Ikeura T, Sekimoto M. Long-term outcomes of patients with multifocal intraductal papillary mucinous neoplasm following pancreatectomy. Pancreatology 2022; 22:1046-1053. [PMID: 35871123 DOI: 10.1016/j.pan.2022.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/29/2022] [Accepted: 07/11/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The decision to perform surgery is complicated by the presence of multifocal (MF) intraductal papillary mucinous neoplasms (IPMNs), which are characterized by two or more cysts located in different areas of the pancreas. OBJECTIVES We aimed to establish a suitable treatment strategy and surgical indications in patients with MF-IPMNs. METHODS This single-center retrospective study included patients with IPMNs who underwent pancreatic resection from 2006 to 2020. Patients with distant metastasis and patients with IPMNs of the main pancreatic duct were excluded from the analysis. RESULTS After excluding 22 patients, 194 patients were included. One hundred thirteen patients (58.2%) had unifocal IPMNs, while 81 patients (41.8%) had MF-IPMNs. There were no significant differences in the 5-year disease-specific survival (DSS) rate (92.3% vs. 92.4%, p = 0.976) and the 5-year disease-free survival rate (88.6% vs. 86.5%, p = 0.461). The multivariate analysis identified high-risk stigmata, invasive carcinoma, and lymph node metastasis as independent predictors of DSS. The presence of cystic lesions in the pancreatic remnant was not a predictor of survival. Even in the MF-IPMN group, there were no significant differences in DSS when stratified by procedure (total pancreatectomy vs. segmental pancreatectomy, p = 0.268) or presence of cystic lesions in the pancreatic remnant (p = 0.476). The multivariate analysis identified lymph node metastasis as an independent predictor of DSS in the MF-IPMN group. CONCLUSIONS In patients with MF-IPMNs, each cyst should be evaluated individually for the presence of features associated with malignancy.
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Affiliation(s)
- Daisuke Hashimoto
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan; Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Tomohisa Yamamoto
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
| | - So Yamaki
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
| | - Mitsuaki Ishida
- Department of Pathology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
| | - Satoshi Hirooka
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
| | - Nobuhiro Shibata
- Cancer Treatment Center, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
| | - Shogen Boku
- Cancer Treatment Center, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
| | - Tsukasa Ikeura
- Third Department of Internal Medicine, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
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6
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Alwahbi O, Ghumman Z, van der Pol CB, Patlas M, Gopee-Ramanan P. Pancreatic Cystic Lesions: Review of the Current State of Diagnosis and Surveillance. Can Assoc Radiol J 2022:8465371221130524. [PMID: 36220377 DOI: 10.1177/08465371221130524] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pancreatic cystic lesions (PCLs) are both common and often incidental. These encompass a range of pathologies with varying degrees of concern for malignancy. Although establishing a diagnosis is helpful for determining malignant potential, many PCLs are either too small to characterize or demonstrate nonspecific morphologic features. The most salient modalities involved in diagnosis and surveillance are magnetic resonance imaging, multidetector computerized tomography, and endoscopic ultrasound. Fine needle aspiration has a role in conjunction with molecular markers as a diagnostic tool, particularly for identifying malignant lesions. Although several major consensus guidelines exist internationally, there remains uncertainty in establishing the strength of the association between all PCLs and pancreatic adenocarcinoma, and in showing a benefit from extended periods of imaging surveillance. No consensus exists between the major guidelines, particularly regarding surveillance duration, frequency, or endpoints. This review paper discusses PCL subtypes, diagnosis, and compares the major consensus guidelines with considerations for local adaptability along with questions regarding current and future priorities for research.
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Affiliation(s)
- Omar Alwahbi
- Department of Radiology, 62703McMaster University Health Sciences Centre (HSC - 3N26), Hamilton, ON, Canada
| | - Zonia Ghumman
- Department of Radiology, 62703McMaster University Health Sciences Centre (HSC - 3N26), Hamilton, ON, Canada.,Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Christian B van der Pol
- Department of Radiology, 62703McMaster University Health Sciences Centre (HSC - 3N26), Hamilton, ON, Canada.,Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Michael Patlas
- Department of Radiology, 62703McMaster University Health Sciences Centre (HSC - 3N26), Hamilton, ON, Canada.,Hamilton General Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Prasaanthan Gopee-Ramanan
- Department of Radiology, 62703McMaster University Health Sciences Centre (HSC - 3N26), Hamilton, ON, Canada.,Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, ON, Canada
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7
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Alwahbi O, Larocque N, Kulkarni A, Gopee-Ramanan PP, Ghumman Z, Sarkar R, Kagoma Y, Alabousi A, Tsai S, Wat J, McInnes M, van der Pol CB. Pancreatic Cystic Lesions on MRI: What Is The Likelihood of a Present or Future Diagnosis of Pancreatic Carcinoma? J Magn Reson Imaging 2022; 57:1567-1575. [PMID: 36151888 DOI: 10.1002/jmri.28438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Pancreatic cystic lesions (PCLs) are followed for years due to older and likely biased works demonstrating a strong association with pancreatic carcinoma; more recent data are needed clarifying this relationship. PURPOSE To determine the association between PCLs on MRI and a synchronous or future diagnosis of pancreatic carcinoma. STUDY TYPE Single-center retrospective cohort. POPULATION A total of 192 patients (111 female, 58%) with median age 66 years (range 26-87 years) with PCLs on abdominal MRI from 2011 to 2016. FIELD STRENGTH/SEQUENCES 1.5 T and 3 T, including T2 WI, T1 WI, diffusion weighted imaging and contrast-enhanced T1 WI. ASSESSMENT Each PCL was reviewed independently by 2 of 10 fellowship-trained abdominal radiologists. Fukuoka guideline worrisome features and high-risk stigmata were evaluated. Follow-up imaging and clinical notes were reviewed within a system that captures pancreatic carcinoma for the region, for a median follow-up of 67 months (interquartile range: 43-88 months). STATISTICAL TESTS Pancreatic carcinoma prevalence and incidence rate for future carcinoma with 95% confidence intervals (95% CI). Fisher exact test, logistic regression with odds ratios (OR) and the Wilcoxon rank-sum test were used to assess PCL morphologic features with the Kolmogorov-Smirnov test used to assess for normality. P < 0.05 defined statistical significance. RESULTS The prevalence of pancreatic carcinoma on initial MRI showing a PCL was 2.4% (95% CI: 0.9%, 5.2%). Thickened/enhancing cyst wall was associated with pancreatic carcinoma, OR 52 (95% CI: 4.5, 1203). Of 189 patients with a PCL but without pancreatic carcinoma at the time of initial MRI, one developed high-grade dysplasia and none developed invasive carcinoma for an incidence rate of 0.97 (95% CI: 0.02, 5.43) and 0 (95% CI: 0, 3.59) cases per 1000 person-years, respectively. DATA CONCLUSION A low percentage of patients with a PCL on MRI had a pancreatic carcinoma at the time of initial evaluation and none developed carcinoma over a median 67 months of follow-up. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: 5.
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Affiliation(s)
- Omar Alwahbi
- Department of Radiology, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Natasha Larocque
- Department of Radiology, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Department of Diagnostic Imaging, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Ameya Kulkarni
- Department of Radiology, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Prasaanthan Prasa Gopee-Ramanan
- Department of Radiology, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Zonia Ghumman
- Department of Radiology, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Rahul Sarkar
- Department of Radiology, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Yoan Kagoma
- Department of Radiology, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Abdullah Alabousi
- Department of Radiology, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Department of Diagnostic Imaging, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Scott Tsai
- Department of Radiology, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Josephine Wat
- Department of Radiology, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Matthew McInnes
- Department of Radiology and Epidemiology, University of Ottawa, Canada.,Ottawa Hospital Research Institute Clinical Epidemiology Program, Ontario, Canada
| | - Christian B van der Pol
- Department of Radiology, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.,Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
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8
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Aleotti F, Crippa S, Belfiori G, Tamburrino D, Partelli S, Longo E, Palumbo D, Pecorelli N, Lena MS, Capurso G, Arcidiacono PG, Falconi M. Pancreatic resections for benign intraductal papillary mucinous neoplasms: Collateral damages from friendly fire. Surgery 2022; 172:1202-1209. [PMID: 35667898 DOI: 10.1016/j.surg.2022.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/05/2022] [Accepted: 04/28/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Surgical resection of intraductal papillary mucinous neoplasms is based on preoperative high-risk stigmata/worrisome features, but the risk of overtreatment remains high. The aim of this study was to evaluate surgical indications and perioperative and long-term complications in patients with low-grade intraductal papillary mucinous neoplasms. METHODS Patients who underwent surgical resection between 2009 and 2018 with a final histology of low-grade intraductal papillary mucinous neoplasms were included. Surgical indications, type of surgery, and short- and long-term outcomes were evaluated. RESULTS A significant decrease in the rate of patients resected for low-grade intraductal papillary mucinous neoplasms was observed (43.6% in 2009-2012 vs 27.8% in 2013-2018; P = .003), and 133 patients were finally included (62 women, median age: 68 years). Of these, 24.1% had 1 worrisome feature, 39.8% had ≥2 worrisome features, 18.8% had ≥1 high-risk stigmata, and 15.8% had ≥1 worrisome features + 1 high-risk stigmata. Overall surgical morbidity was 55.6%, 15.8% had Clavien-Dindo ≥3 complications, reoperation rate was 3.8%, and 90-day postoperative mortality was 1.5%. After a median follow-up of 60 months, 13 patients (11.5%) had a recurrence of benign intraductal papillary mucinous neoplasm in the pancreatic remnant, and 2 patients (1.8%) developed pancreatic ductal adenocarcinoma. After partial pancreatectomy, 51.3% of patients were taking pancreatic enzyme replacement therapy. Among nondiabetics, 26% developed diabetes after partial pancreatectomy, of which 38% were insulin-dependent. Eighteen patients (13.7%) developed incisional hernia. CONCLUSION Given the rates of morbidity and long-term complications after pancreatic resections, surgeons should attentively balance the true risks of intraductal papillary mucinous neoplasm degeneration with the risks of surgical resection in each patient.
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Affiliation(s)
- Francesca Aleotti
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Crippa
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Giulio Belfiori
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy. http://www.twitter.com/spartelli
| | - Enrico Longo
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Diego Palumbo
- Division of Radiology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicolò Pecorelli
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy. http://www.twitter.com/nicpecorelli
| | - Marco Schiavo Lena
- Department of Pathology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Capurso
- Pancreas-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy. http://www.twitter.com/lelecapurso
| | - Paolo Giorgio Arcidiacono
- Pancreas-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
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9
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Qu C, Wang HY, Xiu DR. A Rare Liver Tumor Nodule. Gastroenterology 2022; 162:e1-e3. [PMID: 34146565 DOI: 10.1053/j.gastro.2021.05.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Chao Qu
- Department of General Surgery, Peking University Third Hospital, Beijing, China; Peking University Health Science Center, Beijing, China
| | - Hang-Yan Wang
- Department of General Surgery, Peking University Third Hospital, Beijing, China
| | - Dian-Rong Xiu
- Department of General Surgery, Peking University Third Hospital, Beijing, China.
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10
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Predictors of malignancy in main duct intraductal papillary mucinous neoplasm of the pancreas. Gastrointest Endosc 2022; 95:291-296. [PMID: 34474037 DOI: 10.1016/j.gie.2021.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The International Consensus Guidelines updated in 2017 recommended surgery to all main duct intraductal papillary mucinous neoplasms (MD-IPMNs) with the main pancreatic duct (MPD) of 10 mm or more and those with mural nodules regardless of size. The aim of the present study was to identify predictors of malignancy in MD-IPMN among preoperative factors including MPD and mural nodule size. METHODS Twenty-six benign MD-IPMNs (7 resected and 19 nonresected) and 32 malignant MD-IPMNs (31 resected and 1 nonresected) were included in the study. MRCP, CT, EUS, and cytology were performed using pancreatic juice collected by endoscopic retrograde pancrestography (ERP). Resected IPMNs were classified as benign or malignant by histologic examination and nonresected MD-IPMNs by imaging, cytology, and observation. Cutoff values of candidate parameters were determined by receiver operating characteristic curves. Univariate and multivariate analyses by regression model were performed. RESULTS MPD and mural nodule size and cytology results differed significantly between benign and malignant groups. Cutoff values of MPD and mural nodule sizes were 15 mm and 10 mm with areas under the curve of .66 and .86, respectively. Mural nodules of 10 mm or more (odds ratio, 8.32; 95% confidence interval, 1.13-61.2; P = .038) and positive cytology (odds ratio, 42.5; 95% confidence interval, 4.10-439; P = .002) were shown to be independent predictors of malignancy by multivariate analysis. When MD-IPMNs with either predictor were diagnosed to be malignant, sensitivities, specificities, and overall accuracy for malignancy were 94%, 85%, and 90%, respectively. CONCLUSIONS Mural nodules of 10 mm or more and positive cytology were independent predictors of malignancy in MD-IPMN.
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11
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Buerlein RCD, Shami VM. Management of pancreatic cysts and guidelines: what the gastroenterologist needs to know. Ther Adv Gastrointest Endosc 2021; 14:26317745211045769. [PMID: 34589706 PMCID: PMC8474323 DOI: 10.1177/26317745211045769] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/25/2021] [Indexed: 12/15/2022] Open
Abstract
The prevalence of pancreatic cysts has increased significantly over the last
decade, partly secondary to increased quality and frequency of cross-sectional
imaging. While the majority never progress to cancer, a small number will and
need to be followed. The management of pancreatic cysts can be both confusing
and intimidating due to the multiple guidelines with varying recommendations.
Despite the differences in the specifics of the guidelines, they all agree on
several high-risk features that should get the attention of any clinician when
assessing a pancreatic cyst: presence of a mural nodule or solid component,
dilation of the main pancreatic duct (or presence of main duct intraductal
papillary mucinous neoplasm), pancreatic cyst size ⩾3–4 cm, or positive cytology
on pancreatic cyst fluid aspiration. Other important criteria to consider
include rapid cyst growth (⩾5 mm/year), elevated serum carbohydrate antigen 19-9
levels, new-onset diabetes mellitus, or acute pancreatitis thought to be related
to the cystic lesion.
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Affiliation(s)
| | - Vanessa M Shami
- University of Virginia Digestive Health, 1215 Lee Street, Charlottesville, VA 22903, USA
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12
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Zhao W, Liu S, Cong L, Zhao Y. Imaging Features for Predicting High-Grade Dysplasia or Malignancy in Branch Duct Type Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Systematic Review and Meta-Analysis. Ann Surg Oncol 2021; 29:1297-1312. [PMID: 34554343 DOI: 10.1245/s10434-021-10662-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 08/05/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The consensus guidelines for branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) of the pancreas are mostly based on imaging features. This study aimed to determine imaging features and their diagnostic accuracy for predicting high-grade dysplasia (HGD)/malignancy in BD-IPMN, including mixed type. METHODS The PubMed, Embase, and Cochrane databases were searched, and data were extracted from relevant studies. As the main diagnostic accuracy index, diagnostic odds ratios (DORs) of imaging features for diagnosing HGD/malignancy in BD-IPMNs were pooled using the random-effects model. A bivariate random-effects approach was used to construct summary receiver operating characteristic curves for sensitivity and specificity estimation. RESULTS The pooled DOR was the highest for the enhanced solid component/mural nodule (MN) (DOR, 12.21; 95 % confidence interval [CI], 6.14-24.27), followed by a main pancreatic duct (MPD) diameter of 10 mm or greater (DOR, 7.93; 95 % CI, 3.02-20.83), solid component (DOR, 4.85; 95 % CI, 2.49-9.42), lymphadenopathy (DOR, 4.84; 95 % CI, 1.11-21.06), MN (DOR, 4.48; 95 % CI, 3.15-6.39), an MPD diameter of 5 mm or greater (DOR, 3.69; 95 % CI, 2.62-5.19), abrupt change in MPD caliber with distal pancreatic atrophy (DOR, 2.65; 95 % CI, 1.66-4.24), thickened/enhancing walls (DOR, 2.38; 95 % CI, 1.57-3.60), and cyst size of 3 cm or larger (DOR, 1.98; 95 % CI, 1.48-2.64). The largest area under the curve (0.89 and 0.95, respectively) and high specificity (0.95 and 0.98, respectively) also were found for enhanced solid component/MN and an MPD diameter of 10 mm or greater, albeit with low sensitivity (0.38 and 0.14, respectively). CONCLUSIONS The aforementioned imaging features could aid in predicting HGD/malignancy of BD-IPMN. Furthermore, enhanced solid component/MN and an MPD diameter of 10 mm or greater were the most important predictors of HGD/malignancy in BD-IPMN and should be considered as indications for surgery.
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Affiliation(s)
- Wenjing Zhao
- Central Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Shanglong Liu
- Department of General Surgery, Affiliated Hospital of Qingdao University, Shandong, China
| | - Lin Cong
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
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13
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Watanabe S, Toki M, Shibahara J, Hisamatsu T. Utility of endoscopic transpapillary pancreatic cyst drainage for intraductal papillary mucinous neoplasm infection. BMJ Case Rep 2021; 14:14/6/e242583. [PMID: 34088692 PMCID: PMC8183218 DOI: 10.1136/bcr-2021-242583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 61-year-old woman with intraductal papillary mucinous neoplasm (IPMN) infection, who was treated with antibiotics, developed IPMN reinfection with febrile epigastric pain and was febrile. CT showed that the diameter of the IPMN had grown and hardened, with thickening of the cyst wall. Endoscopic retrograde pancreatography was then performed and a nasopancreatic cyst drainage tube was placed into the cyst. Symptoms and inflammatory findings improved considerably 17 days after endoscopic drainage. Few reports and evidence have been found regarding IPMN infections, and the frequency of onset, route of infection and optimal drainage method remain unknown. This study indicated that endoscopic transpapillary pancreatic cyst drainage was effective and is highly recommended for IPMN infection.
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Affiliation(s)
- Shunsuke Watanabe
- Department of Gastroenterology and Hepatology, Kyorin University Hospital, Mitaka, Tokyo, Japan
| | - Masao Toki
- Department of Gastroenterology and Hepatology, Kyorin University Hospital, Mitaka, Tokyo, Japan
| | - Junji Shibahara
- Department of Pathology, Kyorin University Hospital, Mitaka, Tokyo, Japan
| | - Tadakazu Hisamatsu
- Department of Gastroenterology and Hepatology, Kyorin University Hospital, Mitaka, Tokyo, Japan
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14
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McCarty TR, Paleti S, Rustagi T. Molecular analysis of EUS-acquired pancreatic cyst fluid for KRAS and GNAS mutations for diagnosis of intraductal papillary mucinous neoplasia and mucinous cystic lesions: a systematic review and meta-analysis. Gastrointest Endosc 2021; 93:1019-1033.e5. [PMID: 33359054 DOI: 10.1016/j.gie.2020.12.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 12/09/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Although molecular analysis of pancreatic cyst fluid may aid pancreatic cyst classification, clinical practice remains highly variable. Therefore, we performed a systematic review and meta-analysis to evaluate the diagnostic performance of KRAS and GNAS mutations in EUS-acquired pancreatic cyst fluid for diagnosis of intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic lesions (MCLs). METHODS Individualized searches were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines and meta-analysis analyzed according to the Cochrane Diagnostic Test Accuracy working group methodology. A bivariate model was used to compute the pooled sensitivity and specificity and to plot the summary receiver operating characteristics curve with summary point and corresponding 95% confidence interval (95% CI). RESULTS Six studies (785 lesions) were included. For IPMNs and MCLs, KRAS + GNAS (combination) had significantly higher diagnostic accuracy than KRAS alone and GNAS alone (all P < .001). The pooled sensitivity, specificity, and diagnostic accuracy of KRAS + GNAS mutations for diagnosis of IPMNs were 94% (95% CI, 72-99; I2 = 86.74%), 91% (95% CI, 72-98; I2 = 89.83), and 97% (95% CI, 95-98), respectively, with each significantly higher compared with carcinoembryonic antigen (CEA) alone (all P < .001). For diagnosis of MCLs, KRAS + GNAS had a similar sensitivity and specificity compared with CEA alone; however, diagnostic accuracy was significantly improved (97% [95% CI, 95-98] vs 89% [95% CI, 86-91]; P < .001). CONCLUSIONS Molecular analysis for KRAS + GNAS mutations in EUS-acquired pancreatic cyst fluid has high sensitivity and specificity with significantly improved diagnostic accuracy for diagnosis of IPMNs and MCLs when compared with CEA alone.
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Affiliation(s)
- Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Swathi Paleti
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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15
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Muniraj T, Aslanian HR, Laine L, Jamidar PA, Farrell JF, Mitchell KA, Salem RR. Resection of pancreatic cystic neoplasms in recurrent acute pancreatitis prevents recurrent pancreatitis but does not identify more malignancies. World J Gastroenterol 2021; 27:1630-1642. [PMID: 33958848 PMCID: PMC8058652 DOI: 10.3748/wjg.v27.i15.1630] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/24/2021] [Accepted: 03/22/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Recurrent acute pancreatitis (RAP) may be a presenting feature of and an indication for resection of pancreatic cysts, including intra-ductal papillary mucinous neoplasm (IPMN). Few data are available regarding the prevalence of malignancy and post-operative RAP in this population.
AIM To study the role of resection to help prevent RAP and analyze if presentation as RAP would be a predictor for malignancy.
METHODS This retrospective study assessed 172 patients who underwent surgical resection of pancreatic cystic neoplasms at a university hospital between 2002 and 2016. The prevalence of preoperative high-risk cyst features, and of neoplasia was compared between patients with and without RAP. To identify the cause of pancreatitis, all the patients had a detailed history of alcohol, smoking, medications obtained, and had cross-sectional imaging (contrast-enhanced computed tomography/magnetic resonance imaging) and endoscopic ultrasound to look for gallstone etiology and other structural causes for pancreatitis. The incidence of RAP post-resection was the primary outcome.
RESULTS IPMN accounted for 101 cases (58.7%) {[branch duct (BD) 59 (34.3%), main duct (MD) 42] (24.4%)}. Twenty-nine (16.9%) presented with RAP (mean 2.2 episodes): 15 had BD-IPMN, 8 MD-IPMN, 5 mucinous cystic neoplasm and 1 serous cystic neoplasm. Malignancy was similar among those with vs without RAP for all patients [6/29 (20.7%) vs 24/143 (16.8%)] and IPMN patients [6/23 (26.1%) vs 23/78 (29.5%)], although tended to be higher with RAP in BD-IPMN, [5/15 (33.3%) vs 3/44 (6.8%), P = 0.04]. At mean follow-up of 7.2 years, 1 (3.4%) RAP patient had post-resection RAP. The mean episodes of acute pancreatitis before vs after surgery were 3.4 vs 0.02 (P < 0.0001).
CONCLUSION Malignancy was not increased in patients with pancreatic cystic neoplasms who have RAP compared to those without RAP. In addition, specific cyst charac-teristics were not clearly associated with RAP. The incidence of RAP was markedly decreased in almost all patients following cyst resection.
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Affiliation(s)
- Thiruvengadam Muniraj
- Section of Digestive Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, United States
| | - Harry R Aslanian
- Section of Digestive Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, United States
| | - Loren Laine
- Section of Digestive Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, United States
| | - Priya A Jamidar
- Section of Digestive Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, United States
| | - James F Farrell
- Section of Digestive Diseases, Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, United States
| | - Kisha A Mitchell
- Department of Pathology, Yale University School of Medicine, New Haven, CT 06510, United States
| | - Ronald R Salem
- Department of Surgery, Yale University School of Medicine, New Haven, CT 06510, United States
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16
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Minimal main pancreatic duct dilatation in small branch duct intraductal papillary mucinous neoplasms associated with high-grade dysplasia or invasive carcinoma. HPB (Oxford) 2021; 23:468-474. [PMID: 32912834 DOI: 10.1016/j.hpb.2020.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 07/06/2020] [Accepted: 08/04/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to determine the incidence of high-grade dysplasia (HGD) or invasive carcinoma in patients with small branch duct intraductal papillary mucinous neoplasms (BD-IPMNs). METHODS 923 patients who underwent surgical resection for an IPMN were identified. Sendai-negative patients were identified as those without history of pancreatitis or jaundice, main pancreatic duct size (MPD) <5 mm, cyst size <3 cm, no mural nodules, negative cyst fluid cytology for adenocarcinoma, or serum carbohydrate antigen 19-9 (CA 19-9) <37 U/L. RESULTS BD-IPMN was identified in 388 (46.4%) patients and 89 (22.9%) were categorized as Sendai-negative. Overall, 68 (17.5%) of BD-IPMN had HGD and 62 (16.0%) had an associated invasive-carcinoma. Among the 89 Sendai-negative patients, 12 (13.5%) had IPMNs with HGD and only one patient (1.1%) had invasive-carcinoma. Of note, older age (OR 1.13, 95% CI 1.03-1.23; P = 0.008) and minimal dilation of MPD (OR 11.3, 95% CI 2.40-53.65; P = 0.002) were associated with high-risk disease in Sendai-negative patients after multivariable risk adjustment. CONCLUSION The risk of harboring a high-risk disease remains low in small BD-IPMNs. However, Sendai-negative patients who are older than 65 years old and those with minimal dilation of MPD (3-5 mm) are at greater risk of high-risk lesions and should be given consideration to be included as a "worrisome feature" in a future guidelines update.
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17
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Niiya F, Ohike N, Norose T, Takano Y, Azami T, Kobayashi T, Maruoka N, Wakabayashi T, Matsuo K, Tanaka K, Nagahama M. Can the location of the mural nodule indicate benign or malignant in branch duct-type intraductal papillary mucinous neoplasm of the pancreas? Pancreatology 2020; 20:1379-1385. [PMID: 32873485 DOI: 10.1016/j.pan.2020.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 08/09/2020] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Intraductal papillary mucinous neoplasms (IPMNs) are classified into main duct (MD)-type IPMNs, branch duct (BD)-type IPMNs, and mixed type IPMNs. While MD-type IPMN has a high risk of malignancy and should therefore be considered for resection if the patient is fit, BD-type IPMN needs to be carefully judged for surgical indication. The decision to resect BD-type IPMN is often based on international consensus Fukuoka guidelines 2017, but further investigation is required. In this study, we focused on whether the location of the mural nodule (MN) could be an indicator of malignancy. METHODS We enrolled 17 cases who had been diagnosed BD-type IPMNs which were surgically resected from January 2016 to December 2019. These cases were classified into benign and malignant group. Subsequently, a clinicopathological study was conducted based on the localization of MN (MN-central type or MN-peripheral type). RESULTS Although MN was found in 57% (4/11) in the benign group, 88% (7/8) was noted in the malignant group, indicating the presence of MN to be more common in the malignant group. Those with MN consisted of 6 cases of MN-central type and 5 cases of MN-peripheral type. All cases of central type were malignant compared to only one case of the peripheral group being confirmed on histology as cancer. CONCLUSION BD-IPMN with central mural nodule should be considered high risk for malignancy.
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Affiliation(s)
- Fumitaka Niiya
- Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan; Department of Pathology and Laboratory Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan.
| | - Nobuyuki Ohike
- Department of Pathology and Laboratory Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Tomoko Norose
- Department of Pathology and Laboratory Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Yuichi Takano
- Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Tetsushi Azami
- Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Takahiro Kobayashi
- Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Naotaka Maruoka
- Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Tetsuji Wakabayashi
- Department of General and Gastroenterological Surgery, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Kenichi Matsuo
- Department of General and Gastroenterological Surgery, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Kuniya Tanaka
- Department of General and Gastroenterological Surgery, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
| | - Masatsugu Nagahama
- Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan
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18
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Sharib J, Esserman L, Koay EJ, Maitra A, Shen Y, Kirkwood KS, Ozanne EM. Cost-effectiveness of consensus guideline based management of pancreatic cysts: The sensitivity and specificity required for guidelines to be cost-effective. Surgery 2020; 168:601-609. [PMID: 32739138 PMCID: PMC8754171 DOI: 10.1016/j.surg.2020.04.052] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/25/2020] [Accepted: 04/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Detection of cystic lesions of the pancreas has outpaced our ability to stratify low-grade cystic lesions from those at greater risk for pancreatic cancer, raising a concern for overtreatment. METHODS We developed a Markov decision model to determine the cost-effectiveness of guideline-based management for asymptomatic pancreatic cysts. Incremental costs per quality-adjusted life year gained and survival were calculated for current management guidelines. A sensitivity analysis estimated the effect on cost-effectiveness and mortality if overtreatment of low-grade cysts is avoided, and the sensitivity and specificity thresholds required of methods of cyst stratification to improve costs expended. RESULTS "Surveillance" using current management guidelines had an incremental cost-effectiveness ratio of $171,143/quality adjusted life year compared with no surveillance or operative treatment ("do nothing"). An incremental cost-effectiveness ratio for surveillance decreases to $80,707/quality adjusted life year if the operative overtreatment of low-grade cysts was avoided. Assuming a societal willingness-to-pay of $100,000/quality adjusted life year, the diagnostic specificity for high-risk cysts must be >67% for surveillance to be preferred over surgery and "do nothing." Changes in sensitivity alone cannot make surveillance cost-effective. Most importantly, survival in surveillance is worse than "do nothing" for 3 years after cyst diagnosis, although long-term survival is improved. The disadvantage is eliminated when overtreatment of low-grade cysts is avoided. CONCLUSION Current management of pancreatic cystic lesions is not cost-effective and may increase mortality owing to overtreatment of low-grade cysts. The specificity for risk stratification for high-risk cysts must be greater than 67% to make surveillance cost-effective.
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Affiliation(s)
- Jeremy Sharib
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA
| | - Laura Esserman
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA
| | - Eugene J Koay
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anirban Maitra
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yu Shen
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kimberly S Kirkwood
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA.
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
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19
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Predictive Features of Malignancy in Branch Duct Type Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Meta-Analysis. Cancers (Basel) 2020; 12:cancers12092618. [PMID: 32937809 PMCID: PMC7563991 DOI: 10.3390/cancers12092618] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/07/2020] [Accepted: 09/11/2020] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Currently, there are several guidelines that are widely used to establish the treatment strategy for branch duct type intraductal papillary mucinous neoplasms. Although there are some common grounds, there are discrepancies on which features they adopt, how much each feature is weighted, and how the features are combined. Furthermore, some of the features are based on lower level evidences or expert opinions. The aim of this meta-analysis was to investigate important clinical, radiological, and biochemical risk factors for malignancy and their impact as predictors. This study found symptom, size, cyst wall thickening, presence of mural nodule, change in main pancreatic duct caliber, lymphadenopathy, CA 19-9, and CEA as risk factors. Lymphadenopathy (odd ratio [OR]: 8.55), abrupt caliber change (OR: 7.41), and mural nodule (OR: 4.10) had the highest odd ratios. We expect the higher level evidences of this study to help shape better guidelines and reduce discrepancies among future guidelines. Abstract The current guidelines on branch duct type intraductal papillary mucinous neoplasm (BD-IPMN) recommend various predictive features of malignancy as well as different treatment strategies. This study aimed to identify the risk factors for malignancy with higher level of evidence. A meta-analysis was performed on 40 literatures published between 2000 and 2019. These literatures included 6301 patients with pathologically proven IPMN. Malignancy was defined as high-grade dysplasia and invasive carcinoma. It was significantly associated with symptoms (odds ratio [OR] 1.35, confidence interval [CI] 1.01–1.79), size ≥ 3 cm (OR 1.90, CI 1.51–2.40), cystic wall thickening (OR 2.53, CI 1.50–4.27), mural nodule (OR 4.10, CI 3.38–4.97), main pancreatic duct dilatation (OR 2.98, CI 2.11–4.21), abrupt caliber change of the pancreatic duct (OR 7.41, CI 2.49–22.06), lymphadenopathy (OR 8.55, CI 3.25–22.51), elevated carbohydrate antigen 19-9 (OR 4.01, CI 2.55–6.28), and elevated carcinoembryonic antigen (OR 2.04, CI 1.60–2.61). Multilocular cysts and multiple cysts did not show a significant association with malignancy. This study examined the clinical, radiological, and biochemical features of BD-IPMN, often used as malignancy predictors according to the widely used guidelines. The results confirmed that all the features currently being used are valid.
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20
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Tomishima K, Fujisawa T, Fukumura Y, Ushio M, Sato S, Amano N, Murata A, Tsuzura H, Sato S, Matsumoto K, Shimada Y, Genda T, Isayama H. Mucinous Cystadenocarcinoma of the Pancreas with Cyst Infection in a Male Patient. Intern Med 2020; 59:2383-2389. [PMID: 32999265 PMCID: PMC7644490 DOI: 10.2169/internalmedicine.4937-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Follow-up computed tomography revealed a 40-mm pancreatic tail cyst in a 59-year-old man with type 1 diabetes mellitus. An intraductal papillary mucinous neoplasm was suspected; mucinous cystic neoplasm (MCN) was not considered because the patient was a man. During follow-up, cyst infection occurred but was improved by conservative treatment. At the 24-month follow up examination, cyst nodules had developed, corresponding to an increase in the carbohydrate antigen 19-9 level. Mucinous cystadenocarcinoma (MCC) was diagnosed pathologically based on distal pancreatectomy. A diagnosis of male MCN/MCC is often delayed, which may lead to a poor prognosis. MCN infection is also rare and poorly recognized. We observed an atypical male case of MCN/MCC.
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Affiliation(s)
- Ko Tomishima
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Japan
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Toshio Fujisawa
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Japan
| | - Yuki Fukumura
- Department of Human Pathology, Juntendo University School of Medicine, Japan
| | - Mako Ushio
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Japan
| | - Sho Sato
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Nozomi Amano
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Ayato Murata
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Hironori Tsuzura
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Shunsuke Sato
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Kouhei Matsumoto
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Japan
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Yuji Shimada
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Takuya Genda
- Department of Gastroenterology and Hepatology, Juntendo University Shizuoka Hospital, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Japan
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21
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Walczak S, Permuth JB, Velanovich V. Analyzing Intraductal Papillary Mucinous Neoplasms Using Artificial Neural Network Methodologic Triangulation. INTERNATIONAL JOURNAL OF HEALTHCARE INFORMATION SYSTEMS AND INFORMATICS 2019. [DOI: 10.4018/ijhisi.2019100102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Intraductal papillary mucinous neoplasms (IPMN) are a type of mucinous pancreatic cyst. IPMN have been shown to be pre-malignant precursors to pancreatic cancer, which has an extremely high mortality rate with average survival less than 1 year. The purpose of this analysis is to utilize methodological triangulation using artificial neural networks and regression to examine the impact and effectiveness of a collection of variables believed to be predictive of malignant IPMN pathology. Results indicate that the triangulation is effective in both finding a new predictive variable and possibly reducing the number of variables needed for predicting if an IPMN is malignant or benign.
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Affiliation(s)
- Steven Walczak
- School of Information, University of South Florida, Tampa, USA
| | - Jennifer B. Permuth
- Departments of Cancer Epidemiology and Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and R, Tampa, USA
| | - Vic Velanovich
- Department of Surgery, College of Medicine, University of South Florida, Tampa, USA
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22
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Laquière A, Lagarde A, Napoléon B, Bourdariat R, Atkinson A, Donatelli G, Pol B, Lecomte L, Curel L, Urena-Campos R, Helbert T, Valantin V, Mithieux F, Buono JP, Grandval P, Olschwang S. Genomic profile concordance between pancreatic cyst fluid and neoplastic tissue. World J Gastroenterol 2019; 25:5530-5542. [PMID: 31576098 PMCID: PMC6767987 DOI: 10.3748/wjg.v25.i36.5530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/16/2019] [Accepted: 08/19/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND DNA mutational analysis of pancreatic cystic fluid (CF) is a useful adjunct to the evaluation of pancreatic cysts. KRAS/GNAS or RAF/PTPRD/CTNNB1/RNF43 mutations are highly specific to precancerous or advanced neoplasia. Several studies recently demonstrated the ability of next-generation sequencing (NGS) analysis to detect DNA mutations in pancreatic CF, but few studies have performed a systematic comparative analysis between pancreatic CF and neoplastic surgical tissue (NT). The value of CF-NGS analysis indicators for determining surgical resection necessitates evaluation.
AIM To confirm whether CF genomic profiles are a reliable malignancy predictor by comparing NGS mutational analyses of CF and NT.
METHODS Patients requiring surgery for high-risk pancreatic cysts were included in a multicenter prospective pilot study. DNA from CF (collected by endoscopic ultrasound-guided fine needle aspiration (known as EUS-FNA)) and NT (collected by surgery) were analyzed by NGS. The primary objective was to compare the mutation profiles of paired DNA samples. The secondary objective was to correlate the presence of specific mutations (KRAS/GNAS, RAF/ PTPRD/CTNNB1/RNF43/POLD1/TP53) with a final cancer diagnosis. Sensitivity and specificity were also evaluated.
RESULTS Between December 2016 and October 2017, 20 patients were included in this pilot study. Surgery was delayed for 3 patients. Concordant CF-NT genotypes were found in 15/17 paired DNA, with a higher proportion of mutated alleles in CF than in NT. NGS was possible for all pancreatic CF collected by EUS-FNA. In 2 cases, the presence of a KRAS/GNAS mutation was discordant between CF and NT. No mutations were found in 3 patients with NT or pancreatic cysts with high-grade dysplasia. The sensitivity and specificity of KRAS/GNAS mutations in CF to predict an appropriate indication for surgical resection were 0.78 and 0.62, respectively. The sensitivity and specificity of RAF/PTPRD/CTNNB1 /RNF43/POLD1/TP53 mutations in CF were 0.55 and 1.0, respectively.
CONCLUSION Mutational analyses of CF and NT were highly concordant, confirming the value of NGS analysis of CF in the preoperative malignancy assessment. However, these results need to be confirmed on a larger scale.
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Affiliation(s)
- Arthur Laquière
- Department of Gastroenterology, Saint Joseph Hospital, Marseille 13008, France
| | - Arnaud Lagarde
- Aix-Marseille Univ, INSERM, MMG, Marseille 13385, France
- AP-HM, Conception Hospital, Marseille 13385, France
| | | | | | | | | | - Bernard Pol
- Department of Digestive Surgery, Saint-Joseph Hospital, Marseille 13008, France
| | - Laurence Lecomte
- Department of Gastroenterology, Saint Joseph Hospital, Marseille 13008, France
| | - Laurence Curel
- Department of Clinical Research, Saint Joseph Hospital, Marseille 13008, France
| | - Romina Urena-Campos
- Department of Gastroenterology, Saint Joseph Hospital, Marseille 13008, France
| | | | | | | | | | - Philippe Grandval
- Aix-Marseille Univ, INSERM, MMG, Marseille 13385, France
- AP-HM, Timone Hospital, Marseille 13005, France
| | - Sylviane Olschwang
- Aix-Marseille Univ, INSERM, MMG, Marseille 13385, France
- European Hospital, Marseille 13003, France
- AP-HM, Timone Hospital, Marseille 13005, France
- RGDS, Clairval Hospital, Marseille 13009, France
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23
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Sakhdari A, Moghaddam PA, Ok CY, Walter O, Tomaszewicz K, Caporelli ML, Meng X, LaFemina J, Whalen G, Belkin E, Zivny J, Wassef W, Woda BA, Hutchinson LM, Cosar EF. Somatic molecular analysis augments cytologic evaluation of pancreatic cyst fluids as a diagnostic tool. Oncotarget 2019; 10:4026-4037. [PMID: 31258847 PMCID: PMC6592293 DOI: 10.18632/oncotarget.26999] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/20/2019] [Indexed: 12/16/2022] Open
Abstract
Objective: Better tools are needed for early diagnosis and classification of pancreatic cystic lesions (PCL) to trigger intervention before neoplastic precursor lesions progress to adenocarcinoma. We evaluated the capacity of molecular analysis to improve the accuracy of cytologic diagnosis for PCL with an emphasis on non-diagnostic/negative specimens. Design: In a span of 7 years, at a tertiary care hospital, 318 PCL endoscopic ultrasound-guided fine needle aspirations (EUS-FNA) were evaluated by cytologic examination and molecular analysis. Mucinous PCL were identified based on a clinical algorithm and 46 surgical resections were used to verify this approach. The mutation allele frequency (MAF) of commonly altered genes (BRAF, CDKN2A, CTNNB1, GNAS, RAS, PIK3CA, PTEN, SMAD4, TP53 and VHL) was evaluated for their ability to identify and grade mucinous PCL. Results: Cytology showed a diagnostic sensitivity of 43.5% for mucinous PCL due in part to the impact of non-diagnostic (28.8%) and negative (50.5%) specimens. Incorporating an algorithmic approach or molecular analysis markedly increased the accuracy of cytologic evaluation. Detection of mucinous PCL by molecular analysis was 93.3% based on the detection of KRAS and/or GNAS gene mutations (p = 0.0001). Additional genes provided a marginal improvement in sensitivity but were associated with cyst type (e.g. VHL) and grade (e.g. SMAD4). In the surgical cohort, molecular analysis and the proposed algorithm showed comparable sensitivity (88.9% vs. 100%). Conclusions: Incorporating somatic molecular analysis in the cytologic evaluation of EUS-FNA increases diagnostic accuracy for detection, classification and grading of PCL. This approach has the potential to improve patient management.
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Affiliation(s)
- Ali Sakhdari
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
- MD Anderson Cancer Center, Department of Hematopathology, Houston, TX, USA
| | - Parnian Ahmadi Moghaddam
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
- Massachusetts General Hospital, Department of Pathology, Boston, MA, USA
- University of Texas, Health Science Center, Department of Pathology, Houston, TX, USA
| | - Chi Young Ok
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
- MD Anderson Cancer Center, Department of Hematopathology, Houston, TX, USA
| | - Otto Walter
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
| | - Keith Tomaszewicz
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
| | - Mandi-Lee Caporelli
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
| | - Xiuling Meng
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
| | - Jennifer LaFemina
- University of Massachusetts Medical School, Department of Surgery, Worcester, MA, USA
| | - Giles Whalen
- University of Massachusetts Medical School, Department of Surgery, Worcester, MA, USA
| | - Edward Belkin
- University of Massachusetts Medical School, Department of Medicine, Worcester, MA, USA
| | - Jaroslav Zivny
- University of Massachusetts Medical School, Department of Medicine, Worcester, MA, USA
| | - Wahid Wassef
- University of Massachusetts Medical School, Department of Medicine, Worcester, MA, USA
| | - Bruce A. Woda
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
| | - Lloyd M. Hutchinson
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
| | - Ediz F. Cosar
- University of Massachusetts Medical School, Department of Pathology, Worcester, MA, USA
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24
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Pérez-Cuadrado-Robles E, Uribarri-González L, Borbath I, Vila JJ, López-López S, Deprez PH. Risk of advanced lesions in patients with branch-duct IPMN and relative indications for surgery according to European evidence-based guidelines. Dig Liver Dis 2019; 51:882-886. [PMID: 30591368 DOI: 10.1016/j.dld.2018.11.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 10/31/2018] [Accepted: 11/26/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND European evidence-based guidelines proposed surgery for branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) based on the presence of 1-2 relative indications, depending on the comorbidity burden. AIMS To assess the accuracy of the guidelines in patients with relative indications in a surgical cohort of demonstrated BD-IPMNs. METHODS This report describes a multi-centre, observational, retrospective study. All consecutive patients with relative indications and histologically confirmed BD-IPMN were included. The main outcome was risk of invasive carcinoma in patients with relative indications. RESULTS Ninety-one patients with BD-IPMN underwent surgery because of absolute (n = 21), relative (n = 60), or no formal indications (n = 10). In total, there were 60 patients (mean age: 66 ± 9, 50% male) with one (n = 35, 58.3%) or ≥2 relative indications (n = 25, 41.7%). The global advanced lesion and invasive carcinoma rates were 40% and 13.3%, respectively. No risk factor was associated with high-grade dysplasia or invasive carcinoma. Patients with one indication had a lower risk of invasive carcinoma than did those with ≥2 relative indications (5.7% vs. 24%, respectively, p = 0.048); however, the advanced lesion rates were comparable (37.1% vs. 44%, p = 0.593). CONCLUSIONS Invasive carcinoma is considerably more frequent in patients with two or more relative indications. The surgical strategy in these selected cases should be decided on an individual basis.
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Affiliation(s)
| | | | - Ivan Borbath
- Department of Gastroenterology and Hepatology, University Hospitals St-Luc, Brussels, Belgium
| | - Juan J Vila
- Department of Gastroenterology, Navarra Hospital, Navarra, Spain
| | | | - Pierre H Deprez
- Department of Gastroenterology and Hepatology, University Hospitals St-Luc, Brussels, Belgium
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25
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Intraductal Papillary Mucinous Neoplasm of the Pancreas as the Main Focus for Early Detection of Pancreatic Adenocarcinoma. Pancreas 2018; 47:544-550. [PMID: 29702531 DOI: 10.1097/mpa.0000000000001047] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
For early detection of pancreatic cancer, interests are now focused on the detection of high-risk individuals to undergo screening examinations. Intraductal papillary mucinous neoplasm (IPMN) is a unique dual precursor of pancreatic cancer, characterized by progression to invasive cancer and the development of pancreatic adenocarcinoma either concomitantly (synchronous occurrence) or even after resection of IPMN (metachronous occurrence). Careful examination and surveillance of patients with IPMN may therefore lead to early detection of pancreatic cancer. By reviewing only reports describing detailed breakdown of the morphological types of IPMN and numbers of patients with noninvasive and invasive carcinoma in each type, the rough frequencies of noninvasive carcinoma in main duct IPMNs and branch duct IPMNs (BD-IPMNs) are 20% and 10%, respectively, and those of invasive carcinoma are 40% and 13%, respectively. Roughly 5% of all patients with IPMN had concomitant adenocarcinoma. The real frequency of carcinoma in BD-IPMNs would be far lower because most patients with small asymptomatic BD-IPMNs do not undergo resection. Intraductal papillary mucinous neoplasm can be the main focus for early detection of pancreatic cancer to achieve favorable prognosis after surgical resection. The optimal protocol for surveillance and method for early detection of pancreatic cancer are to be determined.
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Abstract
Evidence-based guidelines on the management of pancreatic cystic neoplasms (PCN) are lacking. This guideline is a joint initiative of the European Study Group on Cystic Tumours of the Pancreas, United European Gastroenterology, European Pancreatic Club, European-African Hepato-Pancreato-Biliary Association, European Digestive Surgery, and the European Society of Gastrointestinal Endoscopy. It replaces the 2013 European consensus statement guidelines on PCN. European and non-European experts performed systematic reviews and used GRADE methodology to answer relevant clinical questions on nine topics (biomarkers, radiology, endoscopy, intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystic neoplasm, rare cysts, (neo)adjuvant treatment, and pathology). Recommendations include conservative management, relative and absolute indications for surgery. A conservative approach is recommended for asymptomatic MCN and IPMN measuring <40 mm without an enhancing nodule. Relative indications for surgery in IPMN include a main pancreatic duct (MPD) diameter between 5 and 9.9 mm or a cyst diameter ≥40 mm. Absolute indications for surgery in IPMN, due to the high-risk of malignant transformation, include jaundice, an enhancing mural nodule >5 mm, and MPD diameter >10 mm. Lifelong follow-up of IPMN is recommended in patients who are fit for surgery. The European evidence-based guidelines on PCN aim to improve the diagnosis and management of PCN.
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27
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Evaluation of the International Consensus Guidelines for the Surgical Resection of Intraductal Papillary Mucinous Neoplasms. Dig Dis Sci 2018; 63:860-867. [PMID: 28667432 DOI: 10.1007/s10620-017-4667-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 06/26/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND International consensus guidelines for intraductal papillary mucinous neoplasms (IPMNs) were revised in 2012. AIMS We aimed to evaluate the clinical utility of each predictor in the 2006 and 2012 guidelines and validate the diagnostic value and surgical indications. METHODS Forty-two patients with surgically resected IPMNs were included. Each predictor was applied to evaluate its diagnostic value. RESULTS The 2012 guidelines had greater accuracy for invasive carcinoma than the 2006 guidelines (64.3 vs. 31.0%). Moreover, the accuracy for high-grade dysplasia was also increased (48.6 vs. 77.1%). When the main pancreatic duct (MPD) size ≥8 mm was substituted for MPD size ≥10 mm in the 2012 guidelines, the accuracy for high-grade dysplasia was 80.0%. CONCLUSIONS The 2012 guidelines exhibited increased diagnostic accuracy for invasive IPMN. It is important to consider surgical resection prior to invasive carcinoma, and high-risk stigmata might be a useful diagnostic criterion. Furthermore, MPD size ≥8 mm may be predictive of high-grade dysplasia.
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28
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Einama T, Kamachi H, Sakata T, Shibata K, Wakizaka K, Sugiyama K, Shibuya K, Shimada S, Wakayama K, Orimo T, Yokoo H, Kamiyama T, Mitsuhashi T, Taketomi A. Curative resection of pancreatic ductal adenocarcinoma developing in the remnant pancreas 13 years after distal pancreatectomy for intraductal papillary mucinous neoplasms: A case report. Mol Clin Oncol 2018; 8:417-420. [PMID: 29456847 PMCID: PMC5795772 DOI: 10.3892/mco.2018.1556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 11/22/2017] [Indexed: 11/24/2022] Open
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) are characterized by the papillary proliferation of atypical mucinous epithelial cells in the pancreatic ductal system. There are two recurrence patterns following resection of IPMNs: Metachronous multifocal occurrence of IPMNs, and distinct pancreatic ductal adenocarcinoma (PDAC) in the remnant pancreas. Several recent studies investigated the development of distinct PDAC during follow-up evaluation of IPMNs and the incidence rate ranged from 4.5 to 8%. Thus, IMPNs may be a good predictor for the early detection of PDAC during observation or after the resection of IPMNs. We herein report the rare case of a patient who underwent resection of PDAC that developed in the remnant pancreas 13 years after distal pancreatectomy with splenectomy for IPMNs. PDAC may develop in the remnant pancreas after pancreatectomy for IPMNs; thus, careful long-term follow-up with periodic surveillance, at least every 6 months, is warranted.
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Affiliation(s)
- Takahiro Einama
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Hirofumi Kamachi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Toshihiro Sakata
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Kengo Shibata
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Kazuki Wakizaka
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Ko Sugiyama
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Kazuaki Shibuya
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Shingo Shimada
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Kenji Wakayama
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Tatsuya Orimo
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Hideki Yokoo
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Toshiya Kamiyama
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
| | - Tomoko Mitsuhashi
- Department of Surgical Pathology, Hokkaido University Hospital, Sapporo, Hokkaido 060-8638, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido 060-8638, Japan
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29
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Hughes I, GMT Powell A, Sarireh BA. Intraductal papillary mucinous neoplasm\'s 100 most significant manuscripts: A bibliometric analysis. INTERNATIONAL JOURNAL OF HEPATOBILIARY AND PANCREATIC DISEASES 2018. [DOI: 10.5348/100076z04dh2018ba] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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30
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Impact of MUC1 Expression on the Progression of Intraductal Papillary Mucinous Neoplasm With Worrisome Features During Follow-up. Pancreas 2017; 46:1127-1132. [PMID: 28902782 DOI: 10.1097/mpa.0000000000000902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The aim of this study was to investigate whether MUC1 expression is associated with progression of intraductal papillary mucinous neoplasms with worrisome features during follow-up. METHODS Fifteen patients positive for MUC1 and negative for MUC2 (MUC1 group) and 16 patients negative for MUC1 and MUC2 (control group) were followed up and examined for changes in diameters of the main and ectatic branches of pancreatic ducts, enlargement of mural nodules, and appearance of a solid mass, by imaging studies. All of them presented worrisome features, and none had "high-risk stigmata." RESULTS The sizes of the main and ectatic branches of pancreatic ducts increased in 8 (53.3%) and 8 (53.3%) patients, respectively, of the MUC1 group and in 1 (6.3%) and 1 (6.3%) patients, respectively, of the control group (P = 0.0059 and 0.0059, respectively). A solid mass developed in 6 patients (33.3%) of the MUC1 group but in none of the control group patients (P = 0.0373). CONCLUSIONS Positive MUC1 expression in cell block cytology specimens may be associated with progressive dilation of the main and ectatic branches of pancreatic ducts and appearance of a solid mass in patients with intraductal papillary mucinous neoplasm with worrisome features during follow-up.
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31
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Ridtitid W, Al-Haddad MA. Endoscopic Ultrasound Imaging for Diagnosing and Treating Pancreatic Cysts. Gastrointest Endosc Clin N Am 2017; 27:615-642. [PMID: 28918802 DOI: 10.1016/j.giec.2017.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Cystic pancreatic lesions are increasingly diagnosed owing to the abundant use of cross-sectional imaging. Given their malignant potential, true pancreatic cysts should be considered for resection or periodic follow-up. Cystic lesions of the pancreas (CLPs) require further evaluation and management. Therefore, it is important to establish a solid diagnosis at the time of detection. Endoscopic ultrasound examination is the imaging modality of choice. Fine needle aspiration provides fluid for cytologic, biochemical, and molecular assays to classify lesions and predict biological behavior. This review provides an overview of the diagnosis and management of various types of commonly encountered true CLPs.
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Affiliation(s)
- Wiriyaporn Ridtitid
- Division of Gastroenterology and Hepatology, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100, Indianapolis, IN 46202, USA.
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32
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Christopher WO, Earl TM, Puneky LV, Seawright AH, Wynn JJ, Anderson CD, Orr WS. Invasive Pancreatic Adenocarcinoma Arising in Intraductal Papillary Mucinous Neoplasm of Heterotopic Pancreatic Origin Located in the Stomach. Am Surg 2017. [DOI: 10.1177/000313481708300911] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
| | - Truman M. Earl
- University of Mississippi Medical Center Jackson, Mississippi
| | - Louis V. Puneky
- University of Mississippi Medical Center Jackson, Mississippi
| | | | - James J. Wynn
- University of Mississippi Medical Center Jackson, Mississippi
| | | | - W. Shannon Orr
- University of Mississippi Medical Center Jackson, Mississippi
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Choi SY, Kim JH, Yu MH, Eun HW, Lee HK, Han JK. Diagnostic performance and imaging features for predicting the malignant potential of intraductal papillary mucinous neoplasm of the pancreas: a comparison of EUS, contrast-enhanced CT and MRI. Abdom Radiol (NY) 2017; 42:1449-1458. [PMID: 28144718 DOI: 10.1007/s00261-017-1053-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To compare diagnostic performance for prediction of malignant potential in IPMNs between EUS, contrast-enhanced CT and MRI. MATERIALS AND METHODS 76 patients with IPMN (benign = 37, malignant = 39) underwent EUS, contrast-enhanced CT, and MRI. EUS was analyzed based on formal reports and contrast-enhanced CT and MRI were retrospectively analyzed by two radiologists according to the consensus guidelines 2012. Diagnostic performance and imaging features of malignant IPMNs were analyzed using ROC analysis and multivariate analyses. RESULTS Diagnostic performance of contrast-enhanced CT (AUC = 0.792 in R1, 0.830 in R2), MRI (AUC = 0.742 in R1, 0.776 in R2), and EUS (AUC = 0.733) for predicting malignant IPMNs were comparable without significant difference (p > 0.05). In multivariable analysis, enhancing solid component in contrast-enhanced CT and MRI and mural nodule in EUS (OR 1.8 in CT, 1.36 in MRI, 1.47 in EUS), MPD diameter ≥ 10 mm (OR 1.3 in CT, 1.4 in MRI, 1.66 in EUS), MPD diameter of 5-9 mm (OR 1.23 in CT, 1.31 in MRI), and thickened septa or wall (OR 1.3 in CT and MRI) were significant variables (p < 0.05). Interobserver agreement of thickened cyst septa or wall (k = 0.579-0.617) and abrupt caliber change of MPD (k = 0.689-0.788) was lower than other variables (k > 0.80). CONCLUSION Diagnostic performance of contrast-enhanced CT, MRI, and EUS for predicting malignant IPMNs was comparable with each modalities without significant difference.
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Affiliation(s)
- Seo-Youn Choi
- Department of Radiology, Soonchunhyang University Bucheon Hospital, 170 Jomaru-ro, Wonmi-gu, Bucheon, 420-767, Republic of Korea
| | - Jung Hoon Kim
- Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, 101 Daehang-no, Chongno-gu, Seoul, 110-744, Republic of Korea.
| | - Mi Hye Yu
- Department of Radiology, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Hyo Won Eun
- Department of Radiology, Samsung Medical Center, 50 Ilwon-Dong, Kangnam-Ku, Seoul, 135-710, Republic of Korea
| | - Hae Kyung Lee
- Department of Radiology, Soonchunhyang University Bucheon Hospital, 170 Jomaru-ro, Wonmi-gu, Bucheon, 420-767, Republic of Korea
| | - Joon Koo Han
- Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, 101 Daehang-no, Chongno-gu, Seoul, 110-744, Republic of Korea
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34
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International Intraductal Papillary Mucinous Neoplasms Registry: Long-Term Results Based on the New Guidelines. Pancreas 2017; 46:306-310. [PMID: 28099263 DOI: 10.1097/mpa.0000000000000750] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to analyze the outcomes of a long-term intraductal papillary mucinous neoplasm (IPMN) registry and evaluate new guidelines. METHODS A prospectively maintained IPMN registry involving 6 centers in Europe and the United States was used to collect the data. Patients with more than 1-year follow-up and no malignancy diagnosed within the first 3 months of surveillance were included. RESULTS From 1999 to 2014, 620 patients were included. The median follow-up time was 3 years. Thirty-seven (6%) patients developed malignancy with a median time from IPMN diagnosis to malignancy of 10.3 months. The 1-, 5-, and 10-year actuarial rates of disease-free survival were 97%, 93%, and 92% respectively. Four hundred thirty-one patients met criteria for low-risk branch duct IPMN consisting of cyst size less than 3 cm, with no solid component or main duct dilation. Eight malignancies were diagnosed in this subgroup, all of them within the first 5 years. From this subcohort, 112 patients had a follow-up time of more than 5 years, and no malignancy was diagnosed. CONCLUSIONS In IPMN lesions with low-risk features at baseline, the risk of progression to malignancy after the first 5 years of follow-up was minimal. Furthermore, the main cyst characteristics remained unchanged during their surveillance.
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Chang YR, Park JK, Jang JY, Kwon W, Yoon JH, Kim SW. Incidental pancreatic cystic neoplasms in an asymptomatic healthy population of 21,745 individuals: Large-scale, single-center cohort study. Medicine (Baltimore) 2016; 95:e5535. [PMID: 28002329 PMCID: PMC5181813 DOI: 10.1097/md.0000000000005535] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Although incidental pancreatic cystic neoplasms are being diagnosed with increasing frequency, little is known about the accurate prevalence of pancreatic cysts in the general population. The aims of this study were to evaluate the crude prevalence rate of pancreatic cystic neoplasms in asymptomatic healthy adults, and calculate the age- and sex-adjusted nationwide prevalence rate.A total of 21,745 asymptomatic individuals who underwent abdominal computed tomography (CT) as a health screening examination were enrolled between 2003 and 2013 at the Seoul National University Hospital Healthcare System Gangnam Center. Nationwide population data of 2010 were collected from the National Statistical Office, Korea.Incidental pancreatic cystic neoplasms were found in 457 individuals whose mean age was 58.7 years. The types of neoplasms were reviewed by 2 separate designated radiologists and the final diagnosis was made as follows: intraductal papillary mucinous neoplasm: 376 (82%), serous cystic neoplasm: 19 (4%), mucinous cystic neoplasm: 7 (2%), and indeterminate cysts: 55 (12%). Eight cases underwent operation. The crude prevalence rate was 2.1% and the age- and sex-adjusted expected nationwide prevalence was 2.2%. The prevalence increased with age.Here, we reported the first large-scale study among the healthy population to find out the prevalence rate of pancreatic cystic neoplasms; the age- and sex-adjusted prevalence was 2.2%, and increased with age. Further investigations regarding the clinical implications of incidental pancreatic neoplasms are necessary.
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Affiliation(s)
- Ye Rim Chang
- Department of Surgery, Seoul National University College of Medicine, Seoul
- Department of Surgery, Dankook University College of Medicine, Cheonan
| | - Joo Kyung Park
- Department of Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul National University College of Medicine
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul
| | - Wooil Kwon
- Department of Surgery, Seoul National University College of Medicine, Seoul
| | - Jeong Hee Yoon
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul
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Bournet B, Vignolle-Vidoni A, Grand D, Roques C, Breibach F, Cros J, Muscari F, Carrère N, Selves J, Cordelier P, Buscail L. Endoscopic ultrasound-guided fine-needle aspiration plus KRAS and GNAS mutation in malignant intraductal papillary mucinous neoplasm of the pancreas. Endosc Int Open 2016; 4:E1228-E1235. [PMID: 27995180 PMCID: PMC5161125 DOI: 10.1055/s-0042-117216] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 08/19/2016] [Indexed: 12/11/2022] Open
Abstract
Background:KRAS and GNAS mutations are common in intraductal papillary mucinous neoplasia of the pancreas (IPMN). The aims of this study were to assess the role of pre-therapeutic cytopathology combined with KRAS and GNAS mutation assays within cystic fluid sampled by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) to predict malignancy of IPMN. Patients and methods: We prospectively included 37 IPMN patients with clinical and/or imaging predictors of malignancy (men: 24; mean age: 69.5 years). Cytopathology (performed on cystic fluid and/or IPMN nodules), KRAS (Exon 2, codon 12) and GNAS (Exon 8, codon 201) mutations assays (using TaqMan® allelic discrimination) were performed on EUS-FNA material. The final diagnosis was obtained from IPMN resections (n = 18); surgical biopsies, EUS-FNA analyses, and follow-up (n = 19): 10 and 27 IPMN were benign and malignant, respectively. Results: Sensitivity, specificity, positive and negative predictive values, and accuracy of cytopathology alone to diagnose IPMN malignancy were 55 %, 100 %, 100 %, 45 %, and 66 %, respectively. When KRAS-mutation analysis was combined with cytopathology these values were 92 %, 50 %, 83 %, 71 %, and 81 %, respectively. GNAS assays did not improve the performances of cytopathology alone or those of cytopathology plus a KRAS assay. Conclusions: In patients with a likelihood of malignant IPMN at pre-therapeutic investigation, testing for KRAS mutations in cystic fluid sampling by EUS-FNA improved the results of cytopathology for the diagnosis of malignancy whereas GNAS mutation assay did not.
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Affiliation(s)
- Barbara Bournet
- Department of Gastroenterology and INSERM UMR 1037, CHU Toulouse Rangueil, University of Toulouse, Toulouse, France,INSERM UMR 1037, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France
| | - Alix Vignolle-Vidoni
- INSERM UMR 1037, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France
| | - David Grand
- Department of Pathology, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France
| | - Céline Roques
- Department of Pathology, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France
| | - Florence Breibach
- Department of Pathology, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France
| | - Jérome Cros
- Department of Pathology, Beaujon Hospital, University of Paris Diderot, Clichy, France
| | - Fabrice Muscari
- Department of Digestive Surgery, CHU Toulouse Rangueil, University of Toulouse, Toulouse, France
| | - Nicolas Carrère
- INSERM UMR 1037, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France,Department of Digestive Surgery, CHU Toulouse Purpan, University of Toulouse, Toulouse, France
| | - Janick Selves
- INSERM UMR 1037, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France,Department of Pathology, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France
| | - Pierre Cordelier
- INSERM UMR 1037, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France
| | - Louis Buscail
- Department of Gastroenterology and INSERM UMR 1037, CHU Toulouse Rangueil, University of Toulouse, Toulouse, France,INSERM UMR 1037, University Institute of Cancer of Toulouse, University of Toulouse, Toulouse, France,Corresponding author Louis Buscail, MD, PhD Department of Gastroenterology and INSERM U1037CHU Rangueil1 avenue Jean PoulhèsTSA 5003231059 Toulouse Cedex 9France+33 5 61 32 30 55+33 5 61 32 22 29
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Fong ZV, Fernández-del Castillo C. Intraductal Papillary Mucinous Neoplasm of the Pancreas. Surg Clin North Am 2016; 96:1431-1445. [DOI: 10.1016/j.suc.2016.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Development and Potential Utility of a New Scoring Formula for Prediction of Malignant Intraductal Papillary Mucinous Neoplasm of the Pancreas. Pancreas 2016; 45:1227-32. [PMID: 27171512 DOI: 10.1097/mpa.0000000000000649] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE A simple system is needed to determine whether surgery is indicated in cases of intraductal papillary mucinous neoplasm (IPMN). METHODS We conducted a retrospective study to identify factors predictive of malignant IPMN and thus simplify the treatment decision-making process. Ninety-six consecutive patients treated surgically for IPMN at Kyorin University Hospital (Tokyo, Japan) between 1994 and 2014 were included. Univariate and multivariate analyses were used to identify preoperative factors predictive of malignancy. A simple scoring formula was derived from the regression equation. RESULTS Twenty-two (23%) of the IPMNs were malignant, and 74 (77%) were benign. Pancreatic head tumor, cyst diameter of 47 mm or greater, and mural nodule diameter of 9 mm or greater were identified as significant predictors of malignant IPMN. The following scoring formula was developed: 4 × tumor location (pancreatic head, 1; pancreatic body or tail, 0) + 3 × cyst diameter (≥47 mm, 1; <47 mm, 0) + 6 × mural nodule diameter (≥9 mm, 1; <9 mm, 0); the area under the receiver operating characteristic curve was 0.970. At a cutoff of 8 points, the diagnostic accuracy was excellent (sensitivity, 90.9%; specificity, 95.9%; accuracy, 94.8%). CONCLUSIONS Our scoring system has potential as a simple screening tool for the identification of malignant IPMN.
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Risk Factors for Malignancy of Branch-Duct Intraductal Papillary Mucinous Neoplasms: A Critical Evaluation of the Fukuoka Guidelines With a Systematic Review and Meta-analysis. Pancreas 2016; 45:1243-1254. [PMID: 27776043 DOI: 10.1097/mpa.0000000000000642] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES This study aimed to evaluate the accuracy of the risk factors proposed by Fukuoka guidelines in detecting malignancy of branch-duct intraductal papillary mucinous neoplasms. METHOD Diagnostic meta-analysis of cohort studies. A systematic literature search was conducted using MEDLINE, the Cochrane Library, Scopus, and the ISI-Web of Science databases to identify all studies published up to 2014. RESULTS Twenty-five studies (2025 patients) were suitable for the meta-analysis. The "high risk stigmata" showed the highest pooled diagnostic odds ratio (jaundice, 6.3; positive citology, 5.5; mural nodules, 4.8) together with 2 "worrisome features" (thickened/enhancing walls, 4.2; duct dilatation, 4.0) and 1 "other parameters" (carbohydrate antigen 19-9 serum levels, 4.6). CONCLUSIONS An "ideal risk factor" capable of recognizing all malignant branch-duct intraductal papillary mucinous neoplasms was not identified and some "dismal areas" remain. However, "high risk stigmata" were strongly related to malignancy, mainly enhancing mural nodules. Among the "worrisome features," duct dilatation and thickened/enhancing walls were underestimated, and their diagnostic performance was similar to those of "high risk stigmata." The carbohydrate antigen 19-9 serum level should be added to the Fukuoka algorithm because this value could help in carrying out correct management.
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Hsiao CY, Yang CY, Wu JM, Kuo TC, Tien YW. Utility of the 2006 Sendai and 2012 Fukuoka guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas: A single-center experience with 138 surgically treated patients. Medicine (Baltimore) 2016; 95:e4922. [PMID: 27661043 PMCID: PMC5044913 DOI: 10.1097/md.0000000000004922] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This study aimed to evaluate the utility of the 2006 Sendai and 2012 Fukuoka guidelines for differentiating malignant intraductal papillary mucinous neoplasm (IPMN) of the pancreas from benign IPMN.Between January 2000 and March 2015, a total of 138 patients underwent surgery and had a pathologically confirmed pancreatic IPMN. Clinicopathological parameters were reviewed, and all patients were classified according to both the 2006 Sendai and 2012 Fukuoka guidelines. Univariate and multivariate analyses were used for identifying significant factors associated with malignancy in IPMN.There were 9 high-grade dysplasia (HGD) and 37 invasive cancers (ICs) in the 138 patients. The positive predictive value (PPV) and negative predictive value (NPV) of the Sendai and Fukuoka guidelines for HGD/IC was 35.1%, 43.3%, 100%, and 85.4%, respectively. Of the 36 patients with worrisome features using the Fukuoka guideline, 7 patients had HGD/IC in their IPMNs. According to the multivariate analysis, jaundice, tumors of ≥3 cm, presence of mural nodule on imaging, and aged <65 years were associated with HGD/IC in patients with IPMN.The Sendai guideline had a better NPV, but the Fukuoka guideline had a better PPV. We suggest that patients with worrisome features based on the Fukuoka guideline be aggressively managed.
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Affiliation(s)
| | | | | | | | - Yu-Wen Tien
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan, ROC
- Correspondence: Yu-Wen Tien, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Rd, Taipei 10002, Taiwan, ROC (e-mail: )
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Affiliation(s)
- Alexandra M Roch
- Department of Surgery, Indiana University School of Medicine, 980 W Walnut Street R3-C541, Indianapolis, IN 46202, USA
| | - Christian Max Schmidt
- IU Health Pancreatic Cyst and Cancer Early Detection Center, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, EH 129, Indianapolis, IN 46202, USA.
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Stromal Fibrosis and Expression of Matricellular Proteins Correlate With Histological Grade of Intraductal Papillary Mucinous Neoplasm of the Pancreas. Pancreas 2016; 45:1145-52. [PMID: 26967452 PMCID: PMC4993122 DOI: 10.1097/mpa.0000000000000617] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The aim of the study was to clarify the correlation between the microenvironmental factors and histological grade in intraductal papillary mucinous neoplasm (IPMN). METHODS We investigated 65 IPMNs resected at Yamagata University Hospital between 2000 and 2011, and all cases were categorized to low-inter (including low- and intermediate-grade dysplasia) and high-inv (including high-grade dysplasia and IPMN with an associated invasive carcinoma) groups. We compared between the 2 groups pathologically with regard to fibrosis and the expression of alpha-smooth muscle actin (α-SMA), periostin, and galectin-1 in the periductal stroma of IPMN. RESULTS There were 41 low-inter and 24 high-inv. The subtype was categorized as 22 main duct type (MD-IPMN) and 43 branch duct type (BD-IPMN). The degree of fibrosis and the expression of α-SMA, periostin, and galectin-1 were significantly higher in high-inv than in low-inter within BD-IPMNs. Multivariate logistic regression analysis indicated that high expression of α-SMA (odds ratio, 13.802; 95% confidence interval, 1.108-171.893; P = 0.0414) was a significant independent related factor of high-inv in BD-IPMN. CONCLUSIONS Stromal fibrosis and expression of α-SMA, periostin, and galectin-1 are more marked in high-inv than in low-inter within BD-IPMNs, and they could become new markers for determining the indications for surgery in BD-IPMN.
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Rodríguez Torres C, Larrosa López R. Descripción radiológica de las neoplasias quísticas pancreáticas. RADIOLOGIA 2016; 58:404-14. [DOI: 10.1016/j.rx.2016.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 06/07/2016] [Accepted: 06/09/2016] [Indexed: 11/28/2022]
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Yoshioka T, Shigekawa M, Yamai T, Suda T, Kegasawa T, Iwahashi K, Ikezawa K, Sakamori R, Yakushijin T, Hiramatsu N, Tatsumi T, Takehara T. The safety and benefit of pancreatic juice cytology under ERCP in IPMN patients. Pancreatology 2016; 16:1020-1027. [PMID: 27567445 DOI: 10.1016/j.pan.2016.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 08/04/2016] [Accepted: 08/15/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND International consensus guidelines 2012 for intraductal papillary mucinous neoplasia (IPMN), defined two characteristics: high-risk stigmata (HRS) and worrisome features (WF). Patients with WF require detailed examination including cytology. However, routine endoscopic retrograde cholangiopancreatography (ERCP) for cytology is not recommended in the guidelines due to risk of post-ERCP pancreatitis (PEP). Our aim was to clarify what types of IPMN were susceptible for PEP and gain benefit of ERCP. PATIENTS/METHODS We examined 138 consecutive IPMN patients who underwent ERCP in our hospital, retrospectively. Patients were classified into HRS, WF and the others (N) based on imaging findings before ERCP. We assessed pancreatic juice cytology, PEP frequency and rate of malignant IPMN at 12 months after ERCP. RESULTS The rates of cytological malignancy were 0% (N), 4.8% (WF) and 19.5% (HRS). The PEP frequency was 14.5%, and these risk factors were branch duct (BD)-IPMN, body/tail cysts and brush cytology by multivariate logistic analysis. The rates of malignant IPMN were 0% (N), 16.4% (WF) and 48.8% (HRS). Furthermore, we examined patients with WF in detail. The PEP frequency/rate of malignancy were 3.6%/23.1% in patients with main pancreatic duct (MPD) dilatation (5-9 mm), and the sensitivity of cytology was 33.3%. On the other hand, the PEP frequency/rate of malignancy were 17.2%/0% in patients with BD-IPMN fulfilling only cyst size over 30 mm. CONCLUSIONS Routine ERCP for IPMN, especially for BD-IPMN, is not recommended. ERCP may be beneficial for WF patients with MPD dilatation based on a balance between PEP risk and presence of malignancy.
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Affiliation(s)
- Teppei Yoshioka
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita 565-0871, Osaka, Japan
| | - Minoru Shigekawa
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita 565-0871, Osaka, Japan
| | - Takuo Yamai
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita 565-0871, Osaka, Japan
| | - Takahiro Suda
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita 565-0871, Osaka, Japan
| | - Tadashi Kegasawa
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita 565-0871, Osaka, Japan
| | - Kiyoshi Iwahashi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita 565-0871, Osaka, Japan
| | - Kenji Ikezawa
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita 565-0871, Osaka, Japan
| | - Ryotaro Sakamori
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita 565-0871, Osaka, Japan
| | - Takayuki Yakushijin
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita 565-0871, Osaka, Japan
| | - Naoki Hiramatsu
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita 565-0871, Osaka, Japan
| | - Tomohide Tatsumi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita 565-0871, Osaka, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita 565-0871, Osaka, Japan.
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Intraductal Papillary Mucinous Neoplasm of the Pancreas: Current State of the Art and Ongoing Controversies. Ann Surg 2016; 263:908-17. [PMID: 26727096 DOI: 10.1097/sla.0000000000001567] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
With the widespread use and advances in radiographic imaging, Intraductal Papillary Mucinous Neoplasms (IPMNs) of the pancreas are identified with increasing frequency. Although many studies have addressed its biology and treatment, true understanding of its natural history continues to elude us. Its malignant potential places careproviders in a clinical dilemma of balancing the morbidity of pancreatectomy against the risk of malignant transformation while under continuous surveillance. Recently, there have been conflicting data published in the literature, generating more uncertainty in the field. In this article, we critically analyze the contrasting consensus guidelines from the International Association of Pancreatology and the American Gastroenterology Association, and address lingering questions and controversies. We also synthesize newly published data in the context of current standard of care, and provide a comprehensive review and recommendations for the clinical diagnosis, treatment, and follow-up strategy in the management of patients with Intraductal Papillary Mucinous Neoplasms.
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Long-term surveillance is necessary after operative resection for intraductal papillary mucinous neoplasm of the pancreas. Surgery 2016; 160:306-17. [DOI: 10.1016/j.surg.2016.04.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 04/08/2016] [Accepted: 04/12/2016] [Indexed: 01/28/2023]
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Manuel Vázquez A, Carabias Hernández A, Carrascosa Mirón T, Valle Rubio A, Mínguez García J, Sanz Muñoz P, Serantes Gómez A, Jover Navalón JM. What to do with an intraductal papilary mucinous pancreatic neoplasm? Our experience. Cir Esp 2016; 94:467-72. [PMID: 27461233 DOI: 10.1016/j.ciresp.2016.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 04/19/2016] [Accepted: 05/22/2016] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Cystic pancreatic neoplasms are a heterogeneous group of pathology, and intraductal papillary mucinous neoplasia is becoming more common. The aim of this study is to review our series of cystic pancreatic neoplasms that underwent surgery and to evaluate the similarities with Fukuoka recommendations. METHODS Retrospective review of our experience analyzing clinical and radiological data, indication for surgery and pathology study of 11 patients operated on in our centre from july 2011 to july 2015, aiming to evaluate the degree of agreement with the current consensus. RESULTS In our series the majority of cases (7/11) had symptoms at diagnosis. Preoperative diagnosis was achieved in 10 patients using radiology and/or endoscopy. Indications for surgery were the presence of symptoms, radiological data suspicious of malignancy, and secondary branch neoplasia over 30mm. Pathological findings were malignancy in 6/11 cases (2 invasive neoplasia, 4 high grade dysplasia), moderate dysplasia in 2/11, low-grade dysplasia in 2/11 and no dysplasia in one patient. CONCLUSIONS Surgical indication of intraductal mucinous pancreatic neoplasms depends on the associated symptoms, size, location, risk and suspicion of malignancy.
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Affiliation(s)
- Alba Manuel Vázquez
- Servicio de Cirugía General y Digestiva, Hospital Universitario de Getafe, Madrid, España.
| | | | | | - Ainhoa Valle Rubio
- Servicio de Cirugía General y Digestiva, Hospital Universitario de Getafe, Madrid, España
| | - Javier Mínguez García
- Servicio de Cirugía General y Digestiva, Hospital Universitario de Getafe, Madrid, España
| | - Paloma Sanz Muñoz
- Servicio de Cirugía General y Digestiva, Hospital Universitario de Getafe, Madrid, España
| | - Ana Serantes Gómez
- Servicio de Cirugía General y Digestiva, Hospital Universitario de Getafe, Madrid, España
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Abstract
OBJECTIVES Endoscopic ultrasonography-guided ethanol ablation therapy for pancreatic cystic lesions is a minimally invasive treatment but still is an experimental therapy. The aims were to investigate the safety and efficacy of endoscopic ultrasonography-guided ethanol ablation therapy. METHODS The inclusion criteria were the following: clinically indeterminate pancreatic cystic lesions in radiologic imaging studies, 2 to 5 cm unilocular or oligolocular cysts without communication to main pancreatic duct, and patients with high-risk operation. RESULTS There were 91 study patients with median follow-up of 40 months. The response rate was as follows: complete resolution, 41 (45%); partial resolution, 37; and persistent cysts, 13. Pancreatic cystic lesions were categorized based on cystic fluid analysis: 9 intraductal papillary mucinous neoplasms (IPMNs), 12 mucinous cystic neoplasms, 33 serous cystic neoplasms, and 28 uncategorized cysts. The success rate was significantly different according to cystic fluid analysis (serous cystic neoplasm, 58%; mucinous cystic neoplasm, 50%; IPMN, 11%; uncategorized cysts, 39%; P < 0.0001). There were 3 patients with mild pancreatitis after the treatment. CONCLUSIONS Endoscopic ultrasonography-guided ethanol ablation therapy seems to be a safe treatment modality. However, it was only effective in 11% of IPMNs. Therefore, the clinical application should be very limited for certain patients who could not tolerate the surgical treatment.
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Shimura T, Kofunato Y, Okada R, Yashima R, Okada K, Araki K, Hosouchi Y, Kuwano H, Takenoshita S. MIB-1 labeling index, Ki-67, is an indicator of invasive intraductal papillary mucinous neoplasm. Mol Clin Oncol 2016; 5:317-322. [PMID: 27446570 DOI: 10.3892/mco.2016.908] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 05/09/2016] [Indexed: 01/25/2023] Open
Abstract
Despite strict criteria for the observation of intraductal papillary mucinous neoplasm (IPMN), it remains difficult to distinguish invasive IPMN from non-invasive IPMN. The aim of the present study was to identify an indicator of invasive IPMN. The present study retrospectively evaluated 53 patients (28 with non-invasive and 25 with invasive IPMN) who underwent resection of IPMN, and examined the usefulness of the MIB-1 labeling index as an indicator of invasive IPMN. The MIB-1 labeling indexes in patients with invasive IPMN were significantly higher compared with those with non-invasive IPMN (P<0.001). A receiver operating characteristic curve revealed that the area under the curve was 0.822. These results suggested that a cut-off level for the MIB-1 labeling index should be set to 15.5% to distinguish invasive from non-invasive IPMN. A multivariate analysis using a logistic regression model revealed the MIB-1 labeling index (hazard ratio, 18.692; 95% confidential interval, 4.171-83.760; P<0.001) and the existence of mural nodules (hazard ratio, 6.187, 95% confidential interval, 1.039-36.861; P=0.045) were predictive factors for invasive IPMN. However, no statistically significant differences were observed between patients with a lower MIB-1 labeling index and patients with a higher MIB-1 labeling index (P=0.798). The MIB-1 labeling index must be considered as a candidate for the classification of IPMN.
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Affiliation(s)
- Tatsuo Shimura
- Department of Cancer Biology and Electronics, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Yasuhide Kofunato
- Department of Organ Regulatory Surgery, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Ryo Okada
- Department of Organ Regulatory Surgery, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Rei Yashima
- Department of Organ Regulatory Surgery, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Koji Okada
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma 371-8511, Japan
| | - Kenichiro Araki
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma 371-8511, Japan
| | - Yasuo Hosouchi
- Department of Surgery and Laparoscopic Surgery, Gunma Prefecture Saiseikai-Maebashi Hospital, Maebashi, Gunma 371-0821, Japan
| | - Hiroyuki Kuwano
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma 371-8511, Japan
| | - Seiichi Takenoshita
- Department of Organ Regulatory Surgery, Fukushima Medical University, Fukushima 960-1295, Japan
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Seo N, Byun JH. Evaluation of malignant intraductal papillary mucinous neoplasms of the pancreas on computed tomography and magnetic resonance imaging. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Nieun Seo
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Ho Byun
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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