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Vilela A, Quingalahua E, Vargas A, Hawa F, Shannon C, Carpenter ES, Shi J, Krishna SG, Lee UJ, Chalhoub JM, Machicado JD. Global Prevalence of Pancreatic Cystic Lesions in the General Population on Magnetic Resonance Imaging: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2024; 22:1798-1809.e6. [PMID: 38423346 PMCID: PMC11344691 DOI: 10.1016/j.cgh.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND & AIMS Understanding the burden of pancreatic cystic lesions (PCLs) in the general population is important for clinicians and policymakers. In this systematic review, we sought to estimate the global prevalence of PCLs using magnetic resonance imaging (MRI) and to investigate factors that contribute to its variation. METHODS We searched MEDLINE, EMBASE, and Cochrane Central, from database inception through February 2023. We included full-text articles that reported the prevalence of PCLs using MRI in the general population. A proportional meta-analysis was performed, and the prevalence of PCLs was pooled using a random-effects model. RESULTS Fifteen studies with 65,607 subjects were identified. The pooled prevalence of PCLs was 16% (95% confidence interval [CI], 13%-18%; I2 = 99%), most of which were under 10 mm. Age-specific prevalence of PCLs increased from 9% (95% CI, 7%-12%) at 50 to 59 years, to 18% (95% CI, 14%-22%) at 60 to 69 years, 26% (95% CI, 20%-33%) at 70 to 79 years, and 38% at 80 years and above (95% CI, 25%-52%). There was no difference in prevalence between sexes. Subgroup analysis showed higher PCL prevalence when imaging findings were confirmed by independent radiologist(s) (25%; 95% CI, 16%-33%) than when chart review alone was used (5%; 95% CI, 4%-7%; P < .01). There was no independent association of PCL prevalence with geographic location (Europe, North America, or Asia), MRI indication (screening vs evaluation of non-pancreatic pathology), enrollment period, sample size, magnet strength (1.5 vs 3 tesla), and MRI sequence (magnetic resonance cholangiopancreatography vs no magnetic resonance cholangiopancreatography). CONCLUSION In this systematic review, the global prevalence of PCLs using a highly sensitive noninvasive imaging modality ranged between 13% and 18%.
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Affiliation(s)
- Ana Vilela
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, Virginia
| | - Elit Quingalahua
- Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | - Alejandra Vargas
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, Virginia
| | - Fadi Hawa
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Carol Shannon
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan
| | - Eileen S Carpenter
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Jiaqi Shi
- Department of Pathology & Clinical Labs, University of Michigan, Ann Arbor, Michigan
| | - Somashekar G Krishna
- Division of Gastroenterology and Hepatology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Un-Jung Lee
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, Staten Island, New York
| | - Jean M Chalhoub
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York
| | - Jorge D Machicado
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan.
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Berbís MÁ, Godino FP, Rodríguez-Comas J, Nava E, García-Figueiras R, Baleato-González S, Luna A. Radiomics in CT and MR imaging of the liver and pancreas: tools with potential for clinical application. Abdom Radiol (NY) 2024; 49:322-340. [PMID: 37889265 DOI: 10.1007/s00261-023-04071-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/15/2023] [Accepted: 09/19/2023] [Indexed: 10/28/2023]
Abstract
Radiomics allows the extraction of quantitative imaging features from clinical magnetic resonance imaging (MRI) and computerized tomography (CT) studies. The advantages of radiomics have primarily been exploited in oncological applications, including better characterization and staging of oncological lesions and prediction of patient outcomes and treatment response. The potential introduction of radiomics in the clinical setting requires the establishment of a standardized radiomics pipeline and a quality assurance program. Radiomics and texture analysis of the liver have improved the differentiation of hypervascular lesions such as adenomas, focal nodular hyperplasia, and hepatocellular carcinoma (HCC) during the arterial phase, and in the pretreatment determination of HCC prognostic factors (e.g., tumor grade, microvascular invasion, Ki-67 proliferation index). Radiomics of pancreatic CT and MR images has enhanced pancreatic ductal adenocarcinoma detection and its differentiation from pancreatic neuroendocrine tumors, mass-forming chronic pancreatitis, or autoimmune pancreatitis. Radiomics can further help to better characterize incidental pancreatic cystic lesions, accurately discriminating benign from malignant intrapancreatic mucinous neoplasms. Nonetheless, despite their encouraging results and exciting potential, these tools have yet to be implemented in the clinical setting. This non-systematic review will describe the essential steps in the implementation of the radiomics and feature extraction workflow from liver and pancreas CT and MRI studies for their potential clinical application. A succinct overview of reported radiomics applications in the liver and pancreas and the challenges and limitations of their implementation in the clinical setting is also discussed, concluding with a brief exploration of the future perspectives of radiomics in the gastroenterology field.
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Affiliation(s)
- M Álvaro Berbís
- Department of Radiology, HT Médica, San Juan de Dios Hospital, 14960, Córdoba, Spain.
- Department of Radiology, HT Médica, San Juan de Dios Hospital, Av. del Brillante, 106, 14012, Córdoba, Spain.
| | | | | | - Enrique Nava
- Department of Communications Engineering, University of Málaga, 29016, Málaga, Spain
| | - Roberto García-Figueiras
- Abdominal Imaging Section, University Clinical Hospital of Santiago, 15706, Santiago de Compostela, A Coruña, Spain
| | - Sandra Baleato-González
- Abdominal Imaging Section, University Clinical Hospital of Santiago, 15706, Santiago de Compostela, A Coruña, Spain
| | - Antonio Luna
- Department of Radiology, HT Médica, Clínica las Nieves, 23007, Jaén, Spain
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Veron Sanchez A, Santamaria Guinea N, Cayon Somacarrera S, Bennouna I, Pezzullo M, Bali MA. Rare Solid Pancreatic Lesions on Cross-Sectional Imaging. Diagnostics (Basel) 2023; 13:2719. [PMID: 37627978 PMCID: PMC10453474 DOI: 10.3390/diagnostics13162719] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/15/2023] [Accepted: 08/18/2023] [Indexed: 08/27/2023] Open
Abstract
Several solid lesions can be found within the pancreas mainly arising from the exocrine and endocrine pancreatic tissue. Among all pancreatic malignancies, the most common subtype is pancreatic ductal adenocarcinoma (PDAC), to a point that pancreatic cancer and PDAC are used interchangeably. But, in addition to PDAC, and to the other most common and well-known solid lesions, either related to benign conditions, such as pancreatitis, or not so benign, such as pancreatic neuroendocrine neoplasms (pNENs), there are solid pancreatic lesions considered rare due to their low incidence. These lesions may originate from a cell line with a differentiation other than exocrine/endocrine, such as from the nerve sheath as for pancreatic schwannoma or from mesenchymal cells as for solitary fibrous tumour. These rare solid pancreatic lesions may show a behaviour that ranges in a benign to highly aggressive malignant spectrum. This review includes cases of an intrapancreatic accessory spleen, pancreatic tuberculosis, solid serous cystadenoma, solid pseudopapillary tumour, pancreatic schwannoma, purely intraductal neuroendocrine tumour, pancreatic fibrous solitary tumour, acinar cell carcinoma, undifferentiated carcinoma with osteoclastic-like giant cells, adenosquamous carcinoma, colloid carcinoma of the pancreas, primary leiomyosarcoma of the pancreas, primary and secondary pancreatic lymphoma and metastases within the pancreas. Therefore, it is important to determine the correct diagnosis to ensure optimal patient management. Because of their rarity, their existence is less well known and, when depicted, in most cases incidentally, the correct diagnosis remains challenging. However, there are some typical imaging features present on cross-sectional imaging modalities that, taken into account with the clinical and biological context, contribute substantially to achieve the correct diagnosis.
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Affiliation(s)
- Ana Veron Sanchez
- Hôpital Universitaire de Bruxelles, Institut Jules Bordet, 1070 Brussels, Belgium; (I.B.)
| | | | | | - Ilias Bennouna
- Hôpital Universitaire de Bruxelles, Institut Jules Bordet, 1070 Brussels, Belgium; (I.B.)
| | - Martina Pezzullo
- Hôpital Universitaire de Bruxelles, Hôpital Erasme, 1070 Brussels, Belgium
| | - Maria Antonietta Bali
- Hôpital Universitaire de Bruxelles, Institut Jules Bordet, 1070 Brussels, Belgium; (I.B.)
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Quingalahua E, Al-Hawary MM, Machicado JD. The Role of Magnetic Resonance Imaging (MRI) in the Diagnosis of Pancreatic Cystic Lesions (PCLs). Diagnostics (Basel) 2023; 13:diagnostics13040585. [PMID: 36832073 PMCID: PMC9955706 DOI: 10.3390/diagnostics13040585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/22/2023] [Accepted: 02/03/2023] [Indexed: 02/08/2023] Open
Abstract
Pancreatic cystic lesions (PCLs) are a common incidental finding on cross-sectional imaging. Given the high signal to noise and contrast resolution, multi-parametric capability and lack of ionizing radiation, magnetic resonance imaging (MRI) has become the non-invasive method of choice to predict cyst type, risk stratify the presence of neoplasia, and monitor changes during surveillance. In many patients with PCLs, the combination of MRI and the patient's history and demographics will suffice to stratify lesions and guide treatment decisions. In other patients, especially those with worrisome or high-risk features, a multimodal diagnostic approach that includes endoscopic ultrasound (EUS) with fluid analysis, digital pathomics, and/or molecular analysis is often necessary to decide on management options. The application of radiomics and artificial intelligence in MRI may improve the ability to non-invasively stratify PCLs and better guide treatment decisions. This review will summarize the evidence on the evolution of MRI for PCLs, the prevalence of PCLs using MRI, and the MRI features to diagnose specific PCL types and early malignancy. We will also describe topics such as the utility of gadolinium and secretin in MRIs of PCLs, the limitations of MRI for PCLs, and future directions.
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Affiliation(s)
- Elit Quingalahua
- Division of Hematology and Oncology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Mahmoud M. Al-Hawary
- Department of Diagnostic Imaging, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jorge D. Machicado
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI 48109, USA
- Correspondence:
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Singh RR, Gopakumar H, Sharma NR. Diagnosis and Management of Pancreatic Cysts: A Comprehensive Review of the Literature. Diagnostics (Basel) 2023; 13:diagnostics13030550. [PMID: 36766654 PMCID: PMC9914101 DOI: 10.3390/diagnostics13030550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
The prevalence of pancreatic cysts has been rising due to the widespread use of cross-sectional imaging (CT scan and MRI) of the abdomen. While most pancreatic cysts are benign and do not require treatment or surveillance, a significant minority are premalignant and rarely malignant. The risk stratification of these lesions is not straightforward, and individual risk assessment, cyst size, distribution, and alarming morphologic features (when present) can guide the next steps in management. Neoplastic pancreatic cysts are mucinous or non-mucinous. Endoscopic ultrasound with fine-needle aspiration is often required to classify pancreatic cysts into mucinous and non-mucinous cysts and to assess the malignant potential. Advances in endoscopic techniques (confocal laser endomicroscopy, microforceps biopsy) can provide a definitive diagnosis of pancreatic cysts in some cases; however, the use of these techniques involves a higher risk of adverse events.
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Affiliation(s)
- Ritu R. Singh
- Parkview Cancer Institute (PCI), Parkview Regional Medical Center, Fort Wayne, IN 46845, USA
- Department of Medicine, Indiana University School of Medicine, Fort Wayne, IN 46805, USA
| | - Harishankar Gopakumar
- Division of Gastroenterology and Hepatology, University of Illinois College of Medicine, Peoria, IL 61656, USA
| | - Neil R. Sharma
- Parkview Cancer Institute (PCI), Parkview Regional Medical Center, Fort Wayne, IN 46845, USA
- Department of Medicine, Indiana University School of Medicine, Fort Wayne, IN 46805, USA
- Correspondence:
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Granata V, Fusco R, Setola SV, Galdiero R, Maggialetti N, Silvestro L, De Bellis M, Di Girolamo E, Grazzini G, Chiti G, Brunese MC, Belli A, Patrone R, Palaia R, Avallone A, Petrillo A, Izzo F. Risk Assessment and Pancreatic Cancer: Diagnostic Management and Artificial Intelligence. Cancers (Basel) 2023; 15:351. [PMID: 36672301 PMCID: PMC9857317 DOI: 10.3390/cancers15020351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
Pancreatic cancer (PC) is one of the deadliest cancers, and it is responsible for a number of deaths almost equal to its incidence. The high mortality rate is correlated with several explanations; the main one is the late disease stage at which the majority of patients are diagnosed. Since surgical resection has been recognised as the only curative treatment, a PC diagnosis at the initial stage is believed the main tool to improve survival. Therefore, patient stratification according to familial and genetic risk and the creation of screening protocol by using minimally invasive diagnostic tools would be appropriate. Pancreatic cystic neoplasms (PCNs) are subsets of lesions which deserve special management to avoid overtreatment. The current PC screening programs are based on the annual employment of magnetic resonance imaging with cholangiopancreatography sequences (MR/MRCP) and/or endoscopic ultrasonography (EUS). For patients unfit for MRI, computed tomography (CT) could be proposed, although CT results in lower detection rates, compared to MRI, for small lesions. The actual major limit is the incapacity to detect and characterize the pancreatic intraepithelial neoplasia (PanIN) by EUS and MR/MRCP. The possibility of utilizing artificial intelligence models to evaluate higher-risk patients could favour the diagnosis of these entities, although more data are needed to support the real utility of these applications in the field of screening. For these motives, it would be appropriate to realize screening programs in research settings.
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Affiliation(s)
- Vincenza Granata
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Roberta Fusco
- Medical Oncology Division, Igea SpA, 41012 Napoli, Italy
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy
| | - Sergio Venanzio Setola
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Roberta Galdiero
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Nicola Maggialetti
- Department of Medical Science, Neuroscience and Sensory Organs (DSMBNOS), University of Bari “Aldo Moro”, 70124 Bari, Italy
| | - Lucrezia Silvestro
- Division of Clinical Experimental Oncology Abdomen, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Mario De Bellis
- Division of Gastroenterology and Digestive Endoscopy, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Elena Di Girolamo
- Division of Gastroenterology and Digestive Endoscopy, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Giulia Grazzini
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Giuditta Chiti
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Maria Chiara Brunese
- Diagnostic Imaging Section, Department of Medical and Surgical Sciences & Neurosciences, University of Molise, 86100 Campobasso, Italy
| | - Andrea Belli
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Renato Patrone
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Raffaele Palaia
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Antonio Avallone
- Division of Clinical Experimental Oncology Abdomen, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Antonella Petrillo
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Francesco Izzo
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
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Dong Z, Chen X, Cheng Z, Luo Y, He M, Chen T, Zhang Z, Qian X, Chen W. Differential diagnosis of pancreatic cystic neoplasms through a radiomics-assisted system. Front Oncol 2022; 12:941744. [PMID: 36591475 PMCID: PMC9802410 DOI: 10.3389/fonc.2022.941744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022] Open
Abstract
Pancreatic cystic neoplasms (PCNs) are a group of heterogeneous diseases with distinct prognosis. Existing differential diagnosis methods require invasive biopsy or prolonged monitoring. We sought to develop an inexpensive, non-invasive differential diagnosis system for PCNs based on radiomics features and clinical characteristics for a higher total PCN screening rate. We retrospectively analyzed computed tomography images and clinical data from 129 patients with PCN, including 47 patients with intraductal papillary mucinous neoplasms (IPMNs), 49 patients with serous cystadenomas (SCNs), and 33 patients with mucinous cystic neoplasms (MCNs). Six clinical characteristics and 944 radiomics features were tested, and nine features were finally selected for model construction using DXScore algorithm. A five-fold cross-validation algorithm and a test group were applied to verify the results. In the five-fold cross-validation section, the AUC value of our model was 0.8687, and the total accuracy rate was 74.23%, wherein the accuracy rates of IPMNs, SCNs, and MCNs were 74.26%, 78.37%, and 68.00%, respectively. In the test group, the AUC value was 0.8462 and the total accuracy rate was 73.61%. In conclusion, our research constructed an end-to-end powerful PCN differential diagnosis system based on radiomics method, which could assist decision-making in clinical practice.
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Affiliation(s)
- Zhenglin Dong
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Department of orthopedics, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiahan Chen
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Zhaorui Cheng
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuanbo Luo
- Department of Otorhinolaryngology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min He
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Tao Chen
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zijie Zhang
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,*Correspondence: Zijie Zhang, ; Xiaohua Qian, ; Wei Chen,
| | - Xiaohua Qian
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China,*Correspondence: Zijie Zhang, ; Xiaohua Qian, ; Wei Chen,
| | - Wei Chen
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,*Correspondence: Zijie Zhang, ; Xiaohua Qian, ; Wei Chen,
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Khristenko E, Hank T, Gaida MM, Kauczor HU, Hackert T, Klauß M, Mayer P. Imaging features of intraductal tubulopapillary neoplasm of the pancreas and its differentiation from conventional pancreatic ductal adenocarcinoma. Sci Rep 2022; 12:15557. [PMID: 36114217 PMCID: PMC9481632 DOI: 10.1038/s41598-022-19517-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 08/30/2022] [Indexed: 11/19/2022] Open
Abstract
Intraductal tubulopapillary neoplasms (ITPN) are rare pancreatic tumors (< 1% of exocrine neoplasms) and are considered to have better prognosis than classical pancreatic ductal adenocarcinoma (PDAC). The present study aimed to evaluate imaging features of ITPN in computed tomography (CT) and magnetic resonance (MR) imaging. We performed monocentric retrospective analysis of 14 patients with histopathologically verified ITPN, operated in 2003–2018. Images were available for 12 patients and were analysed independently by two radiologists, blinded to reports. Imaging features were compared to a matched control group consisting of 43 patients with PDAC, matched for sex and age. Histopathologic analysis showed invasive carcinoma component in all ITPN patients. CT-attenuation values of ITPN were higher in arterial and venous phases (62.3 ± 14.6 HU and 68 ± 15.6 HU) than in unenhanced phase (39.2 ± 7.9 HU), compatible with solid lesion enhancement. Compared to PDAC, ITPN lesions had significantly higher HU-values in both arterial and venous phases (arterial and venous phases, p < 0.001). ITPN were significantly larger than PDAC (4.1 ± 2.0 cm versus 2.6 ± 0.84 cm, p = 0.021). ITPN lesions were more often well-circumscribed (p < 0.002). Employing a multiple logistic regression analysis with forward stepwise method, higher HU density in the arterial phase (p = 0.012) and well-circumscribed lesion margins (p = 0.047) were found to be significant predictors of ITPN versus PDAC. Our study identified key imaging features for differentiation of ITPN and PDAC. Isodensity or moderate hypodensity and well-circumscribed margins favor the diagnosis of ITPN over PDAC. Being familiar with CT-features of these rare pancreatic tumors is essential for radiologists to accelerate the diagnosis and narrow the differentials.
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Single-operator peroral pancreatoscopy in the preoperative diagnostics of suspected main duct intraductal papillary mucinous neoplasms: efficacy and novel insights on complications. Surg Endosc 2022; 36:7431-7443. [PMID: 35277769 PMCID: PMC9485081 DOI: 10.1007/s00464-022-09156-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/18/2022] [Indexed: 11/20/2022]
Abstract
Background Distinguishing intraductal papillary mucinous neoplasms (IPMNs) from other pancreatic cystic lesions is essential since IPMNs carry the risk of becoming malignant. Differentiating the main pancreatic duct involving IPMNs (MD-IPMNs) through conventional imaging is deficient. Single-operator peroral pancreatoscopy (SOPP) represents a promising method offering additional information on suspected lesions in the pancreatic main duct (MD). We aimed to determine the role of SOPP in the preoperative diagnostics of suspected MD-IPMNs and identify factors contributing to SOPP-related complications. Materials and Methods In this primarily retrospective study, SOPPs were performed at three high-volume centers on suspected MD-IPMNs. Primary outcome was the clinical impact of SOPP to subsequent patient care. Additionally, we documented post-SOPP complications and analyzed several assumed patient- and procedure-related risk factors. Results One hundred and one (101) SOPPs were performed. Subsequent clinical management was affected due to the findings in 86 (85%) cases. Surgery was planned for 29 (29%) patients. A condition other than IPMN explaining MD dilatation was found in 28 (28%) cases. In 35 (35%) cases, follow-up with MRI was continued. Post-SOPP pancreatitis occurred in 20 (20%) patients and one of them was fatal. A decrease in odds of post-SOPP pancreatitis was seen as the MD diameter increases (OR 0.714 for 1.0 mm increase in MD diameter, CI 95% 0.514–0.993, p = 0.045). Furthermore, a correlation between lower MD diameter values and higher severity post-SOPP pancreatitis was seen (TJT = 599, SE = 116.6, z = − 2.31; p = 0.020). History of pancreatitis after endoscopic retrograde cholangiopancreatography was a confirmed risk factor for post-SOPP pancreatitis. Conclusions between complications and other risk factors could not be drawn. Conclusion SOPP aids clinical decision-making in suspected MD-IPMNs. Risk for post-SOPP pancreatitis is not negligible compared to non-invasive imaging methods. The risk for pancreatitis decreases as the diameter of the MD increases.
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Tirkes T, Patel AA, Tahir B, Kim RC, Schmidt CM, Akisik FM. Pancreatic cystic neoplasms and post-inflammatory cysts: interobserver agreement and diagnostic performance of MRI with MRCP. Abdom Radiol (NY) 2021; 46:4245-4253. [PMID: 34014363 DOI: 10.1007/s00261-021-03116-6] [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: 04/01/2021] [Revised: 04/28/2021] [Accepted: 05/06/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE We aimed to answer several clinically relevant questions; (1) the interobserver agreement, (2) diagnostic performance of MRI with MRCP for (a) branch duct intraductal papillary mucinous neoplasms (BD-IPMN), mucinous cystic neoplasms (MCN) and serous cystic neoplasms (SCN), (b) distinguishing mucinous (BD-IPMN and MCN) from non-mucinous cysts, and (c) distinguishing three pancreatic cystic neoplasms (PCN) from post-inflammatory cysts (PIC). METHODS A retrospective analysis was performed at a tertiary referral center for pancreatic diseases on 71 patients including 44 PCNs and 27 PICs. All PCNs were confirmed by surgical pathology to be 17 BD-IPMNs, 13 MCNs, and 14 SCNs. Main duct and mixed type IPMNs were excluded. Two experienced abdominal radiologists blindly reviewed all the images. RESULTS Sensitivity of two radiologists for BD-IPMN, MCN and SCN was 88-94%, 62-69% and 57-64%, specificity of 67-78%, 67-78% and 67-78%, and accuracy of 77-82%, 65-75% and 63-73%, respectively. There was 80% sensitivity, 63-73% specificity, 70-76% accuracy for distinguishing mucinous from non-mucinous neoplasms, and 73-75% sensitivity, 67-78% specificity, 70-76% accuracy for distinguishing all PCNs from PICs. There was moderate-to-substantial interobserver agreement (Cohen's kappa: 0.65). CONCLUSION Two experienced abdominal radiologists had moderate-to-high sensitivity, specificity, and accuracy for BD-IPMN, MCN, and SCN. The interobserver agreement was moderate-to-substantial. MRI with MRCP can help workup of incidental pancreatic cysts by distinguishing PCNs from PICs, and premalignant mucinous neoplasms from cysts with no malignant potential.
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Affiliation(s)
- Temel Tirkes
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N. University Blvd UH 0663, Indianapolis, IN, 46202, USA.
| | - Aashish A Patel
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N. University Blvd UH 0663, Indianapolis, IN, 46202, USA
| | - Bilal Tahir
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N. University Blvd UH 0663, Indianapolis, IN, 46202, USA
| | - Rachel C Kim
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Fatih M Akisik
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N. University Blvd UH 0663, Indianapolis, IN, 46202, USA
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11
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Preliminary evaluation of 18F-FDG-PET/MRI for differentiation of serous from nonserous pancreatic cystic neoplasms: a pilot study. Nucl Med Commun 2021; 41:1257-1264. [PMID: 32925829 DOI: 10.1097/mnm.0000000000001277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of the study was to evaluate preliminary feasibility of 18F-FDG-PET/MRI in differentiation of pancreatic serous cystic neoplasms (SCNs) from non-SCNs. METHODS From August 2017 to June 2019, 10 patients (3 men, 7 women; mean age, 63 years) previously diagnosed with pancreatic cystic neoplasm underwent simultaneous 18F-FDG-PET/MRI prospectively on an integrated 3-Tesla hybrid PET/MRI scanner. PET images were analyzed visually and semiquantitatively measuring standardized uptake values (SUV) including lesion SUVmax and SUVmean, lesion to pancreas and lesion to liver SUVmax and SUVmean ratio independent of MRI diagnosis. The reference standard for lesion diagnosis was by MRI features and interval follow-up. RESULTS Visual assessment of PET images demonstrated uptake in 57% of SCNs. Lesion to liver SUVmax ratio of ≥0.5 showed the highest accuracy (90%) and area under the curve (0.9) followed by lesion SUVmax of ≥1.6 and lesion to pancreas SUVmax ratio of ≥0.77 for diagnosis of SCN. The sensitivity for lesion SUVmax of ≥1.6 was less than two other ones (71 versus 100%). All non-SCNs exhibited SUVmax value less than 1.6 while 33 and 66% demonstrated lesion to liver SUVmax ratio of >0.5 and lesion to pancreas SUVmax ratio of >0.77, respectively. PET/MRI specificity was 67, 100, 67 and 33% through lesion to liver SUVmax ratio, lesion SUVmax, lesion SUVmean and lesion to pancreas SUVmax ratio, respectively, for diagnosis of SCN. CONCLUSION Preliminary results show that PET/MRI utilization is promising for differentiation of pancreatic SCN from non-SCN lesions. This could reduce need for surveillance imaging or avoidance of unnecessary intervention in pancreatic cystic neoplasms with uncertain diagnoses.
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12
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Sun L, Wang W, Zhu H, Jiang F, Peng L, Jin G, Jin Z. High-Risk Characteristics Associated with Advanced Pancreatic Cystic Lesions: Results from a Retrospective Surgical Cohort. Dig Dis Sci 2021; 66:2075-2083. [PMID: 32705437 DOI: 10.1007/s10620-020-06481-2] [Citation(s) in RCA: 3] [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: 10/29/2019] [Accepted: 07/04/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM The management of pancreatic cystic lesions (PCLs) remains controversial. We performed a retrospective study to determine characteristics associated with advanced PCLs (A-PCLs) and whether these characteristics vary in different pathological types of PCLs. The additional diagnostic value of endoscopic ultrasound (EUS) was also evaluated. METHODS Patients who underwent surgical resection for an identified PCLs by imaging modalities were included. A logistic regression model was developed to identify significant characteristics for A-PCLs. EUS data was assessed separately. RESULTS Three hundred and fifty-three patients were included, and 125 patients (35.4%) were A-PCLs. The presence of main pancreatic duct (MPD) diameter ≥ 10 mm (odds ratio [OR], 11.7; 95% confidence interval [CI], 1.53-89.2; P = 0.018), mural nodules ≥ 5 mm (OR, 11.67; 95% CI, 2.3-59.05; P = 0.003), solid components within cysts (OR, 30.87; 95% CI, 7.23-131.7; P < 0.0001) and high serum CA19-9 levels (OR, 1.006; 95% CI, 1.001-1.011; P = 0.02) were independently associated with the presence of A-PCLs. The presence of septa was independently associated with the presence of non-A-PCLs (OR, 0.147; 95% CI, 0.04-0.6; P = 0.008). Males who had a history of tobacco abuse (P < 0.0001) and had a greatly dilated MPD (P < 0.0001) were more common in advanced intraductal papillary mucinous neoplasms (IPMC) patients. Solid pseudopapillary neoplasm (SPT) often occurred in young women (P < 0.0001), mostly asymptomatically (P < 0.0001) and with lower serum CA19-9 levels (P < 0.0001). In the 124 patients who underwent EUS-guided fine-needle aspiration (EUS-FNA), five additional characteristics (4 mural nodules and 1 MPD involvement) were identified by EUS imaging and 17 patients were identified with abnormal cytological results (13 atypical cells and 4 suspicious for malignancy cells) by EUS-FNA. CONCLUSION On the basis of a retrospective study with large sample size, the presence of MPD ≥ 10 mm, mural nodules, solid components, and high serum CA19-9 levels were independently associated with the presence of A-PCLs. The high-risk characteristics may vary across different types of A-PCLs. EUS and EUS-FNA could provide additional diagnostic information for PCLs.
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Affiliation(s)
- Liqi Sun
- Department of Gastroenterology, Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Wei Wang
- Department of Gastroenterology, Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Huiyun Zhu
- Department of Gastroenterology, Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Fei Jiang
- Department of Gastroenterology, Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Lisi Peng
- Department of Gastroenterology, Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Gang Jin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Zhendong Jin
- Department of Gastroenterology, Changhai Hospital, Navy Military Medical University, Shanghai, China.
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Ippolito D, Maino C, Pecorelli A, De Vito A, Riva L, Talei Franzesi C, Sironi S. Incidental pancreatic cystic lesions: comparison between CT with model-based algorithm and MRI. Radiography (Lond) 2021; 27:554-560. [PMID: 33281035 DOI: 10.1016/j.radi.2020.11.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The present study aims to compare low-kV CT reconstructed with MBIR technique with MRI in detecting high-risk stigmata and worrisome features in patients with pancreatic cystic lesions. METHODS We retrospective enrolled 75 patients who underwent low-kV CT with contrast media injection for general abdominal disorders and MRI with MRCP sequences. The reviewer, blinded to clinical and histopathological data, recorded the overall number of pancreatic cystic lesions, size, location, presence of calcifications, septa, or solid enhancing or non-enhancing components, main pancreatic duct (MPD) communication, and MPD dilatation. Mean differences with 95% limits of agreement, ICC, and κ statistics were used to compare CT and MRI. RESULTS More pancreatic cystic lesions were detected with MRI than with CT, however, the ICC value of 0.81 suggested a good agreement. According to the evaluated target lesion, a very good agreement (ICC = 0.98) was found regarding the diameter (21.4 mm CT vs 21.8 mm MRI), the location (κ = 0.90), the detection of MPD dilatation (κ = 1), the presence of septa (κ = 0.86) and the MPD communication (κ = 0.87). A moderate agreement on the assessment of enhanced components was noted (κ = 0.44), while there was only a fair agreement about the presence of calcifications (κ = 0.87). CONCLUSION MDCT can be considered almost equivalent to MRI with MRCP in the evaluation of worrisome features and high-risk stigmata, offering detailed morphologic features helpful for their characterization. IMPLICATIONS FOR PRACTICE Even if MRI is considered the reference standard in pancreatic cystic lesions characterization, CT can be considered a useful tool as a first-line imaging technique to identify worrisome features and high-risk stigmata.
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Affiliation(s)
- D Ippolito
- Department of Diagnostic Radiology, San Gerardo Hospital, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - C Maino
- Department of Diagnostic Radiology, San Gerardo Hospital, Via Pergolesi 33, 20900, Monza, MB, Italy.
| | - A Pecorelli
- Department of Diagnostic Radiology, San Gerardo Hospital, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - A De Vito
- Department of Diagnostic Radiology, San Gerardo Hospital, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - L Riva
- Department of Diagnostic Radiology, San Gerardo Hospital, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - C Talei Franzesi
- Department of Diagnostic Radiology, San Gerardo Hospital, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - S Sironi
- Department of Diagnostic Radiology, H Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, BG, Italy
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Hecht EM, Khatri G, Morgan D, Kang S, Bhosale PR, Francis IR, Gandhi NS, Hough DM, Huang C, Luk L, Megibow A, Ream JM, Sahani D, Yaghmai V, Zaheer A, Kaza R. Intraductal papillary mucinous neoplasm (IPMN) of the pancreas: recommendations for Standardized Imaging and Reporting from the Society of Abdominal Radiology IPMN disease focused panel. Abdom Radiol (NY) 2021; 46:1586-1606. [PMID: 33185741 DOI: 10.1007/s00261-020-02853-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 02/07/2023]
Abstract
There have been many publications detailing imaging features of malignant transformation of intraductal papillary mucinous neoplasms (IPMN), management and recommendations for imaging follow-up of diagnosed or presumed IPMN. However, there is no consensus on several practical aspects of imaging IPMN that could serve as a clinical guide for radiologists and enable future data mining for research. These aspects include how to measure IPMN, define reporting terminology, standardize reporting and unify guidelines for surveillance. The Society of Abdominal Radiology (SAR) created multiple Disease-Focused Panels (DFP) comprised multidisciplinary panel members who focus on a particular disease, with the goal to develop ways for radiologists to improve patient care, education, and research. DFP members met to identify the current controversies and limitations of imaging pancreatic IPMN. This paper aims to provide a practical review of the key imaging characteristics of IPMN for trainees and practicing radiologists, to guide uniformity of performance and interpretation of surveillance imaging studies, and to improve communication with clinicians by providing a lexicon and reporting template based on the experience of the SAR-DFP panel members.
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Affiliation(s)
- Elizabeth M Hecht
- Department of Radiology, New York Presbyterian-Weill Cornell Medicine, New York, NY, USA.
| | - Gaurav Khatri
- Department of Diagnostic Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Desiree Morgan
- Department of Radiology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stella Kang
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Priya R Bhosale
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Isaac R Francis
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Namita S Gandhi
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - David M Hough
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Chenchan Huang
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Lyndon Luk
- Department of Radiology, New York Presbyterian-Columbia University Medical Center, New York, NY, USA
| | - Alec Megibow
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Justin M Ream
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Dushyant Sahani
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Vahid Yaghmai
- Department of Radiological Sciences, University of California, Irvine, Orange, CA, USA
| | - Atif Zaheer
- Department of Radiology, John Hopkins Medicine, Baltimore, MD, USA
| | - Ravi Kaza
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
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15
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Fábrega-Foster K, Kamel IR, Horowitz JM, Arif-Tiwari H, Bashir MR, Chernyak V, Goldstein A, Grajo JR, Hindman NM, Kamaya A, McNamara MM, Porter KK, Scheiman JM, Solnes LB, Srivastava PK, Zaheer A, Carucci LR. ACR Appropriateness Criteria® Pancreatic Cyst. J Am Coll Radiol 2020; 17:S198-S206. [PMID: 32370963 DOI: 10.1016/j.jacr.2020.01.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 01/25/2020] [Indexed: 02/07/2023]
Abstract
Incidental pancreatic cysts are increasingly detected on imaging studies performed for unrelated indications and may be incompletely characterized on these studies. Adequate morphological characterization is critical due to the small risk of malignant degeneration associated with neoplastic pancreatic cysts, as well as the risk of associated pancreatic adenocarcinoma. For all pancreatic cysts, both size and morphology determine management. Specifically, imaging detection of features, such as pancreatic ductal communication and presence or absence of worrisome features or high-risk stigmata, have important management implications. The recommendations in this publication determine the appropriate initial imaging study to further evaluate a pancreatic cyst that was incidentally detected on a nondedicated imaging study. The recommendations are designed to maximize the yield of diagnostic information in order to better risk-stratify pancreatic cysts and assist in guiding future management. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Ihab R Kamel
- Panel Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | | | - Hina Arif-Tiwari
- University of Arizona, Banner University Medical Center, Tucson, Arizona
| | | | | | | | - Joseph R Grajo
- University of Florida College of Medicine, Gainesville, Florida
| | | | - Aya Kamaya
- Stanford University Medical Center, Stanford, California
| | | | | | - James M Scheiman
- University of Virginia Health System, Charlottesville, Virginia; American Gastroenterological Association
| | | | - Pavan K Srivastava
- University of Illinois College of Medicine, Chicago, Illinois; American College of Physicians
| | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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16
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Total Pancreatectomy for Malignant Intraductal Papillary Mucinous Neoplasm (IPMN) Complicated by Gastropancreatic Fistulae. Case Rep Surg 2020; 2020:8547526. [PMID: 32274240 PMCID: PMC7132345 DOI: 10.1155/2020/8547526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/17/2020] [Indexed: 11/17/2022] Open
Abstract
Background Intraductal papillary mucinous neoplasms (IPMN) of the pancreas complicated by fistula formation to adjacent organs are an uncommon phenomenon. We present an IPMN of the pancreas with malignant transformation and multiple fistulae to the stomach and duodenum. Case Presentation. A 50-year-old female was referred for investigation of recent epigastric pain and a past history of recurrent pancreatitis. Imaging with computed tomography showed a gross dilatation of the entire pancreatic duct with a heterogeneous enhancement of the periductal parenchyma. A passage of oral contrast was noted from the greater curvature and pylorus of the stomach into the dilated duct suggestive of fistulae formation. Gastroduodenoscopy demonstrated these fistulae in the stomach and the proximal duodenum and an exophytic growth at the ampulla obliterating the view of ampullary opening. Endosonography- (EUS-) guided fine-needle aspiration cytology (FNAC) showed cells with high-grade atypia. A total pancreatectomy, distal gastrectomy, and splenectomy were performed, and recovery was uneventful. Histology revealed a ductal adenocarcinoma arising from an intestinal type intraductal papillary mucinous neoplasm with high-grade dysplasia. A year and a half after surgery, she is healthy with good glycaemic control and nutritional status. Conclusion This case highlights the importance investigating patients for the aetiology in recurrent acute pancreatitis and their follow-up. Awareness of cystic pancreatic neoplasms including IPMN is important to avoid misdiagnosis or delayed diagnosis. Referral of these patients to centres with facilities for multidisciplinary input and specialised management is strongly recommended.
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17
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Lee ES, Kim JH, Yu MH, Choi SY, Kang HJ, Park HJ, Park YS, Byun JH, Shin SS, Lee CH. Diagnosis and Surveillance of Incidental Pancreatic Cystic Lesions: 2017 Consensus Recommendations of the Korean Society of Abdominal Radiology. Korean J Radiol 2020; 20:542-557. [PMID: 30887737 PMCID: PMC6424832 DOI: 10.3348/kjr.2018.0640] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 11/30/2018] [Indexed: 02/06/2023] Open
Abstract
The occurrence of incidentally detected pancreatic cystic lesions (PCLs) is continuously increasing. Radiologic examinations including computed tomography and magnetic resonance imaging with magnetic resonance cholangiopancreatography have been widely used as the main diagnostic and surveillance methods for patients with incidental PCLs. Although most incidentally detected PCLs are considered benign, they have the potential to become malignant. Currently, we have several guidelines for the management of incidental PCLs. However, there is still debate over proper management, in terms of accurate diagnosis, optimal follow-up interval, and imaging tools. Because imaging studies play a crucial role in the management of incidental PCLs, the 2017 consensus recommendations of the Korean Society of Abdominal Radiology for the diagnosis and surveillance of incidental PCLs approved 11 out of 16 recommendations. Although several challenges remain in terms of optimization and standardization, these consensus recommendations might serve as useful tools to provide a more standardized approach and to optimize care of patients with incidental PCLs.
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Affiliation(s)
- Eun Sun Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Jung Hoon Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.
| | - Mi Hye Yu
- Department of Radiology, Konkuk University Medical Center, Seoul, Korea
| | - Seo Youn Choi
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Hyo Jin Kang
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.
| | - Hyun Jeong Park
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Yang Shin Park
- Department of Radiology, Korea University Guro Hospital, Seoul, Korea
| | - Jae Ho Byun
- Department of Radiology, Asan Medical Center, Seoul, Korea
| | - Sang Soo Shin
- Department of Radiology, Chonnam National University Hospital, Gwangju, Korea
| | - Chang Hee Lee
- Department of Radiology, Korea University Guro Hospital, Seoul, Korea
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18
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Zhu S, Wang WT, Shang XS, Ni T, Wu WC, Lou WH, Zeng MS, Rao SX. Difference analysis in prevalence of incidental pancreatic cystic lesions between computed tomography and magnetic resonance imaging. BMC Med Imaging 2019; 19:43. [PMID: 31126251 PMCID: PMC6534824 DOI: 10.1186/s12880-019-0341-5] [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: 02/10/2019] [Accepted: 05/14/2019] [Indexed: 12/18/2022] Open
Abstract
Background The purpose was to investigate the difference of detection rate of incidental pancreatic cystic lesions (PCLs) with computed tomography (CT) and magnetic resonance imaging (MRI) and to compare the difference between CT and MRI and to explore the effect of this difference on surgical resection. Methods We reviewed the diagnostic reports for incidental PCLs between 2013 and 2016. Images of PCLs would be re-evaluated. Clinical and imaging data were recorded. The chi-square and independent t-test were conducted for categorical and continuous variables. Results The prevalence of PCLs was 1.91% (1038/54210) and 3.36% (1282/38099) on CT and MRI respectively, and increased with increasing age (P < 0.001). No significant differences were found in the annual prevalence of PCLs on CT (P = 0.796) and MRI (P = 0.213) from 2013 to 2016 while the number of examinations was increasing every year. The annual detection rate of MRI for small PCLs (< 20 mm) was significantly higher than CT (P < 0.001), but was not significantly different for large PCLs (≥20 mm). The rate of surgical resection of PCLs (≥20 mm) in MRI group was higher than CT (55.2% vs. 37.0%, P < 0.001). Conclusions The detection rate of PCLs on CT and MRI tended to be stable despite increasing scan volumes. Female had a slightly more frequency of PCLs than male. MRI detected more small PCLs(< 20 mm) and had higher impact on surgical resection of large PCL(≥20 mm) compared with CT.
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Affiliation(s)
- Shuo Zhu
- Department of Radiology, Zhongshan Hospital, Fudan University, and Shanghai Institute of Medical Imaging, 180 Fenglin Rd., Shanghai, 200032, China
| | - Wen-Tao Wang
- Department of Radiology, Zhongshan Hospital, Fudan University, and Shanghai Institute of Medical Imaging, 180 Fenglin Rd., Shanghai, 200032, China
| | - Xiao-Sha Shang
- Department of Radiology, Zhongshan Hospital, Fudan University, and Shanghai Institute of Medical Imaging, 180 Fenglin Rd., Shanghai, 200032, China
| | - Ting Ni
- Department of Radiology, Zhongshan Hospital, Fudan University, and Shanghai Institute of Medical Imaging, 180 Fenglin Rd., Shanghai, 200032, China
| | - Wen-Chuan Wu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wen-Hui Lou
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Meng-Su Zeng
- Department of Radiology, Zhongshan Hospital, Fudan University, and Shanghai Institute of Medical Imaging, 180 Fenglin Rd., Shanghai, 200032, China
| | - Sheng-Xiang Rao
- Department of Radiology, Zhongshan Hospital, Fudan University, and Shanghai Institute of Medical Imaging, 180 Fenglin Rd., Shanghai, 200032, China.
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Dioguardi Burgio M, Ronot M, Vilgrain V. Rare Solid Tumor of the Exocrine Pancreas: A Pictorial Review. Semin Ultrasound CT MR 2019; 40:483-499. [PMID: 31806147 DOI: 10.1053/j.sult.2019.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Numerous other solid primary neoplasms may arise from the pancreas besides primary ductal adenocarcinomas and neuroendocrine tumors. Although diagnosis can be difficult because of the very low incidence of these tumors, knowledge of several, typical, epidemiologic, biological, and imaging features can help obtain a correct diagnosis. This pictorial review describes the features of solid rare primary pancreatic neoplasms on computed tomography and magnetic resonance imaging focusing on characteristics that can help radiologists differentiate them from classical forms of ductal pancreatic adenocarcinoma and neuroendocrine tumors. Cystic pancreatic neoplasms are beyond the scope of the current review.
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Affiliation(s)
- Marco Dioguardi Burgio
- Department of Radiology, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France; INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France.
| | - Maxime Ronot
- Department of Radiology, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France; INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Valérie Vilgrain
- Department of Radiology, University Hospitals Paris Nord Val de Seine, Beaujon, Clichy, Hauts-de-Seine, France; INSERM U1149, Centre de Recherche Biomédicale Bichat-Beaujon, CRB3, Paris, France; University Paris Diderot, Sorbonne Paris Cité, Paris, France
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20
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Added value of apparent diffusion coefficient in distinguishing between serous and mucin-producing pancreatic cystic neoplasms. Eur Radiol 2019; 29:4660-4669. [DOI: 10.1007/s00330-019-6010-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 12/14/2018] [Accepted: 01/15/2019] [Indexed: 12/18/2022]
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Comparison of Navigator Triggering Reduced Field of View and Large Field of View Diffusion-Weighted Imaging of the Pancreas. J Comput Assist Tomogr 2019; 43:143-148. [PMID: 30119065 DOI: 10.1097/rct.0000000000000778] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
RATIONALE AND OBJECTIVES The purpose of this study is to compare image quality, presence and grade of artifacts, signal-to-noise ratio, and apparent diffusion coefficient (ADC) values in pancreatic tissue between high-resolution navigator-triggered (NT) restricted field of view (rFOV) FOCUS single-shot (SS) echo-planar imaging (EPI) diffusion-weighted imaging (DWI) and NT large FOV SS-EPI DWI. MATERIALS AND METHODS Magnetic resonance imaging examinations were performed with GE 3-T systems using a 32-channel body array coil. Seventeen consecutive patients were imaged. A 5-point scale semiquantitative grading system was used to evaluate image quality and general artifacts. Signal-to-noise ratio and ADC were measured in the head, body, and tail of the pancreas. Statistical analysis was performed using Student t test and Wilcoxon signed rank test, with differences considered significant for P value less than 0.05. RESULTS More artifacts were present on large FOV compared with rFOV FOCUS SS-EPI DW images (P < 0.01). Restricted field of view image quality was subjectively better (P < 0.01). No difference in the signal-to-noise ratio was demonstrated between the 2 image datasets. Apparent diffusion coefficient values were significantly lower (P < 0.01) when calculated from rFOV images than large FOV images. CONCLUSIONS Our results demonstrate better image quality and reduced artifacts in rFOV images compared with large FOV DWI. Measurements from ADC maps derived from rFOV DWI show significantly lower ADC values when compared with ADC maps derived from large FOV DWI.
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Rosendahl J, Michl P. [Cystic lesions of the pancreas : Differential diagnostics and treatment]. Internist (Berl) 2019; 60:219-225. [PMID: 30617702 DOI: 10.1007/s00108-018-0547-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Cystic space-occupying lesions of the pancreas represent incidental findings in most cases. As there is a potential risk of malignant transformation further evaluation of the lesions as well as a follow-up of these patients is usually recommended. Before this work-up is initiated the clinical situation of the patient as a whole and comorbidities, age and personal preferences have to be taken into account. So far there are no biomarkers that reliably predict the risk of malignant transformation. Imaging by magnetic resonance tomography (MRI) in combination with magnetic resonance cholangiopancreatography (MRCP) is more accurate than computed tomography to identify worrisome features. During follow-up, endoscopic ultrasound (EUS) can be used as complementary method to MRI/MRCP. Using contrast enhancement or endoscopic fine needle aspiration (EUS-FNA) may influence the therapeutic strategy in some patients. Whereas for some cystic pancreatic lesions consensus has been reached, varying recommendations exist for intraductal papillary mucinous neoplasms (IPMN). There is consensus that in main-duct as well as in mixed-type IPMN surgery is recommended. The management of branch-duct type IPMN, however, remains controversial. A multidisciplinary expert panel including gastroenterologists, visceral surgeons, radiologists and pathologists is essential to discuss all cases of patients with cystic pancreatic lesions and to guarantee an optimal, patient-centered treatment recommendation.
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Affiliation(s)
- J Rosendahl
- Klinik für Innere Medizin I, Universitätsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland.
| | - P Michl
- Klinik für Innere Medizin I, Universitätsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland
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Mohamed E, Jackson R, Halloran CM, Ghaneh P. Role of Radiological Imaging in the Diagnosis and Characterization of Pancreatic Cystic Lesions: A Systematic Review. Pancreas 2018; 47:1055-1064. [PMID: 30199486 DOI: 10.1097/mpa.0000000000001134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The evidence on the ability of radiological tests to predict a specific diagnosis and also their aptitude in identifying pathological markers indicative of malignancy in cystic lesions of the pancreas remains inconclusive. We conducted a systematic review on MEDLINE for the use of computed tomography (CT), magnetic resonance imaging, and positron emission tomography/CT (PET/CT) in the diagnosis and characterization of these cysts. The accuracy of CT scan for reaching a specific diagnosis was 39% to 61.4%, whereas its accuracy for differentiating benign from malignant lesions was 61.9% to 80%. Magnetic resonance imaging showed a better accuracy in identifying a specific diagnosis of 50% to 86%, whereas its accuracy in differentiating benign from malignant lesions was 55.6% to 87%. The use of magnetic resonance imaging was superior to CT scan in identifying septations, mural nodules, and ductal communication. The sensitivity of PET/CT in diagnosing malignancy was 85.7% to 100% with a reported accuracy of 88% to 95%. The evidence gathered from this review suggests that the adequacy of CT imaging in full characterization of pancreatic cysts is suboptimal, and therefore a low threshold for supplementary imaging is advised. The use of PET/CT should be considered in high-risk patients with equivocal findings.
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Affiliation(s)
- Eyas Mohamed
- From the Department of Molecular and Clinical Cancer Medicine and
| | - Richard Jackson
- Liverpool Cancer Research UK Cancer Trials Unit, Liverpool Cancer Research UK Centre, University of Liverpool, Liverpool, United Kingdom
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Levink I, Bruno MJ, Cahen DL. Management of Intraductal Papillary Mucinous Neoplasms: Controversies in Guidelines and Future Perspectives. ACTA ACUST UNITED AC 2018; 16:316-332. [PMID: 30196428 PMCID: PMC6153570 DOI: 10.1007/s11938-018-0190-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose of review Management of intraductal papillary mucinous neoplasm (IPMN) is currently based on consensus, in the absence of evidence-based guidelines. In recent years, several consensus guidelines have been published, with distinct management strategies. In this review, we will discuss these discrepancies, in order to guide treating physicians in clinical management. Recent findings The detection rate of pancreatic cysts has increased substantially with the expanded use of high-quality imaging techniques to up to 45%. Of these cysts, 24–82% are IPMNs, which harbour a malignant potential. Timely detection of high-risk lesions is therefore of great importance. Surgical management is based on the presence of clinical and morphological high-risk features, yet the majority of resected specimens appear to be low risk. Summary International collaboration and incentive large-scale prospective registries of individuals undergoing cyst surveillance are needed to accumulate unbiased data and develop evidence-based guidelines. Additionally, development of non-invasive, accurate diagnostic tools (e.g. biomarkers) is needed to differentiate between neoplastic and non-neoplastic pancreatic cysts and detect malignant transformation at an early stage (i.e. high-grade dysplasia).
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Affiliation(s)
- Ijm Levink
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - D L Cahen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
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Abstract
PURPOSE OF REVIEW With recent advances in radiographic testing, there have been increases in the incidental identification of pancreatic cysts. Determining management, specifically, which cysts can be watched versus intervened upon has significant impact on at the patient-physician level as well as globally on resource allocation and healthcare expenditures. This review focuses on the three main guidelines (Fukuoka guidelines, European consensus, and American Gastroenterological Association recommendations) for management of pancreatic cystic disease after incidental identification. RECENT FINDINGS There are iterant revisions to each set of recommendations every few years as new data is published on the subject. This review encompasses the most up-to-date recommendations for management while also providing a framework for conceptualizing work-up for varying types of pancreatic cystic disease before and after incidental identification. SUMMARY Pancreatic cystic disease should be approached in thoughtful clinical manner, and each cyst should be evaluated in the context of patient's health and healthcare goals. All cysts, however, should be considered malignant until proven otherwise. Applications of different diagnostic modalities like MRI and EUS with FNA can better characterize cystic lesions and assess malignant potential. Resection should always be considered in cysts with concerning features. If deferred, surveillance should be continued indefinitely. Early termination of surveillance risks future malignant progression.
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Jiang L, Tang Q, Panje CM, Nie H, Zhao G, Shi H. Assessment of pancreatic colloid carcinoma using 18F-FDG PET/CT compared with MRI and enhanced CT. Oncol Lett 2018; 16:1557-1564. [PMID: 30008837 PMCID: PMC6036464 DOI: 10.3892/ol.2018.8859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 05/22/2018] [Indexed: 11/06/2022] Open
Abstract
Pancreatic colloid carcinoma (CC) is a rare sub-type of pancreatic adenocarcinoma which has an improved prognosis compared with pancreatic ductal carcinoma. Consequently, the early detection of CC by imaging may be of great significance in guiding patient management and therapeutic decisions. The present study aimed to analyze 18F-FDG PET/CT findings of CC in comparison to MRI and CT. PET/CT findings in 5 patients with CC were retrospectively reviewed based on visual interpretation and semi-quantitative index of SUVmax and TNR. Four patients received dual-time-point PET/CT scans. Additionally, one patient underwent contrast-enhanced CT scan, one MRI, and three received both. A total of five lesions were detected in five patients. Visually, two cases presented with mild FDG uptake, two with moderate and one with high. The mean of SUVmax and TNR was 5.1±2.2 and 2.8±0.7, respectively. Compared with CCs with low SUVmax, CCs with high SUVmax were more aggressive. No distant metastases were observed in five cases. Among four patients with dual-time-point PET/CT imaging, SUVmax increased in three cases and decreased in one case. The mean early and delayed SUVmax were 4.2±1.1 and 4.7±1.9, respectively (P>0.05). Radiological findings mainly included septated cystic components, internal sponge-like contrast-enhancement, calcification and 'salt-and-pepper sign' on MRI T2-weighted imaging. Thus, PET/CT provided additional information on metabolic tumor activity as well as locoregional and distant staging, which are important prognostic markers and may improve further patient management. However, PET/CT did not show any findings in addition to MRI and contrast-enhanced CT that were unique to CC and allowed a clear differentiation from other pancreatic malignancies.
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Affiliation(s)
- Lei Jiang
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Nuclear Medicine Institute of Fudan University, Shanghai 200032, P.R. China.,Shanghai Institute of Medical Imaging, Shanghai 200032, P.R. China
| | - Qiying Tang
- Nuclear Medicine Institute of Fudan University, Shanghai 200032, P.R. China.,Shanghai Institute of Medical Imaging, Shanghai 200032, P.R. China.,Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Cedric M Panje
- St Gallen Cantonal Hospital, St Gallen, CH-9000 Switzerland
| | - Hongting Nie
- Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Guochao Zhao
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China
| | - Hongcheng Shi
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai 200032, P.R. China.,Nuclear Medicine Institute of Fudan University, Shanghai 200032, P.R. China.,Shanghai Institute of Medical Imaging, Shanghai 200032, P.R. China
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Diagnostic Accuracy of Preoperative Imaging for Differentiation of Branch Duct Versus Mixed Duct Intraductal Papillary Mucinous Neoplasms. Pancreas 2018; 47:556-560. [PMID: 29683969 DOI: 10.1097/mpa.0000000000001040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The aim of this study is to determine the diagnostic accuracy of preoperative evaluation to detect main pancreatic duct involvement in pancreatic cystic lesions thus differentiating mixed intraductal papillary mucinous neoplasm (IPMN) from branch duct (BD)-IPMN. METHODS The pathology database of pancreatic resections from 2000 to 2014 was reviewed. Main pancreatic duct-IPMNs and IPMNs with intracystic mass/nodules were excluded. The preoperative test characteristics were analyzed using surgical histopathology as the "gold standard." RESULTS Sixty BD-IPMNs and 23 mixed-IPMNs were identified. Mixed-IPMNs were larger (mean [standard deviation], 4.14 [2.9] vs 2.74 [1.9] mm; P = 0.03) and demonstrated frequent high-grade dysplasia/adenocarcinoma (43% vs 12%, P = 0.004) than BD-IPMNs. Endoscopic ultrasound (EUS) (sensitivity, 80%; specificity, 78%; accuracy, 79%) had the best diagnostic accuracy, whereas magnetic resonance imaging (MRI) (sensitivity, 83%; specificity, 63%; accuracy, 68%) had the highest sensitivity for the diagnosis of mixed-IPMN. A combination of EUS and MRI reached maximum sensitivity but with decreased accuracy (sensitivity, 100%; specificity, 64%; accuracy, 67%). The area under the curve for receiver operation curve was 0.71 whereas the optimal cyst size to detect main duct involvement was 3 cm. CONCLUSIONS For preoperative evaluation of pancreatic cystic lesions without evidence of intracystic nodules, a combination of MRI and EUS should be considered for improved detection of main duct involvement.
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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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Uribarri-Gonzalez L, Keane MG, Pereira SP, Iglesias-García J, Dominguez-Muñoz JE, Lariño-Noia J. Agreement among Magnetic Resonance Imaging/Magnetic Resonance Cholangiopancreatography (MRI-MRCP) and Endoscopic Ultrasound (EUS) in the evaluation of morphological features of Branch Duct Intraductal Papillary Mucinous Neoplasm (BD-IPMN). Pancreatology 2018; 18:170-175. [PMID: 29338919 DOI: 10.1016/j.pan.2018.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 01/02/2018] [Accepted: 01/04/2018] [Indexed: 02/09/2023]
Abstract
BACKGROUND/OBJECTIVES To evaluate the agreement between the imaging modalities MRI-MRCP and EUS in cystic lesions of the pancreas which were thought to be a BD-IPMN. METHODS Multicenter retrospective study included all patients between 2010 and 2015 with a suspected BD-IPMN who underwent an EUS and MRI-MRCP within 6 months or less of each other. Location, number, size, worrisome features and high-risk stigmata were evaluated. Interobserver agreement was evaluated by Kappa score. RESULTS 173 patients were included (97 UHSC, 76 UCLH-RFH), mean age 65 (range 25-87 years), 66 males. When comparing both modalities there was good agreement for the location of the cyst. The median lesion size was larger by MRI-MRCP than EUS although it was not significant. With regards to worrisome features, there was moderate agreement for main PD of 5-9 mm and abrupt change (k = 0.45 and 0.52). Fair agreement was seen for the cyst wall thickening (k = 0.25). No agreement was seen between the presence of non-enhanced mural nodules or lymphadenopathy (k < 0). With regards to high-risk stigmata, poor agreement was obtained for the detection of an enhanced solid component (k = 0.12). No agreement was observed for main PD > 10 mm (k < 0). CONCLUSIONS In this multicentre study of patients with a BD-IPMN under active surveillance, most disagreement between these modalities was seen in the proximal pancreas. There was generally only minimal concordance between the imaging findings of EUS and MRI-MRCP for the detection of high-risk stigmata and worrisome features.
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Affiliation(s)
- Laura Uribarri-Gonzalez
- Gastroenterology Department, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain.
| | - Margaret G Keane
- Gastroenterology Department, University College London Hospital NHS Foundation Trust and the Royal Free Hospital NHS Foundation Trust, London, UK.
| | - Stephen P Pereira
- Gastroenterology Department, University College London Hospital NHS Foundation Trust and the Royal Free Hospital NHS Foundation Trust, London, UK.
| | - Julio Iglesias-García
- Gastroenterology Department, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain.
| | - J Enrique Dominguez-Muñoz
- Gastroenterology Department, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain.
| | - Jose Lariño-Noia
- Gastroenterology Department, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain.
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31
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Are pancreatic IPMN volumes measured on MRI images more reproducible than diameters? An assessment in a large single-institution cohort. Eur Radiol 2018; 28:2790-2800. [DOI: 10.1007/s00330-017-5268-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/09/2017] [Accepted: 12/20/2017] [Indexed: 12/15/2022]
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32
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MRI in cystic pancreatic lesions, is it of value? THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2017. [DOI: 10.1016/j.ejrnm.2017.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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33
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Pausawasdi N, Ratanachu-Ek T. Endoscopic ultrasonography evaluation for pancreatic cysts: Necessity or overkill? Dig Endosc 2017; 29:444-454. [PMID: 28321928 DOI: 10.1111/den.12873] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/16/2017] [Indexed: 02/06/2023]
Abstract
Incidental pancreatic cysts have become gradually more recognized in clinical practice as a result of increased use of transabdominal ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI). These lesions consist of inflammatory cysts (pseudocysts) and pancreatic cystic neoplasms (PCN) which have been classified as benign, premalignant and malignant. The diagnosis and management strategy of incidentally discovered pancreatic cysts can be challenging as the majority of them are PCN and CT or MRI alone may not be sufficient to provide an accurate diagnosis. Endoscopic ultrasound (EUS)-guided fine-needle aspiration provides a method to obtain cyst fluid for analysis and the recently developed EUS-based technology including contrast-enhanced ultrasound, cystoscopy and needle-based confocal laser endomicroscopy allows endosonographers to gain additional useful information. The current data suggest that EUS evaluation of pancreatic cysts offers some benefits especially in cases of inconclusive CT or MRI.
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Affiliation(s)
- Nonthalee Pausawasdi
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine Siriraj Hospital, Siriraj Endoscopy Center, Mahidol Univeristy, Bangkok, Thailand
| | - Thawee Ratanachu-Ek
- Department of Surgery, Digestive Endoscopy Center, Rajavithi Hospital, Bangkok, Thailand
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Best LMJ, Rawji V, Pereira SP, Davidson BR, Gurusamy KS. Imaging modalities for characterising focal pancreatic lesions. Cochrane Database Syst Rev 2017; 4:CD010213. [PMID: 28415140 PMCID: PMC6478242 DOI: 10.1002/14651858.cd010213.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Increasing numbers of incidental pancreatic lesions are being detected each year. Accurate characterisation of pancreatic lesions into benign, precancerous, and cancer masses is crucial in deciding whether to use treatment or surveillance. Distinguishing benign lesions from precancerous and cancerous lesions can prevent patients from undergoing unnecessary major surgery. Despite the importance of accurately classifying pancreatic lesions, there is no clear algorithm for management of focal pancreatic lesions. OBJECTIVES To determine and compare the diagnostic accuracy of various imaging modalities in detecting cancerous and precancerous lesions in people with focal pancreatic lesions. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase, and Science Citation Index until 19 July 2016. We searched the references of included studies to identify further studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. SELECTION CRITERIA We planned to include studies reporting cross-sectional information on the index test (CT (computed tomography), MRI (magnetic resonance imaging), PET (positron emission tomography), EUS (endoscopic ultrasound), EUS elastography, and EUS-guided biopsy or FNA (fine-needle aspiration)) and reference standard (confirmation of the nature of the lesion was obtained by histopathological examination of the entire lesion by surgical excision, or histopathological examination for confirmation of precancer or cancer by biopsy and clinical follow-up of at least six months in people with negative index tests) in people with pancreatic lesions irrespective of language or publication status or whether the data were collected prospectively or retrospectively. DATA COLLECTION AND ANALYSIS Two review authors independently searched the references to identify relevant studies and extracted the data. We planned to use the bivariate analysis to calculate the summary sensitivity and specificity with their 95% confidence intervals and the hierarchical summary receiver operating characteristic (HSROC) to compare the tests and assess heterogeneity, but used simpler models (such as univariate random-effects model and univariate fixed-effect model) for combining studies when appropriate because of the sparse data. We were unable to compare the diagnostic performance of the tests using formal statistical methods because of sparse data. MAIN RESULTS We included 54 studies involving a total of 3,196 participants evaluating the diagnostic accuracy of various index tests. In these 54 studies, eight different target conditions were identified with different final diagnoses constituting benign, precancerous, and cancerous lesions. None of the studies was of high methodological quality. None of the comparisons in which single studies were included was of sufficiently high methodological quality to warrant highlighting of the results. For differentiation of cancerous lesions from benign or precancerous lesions, we identified only one study per index test. The second analysis, of studies differentiating cancerous versus benign lesions, provided three tests in which meta-analysis could be performed. The sensitivities and specificities for diagnosing cancer were: EUS-FNA: sensitivity 0.79 (95% confidence interval (CI) 0.07 to 1.00), specificity 1.00 (95% CI 0.91 to 1.00); EUS: sensitivity 0.95 (95% CI 0.84 to 0.99), specificity 0.53 (95% CI 0.31 to 0.74); PET: sensitivity 0.92 (95% CI 0.80 to 0.97), specificity 0.65 (95% CI 0.39 to 0.84). The third analysis, of studies differentiating precancerous or cancerous lesions from benign lesions, only provided one test (EUS-FNA) in which meta-analysis was performed. EUS-FNA had moderate sensitivity for diagnosing precancerous or cancerous lesions (sensitivity 0.73 (95% CI 0.01 to 1.00) and high specificity 0.94 (95% CI 0.15 to 1.00), the extremely wide confidence intervals reflecting the heterogeneity between the studies). The fourth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (dysplasia) provided three tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing invasive carcinoma were: CT: sensitivity 0.72 (95% CI 0.50 to 0.87), specificity 0.92 (95% CI 0.81 to 0.97); EUS: sensitivity 0.78 (95% CI 0.44 to 0.94), specificity 0.91 (95% CI 0.61 to 0.98); EUS-FNA: sensitivity 0.66 (95% CI 0.03 to 0.99), specificity 0.92 (95% CI 0.73 to 0.98). The fifth analysis, of studies differentiating cancerous (high-grade dysplasia or invasive carcinoma) versus precancerous (low- or intermediate-grade dysplasia) provided six tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing cancer (high-grade dysplasia or invasive carcinoma) were: CT: sensitivity 0.87 (95% CI 0.00 to 1.00), specificity 0.96 (95% CI 0.00 to 1.00); EUS: sensitivity 0.86 (95% CI 0.74 to 0.92), specificity 0.91 (95% CI 0.83 to 0.96); EUS-FNA: sensitivity 0.47 (95% CI 0.24 to 0.70), specificity 0.91 (95% CI 0.32 to 1.00); EUS-FNA carcinoembryonic antigen 200 ng/mL: sensitivity 0.58 (95% CI 0.28 to 0.83), specificity 0.51 (95% CI 0.19 to 0.81); MRI: sensitivity 0.69 (95% CI 0.44 to 0.86), specificity 0.93 (95% CI 0.43 to 1.00); PET: sensitivity 0.90 (95% CI 0.79 to 0.96), specificity 0.94 (95% CI 0.81 to 0.99). The sixth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (low-grade dysplasia) provided no tests in which meta-analysis was performed. The seventh analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) provided two tests in which meta-analysis was performed. The sensitivity and specificity for diagnosing cancer were: CT: sensitivity 0.83 (95% CI 0.68 to 0.92), specificity 0.83 (95% CI 0.64 to 0.93) and MRI: sensitivity 0.80 (95% CI 0.58 to 0.92), specificity 0.81 (95% CI 0.53 to 0.95), respectively. The eighth analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) or benign lesions provided no test in which meta-analysis was performed.There were no major alterations in the subgroup analysis of cystic pancreatic focal lesions (42 studies; 2086 participants). None of the included studies evaluated EUS elastography or sequential testing. AUTHORS' CONCLUSIONS We were unable to arrive at any firm conclusions because of the differences in the way that study authors classified focal pancreatic lesions into cancerous, precancerous, and benign lesions; the inclusion of few studies with wide confidence intervals for each comparison; poor methodological quality in the studies; and heterogeneity in the estimates within comparisons.
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Affiliation(s)
- Lawrence MJ Best
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRowland Hill StreetLondonUKNW32PF
| | - Vishal Rawji
- University College London Medical SchoolLondonUK
| | - Stephen P Pereira
- Royal Free Hospital CampusUCL Institute for Liver and Digestive HealthUpper 3rd FloorLondonUKNW3 2PF
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRowland Hill StreetLondonUKNW32PF
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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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Groove pancreatitis: Imaging features and management. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2016. [DOI: 10.1016/j.ejrnm.2016.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Validation of the 2012 International Consensus Guidelines Using Computed Tomography and Magnetic Resonance Imaging: Branch Duct and Main Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas. Ann Surg 2016; 263:557-64. [PMID: 25822687 DOI: 10.1097/sla.0000000000001217] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To validate the 2012 guidelines for intraductal papillary mucinous neoplasm (IPMN) of the pancreas and to compare diagnostic performances of computed tomography (CT) and magnetic resonance imaging (MRI) for differentiating malignant from benign IPMN. BACKGROUND As IPMN has variable risks of malignancy and management of this entity is closely related to its malignant potential, it is important to predict risks of IPMN malignancy. METHODS This retrospective study included 158 patients with surgically confirmed IPMN of the pancreas who underwent both preoperative CT and MRI. Two radiologists evaluated the "high-risk stigmata" and "worrisome features" of the 2012 guidelines for branch duct (BD)-IPMN and main duct (MD)-IPMN. Univariate and multivariable analyses were used to identify significant predictors of malignancy in IPMN. The diagnostic performance was compared between CT and MRI. RESULTS Malignant IPMN was seen in 8 of 60 patients (13.3%) with BD-IPMN and 44 of 98 patients (44.9%) with MD-IPMN. Presence of mural nodule was the most important predictor in BD-IPMN and MD-IPMN (odds ratios, 9.2 and 7.6, respectively, P = 0.01 on CT; and odds ratios, 5.7 and 13.3, respectively, P ≤ 0.04 on MRI), whereas mural nodule size and lymphadenopathy were significant only in MD-IPMN (P < 0.05). The diagnostic performance of CT and MRI for significant findings was not statistically different in both types of IPMN (P > 0.34). CONCLUSIONS The presence of mural nodule was the most important predictor of malignancy in both types of IPMN. Mural nodule size and lymphadenopathy were also significant predictors in MD-IPMN. Computed tomography and MRI showed similar diagnostic performances for differentiating malignant from benign IPMN.
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38
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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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Verma A, Shukla S, Verma N. Diagnosis, Preoperative Evaluation, and Assessment of Resectability of Pancreatic and Periampullary Cancer. Indian J Surg 2016; 77:362-70. [PMID: 26722198 DOI: 10.1007/s12262-015-1370-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/30/2015] [Indexed: 01/04/2023] Open
Abstract
Periampullary region encircles a radius of 2 cm around the ampulla of Vater; accordingly, four distinct neoplasias with overlapping imaging features originate in the region. Each of these lesions has a different long-term prognosis; hence, imaging evaluation to characterize the lesion is important. Further certain specific features pertaining to the vascular invasion and systemic spread may decide about the treatment as well as surgical approach. An understanding of the advances in imaging and image processing technology as well as in the methods of image acquisition, for the purpose, is quite relevant towards etching out a rational pre-treatment evaluation protocol. Further, an evidence-based decision as to the choice of optimum modality for answering specific clinical question is of prime importance in achieving a reasonable post-treatment outcome. Pancreatic adenocarcinoma is the fourth most common cancer and a malignancy with one of the least 5-year survival rates (ranging from 6.8 to 15 % depending on peripancreatic extensions, dropping to 1.8 % for metastatic disease). A survival rate of 15-27 % can be achieved if the lesion is resectable but unfortunately, only 10-15 % of patients are eligible for resection. Cystic tumors of pancreas are a rarer variety of pancreatic neoplasia (5-15 % of pancreatic cysts and 1 % of all pancreatic cancers) which have a much better outcome and chances of resection. Being mostly incidentalomas, a timely differentiation of this lesion from the much more common pseudocyst (which would mandate a medical management and a different surgical protocol) is the key for curability. Lastly, the neuroendocrine tumors of pancreas are equally rare (1 % of all pancreatic tumors), but importantly due to associated clinical syndromes and their capability to metastasize early in the course of disease, a timely detection may hence be the key for successful treatment of these lesions. Imaging plays a vital role in the initial detection and characterization as well as in determination of resectability of each of these pancreatic neoplasias. Further, the differentiation of pancreatic head tumors from other periampullary neoplasias is important; the fact that most recurrences are as a result of surgical intervention in an otherwise inoperable disease while most treatment failures are due to improper characterization of the lesion is notable.
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Affiliation(s)
- Ashish Verma
- Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005 India
| | - Sunit Shukla
- Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005 India
| | - Nimisha Verma
- Department of Anesthesiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005 India
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Sultana A, Jackson R, Tim G, Bostock E, Psarelli EE, Cox TF, Sutton R, Ghaneh P, Raraty MGT, Neoptolemos JP, Halloran CM. What Is the Best Way to Identify Malignant Transformation Within Pancreatic IPMN: A Systematic Review and Meta-Analyses. Clin Transl Gastroenterol 2015; 6:e130. [PMID: 26658837 PMCID: PMC4816095 DOI: 10.1038/ctg.2015.60] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 11/03/2015] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Pancreatic intraductal papillary mucinous neoplasias (IPMNs) represent 25% of all cystic neoplasms and are precursor lesions for pancreatic ductal adenocarcinoma. This study aims to identify the best imaging modality for detecting malignant transformation in IPMN, the sensitivity and specificity of risk features on imaging, and the usefulness of tumor markers in serum and cyst fluid to predict malignancy in IPMN. METHODS Databases were searched from November 2006 to March 2014. Pooled sensitivity and specificity of diagnostic techniques/imaging features of suspected malignancy in IPMN using a hierarchical summary receiver operator characteristic (HSROC) approach were performed. RESULTS A total of 467 eligible studies were identified, of which 51 studies met the inclusion criteria and 37 of these were incorporated into meta-analyses. The pooled sensitivity and specificity for risk features predictive of malignancy on computed tomography/magnetic resonance imaging were 0.809 and 0.762 respectively, and on positron emission tomography were 0.968 and 0.911. Mural nodule, cyst size, and main pancreatic duct dilation found on imaging had pooled sensitivity for prediction of malignancy of 0.690, 0.682, and 0.614, respectively, and specificity of 0.798, 0.574, and 0.687. Raised serum carbohydrate antigen 19-9 (CA19-9) levels yielded sensitivity of 0.380 and specificity of 0903. Combining parameters yielded a sensitivity of 0.743 and specificity of 0.906. CONCLUSIONS PET holds the most promise in identifying malignant transformation within an IPMN. Combining parameters increases sensitivity and specificity; the presence of mural nodule on imaging was the most sensitive whereas raised serum CA19-9 (>37 KU/l) was the most specific feature predictive of malignancy in IPMNs.
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Affiliation(s)
- Asma Sultana
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Richard Jackson
- Medical Statistics, CRUK Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - Gilbert Tim
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Emma Bostock
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Eftychia E Psarelli
- Medical Statistics, CRUK Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - Trevor F Cox
- Medical Statistics, CRUK Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, UK
| | - Robert Sutton
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Paula Ghaneh
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Michael G T Raraty
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - John P Neoptolemos
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Christopher M Halloran
- NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Pravisani R, Intini SG, Girometti R, Avellini C, Leo CA, Bugiantella W, Risaliti A. Macrocystic serous cystadenoma of the pancreas: Report of 4 cases. Int J Surg 2015; 21 Suppl 1:S98-S101. [PMID: 26118606 DOI: 10.1016/j.ijsu.2015.04.097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 03/27/2015] [Accepted: 04/10/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Macrocystic serous cystadenomas (MaSCA) are rare benign tumor of the pancreas which represent an atypical macroscopic morphologic variant of serous cystadenomas (SCA). They are characterized by a limited number of cysts with a diameter of >2 cm and share imaging features overlapping those of mucinous cystic neoplasm (MCN) and branch-duct intraductal papillary mucinous neoplasm (BD-IPMN), thus frequently making the pre-operative radiologic diagnosis difficult. MATERIALS AND METHODS Four cases of MaSCA, which were surgically treated in our structure, are reported. RESULTS Two women (62 and 39 year-old) presented with upper abdominal pain and palpable mass underwent CT with evidence of a lobulated cystic neoformation (98 × 70 and 94 × 75 mm respectively) originating from the body and the tail of the pancreas respectively. They underwent distal pancreatectomy for suspected MCN. A 38 year-old woman underwent laparoscopic distal pancreatectomy because of the incidental finding of an unilocular cystic lesion in the pancreatic tail (23 mm) of indeterminate origin (MCN, SCA or metastasis). In a 40 year-old woman, admitted for acalculous acute pancreatitis, an unilocular cystic lesion in the body of the pancreas (62 mm) was detected and confirmed after 2 months at CT, therefore she underwent distal pancreatectomy for suspected pseudocyst or SCA. In all of the 4 patients the histological examination of the specimens revealed a MaSCA. CONCLUSION Imaging techniques have a low diagnostic power in terms of differentiation of MaSCA from malignant lesions (as MCNs and BD-IPMN). In the clinical practise of MaSCA, surgery appears to gain indications that are wider than those correlated to the pathologic outcome, because of the necessity of a correct differential diagnosis from potentially malignant cystic tumors and the frequent symptoms requiring treatment.
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Affiliation(s)
- Riccardo Pravisani
- Dipartimento di Scienze Mediche e Biologiche, Universitá degli Studi di Udine, Piazzale Kolbe, 4, 33100 Udine, Italy.
| | - Sergio Giuseppe Intini
- Dipartimento di Scienze Mediche e Biologiche, Universitá degli Studi di Udine, Piazzale Kolbe, 4, 33100 Udine, Italy.
| | - Rossano Girometti
- Institute of Radiology, University Hospital "S. Maria della Misericordia", Udine, Italy.
| | - Claudio Avellini
- Institute of Pathology, University Hospital "S. Maria della Misericordia", Udine, Italy.
| | - Cosimo Alex Leo
- Dipartimento di Scienze Mediche e Biologiche, Universitá degli Studi di Udine, Piazzale Kolbe, 4, 33100 Udine, Italy.
| | - Walter Bugiantella
- General Surgery, AUSL Umbria 2, Italy, PhD School of Biotechnologies, University of Perugia, Italy.
| | - Andrea Risaliti
- Dipartimento di Scienze Mediche e Biologiche, Universitá degli Studi di Udine, Piazzale Kolbe, 4, 33100 Udine, Italy.
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Abstract
Management of Bd-IPMN remains challenging. Critical appraisal of the published literature reveals that the actual treatment of what is presumed to be Bd-IPMN remains unsatisfactory, with a high rate of surgically overtreated patients. Until we accrue more precise knowledge of the natural history of Bd-IPMN, management of patients with this presumed diagnosis should be individually tailored and preferably carried out in centers with a high expertise. For now, the authors strongly think that the old guidelines should be followed in most patients because these have proven to correctly identify lesions that can be safely followed. Although the new guidelines allow for follow-up of lesions greater than 3 cm, and for the most part this is safe, they should be used cautiously in younger patients because very close surveillance would be required for their long remaining lifespan.
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Kim SH, Lee JM, Lee ES, Baek JH, Kim JH, Han JK, Choi BI. Intraductal papillary mucinous neoplasms of the pancreas: evaluation of malignant potential and surgical resectability by using MR imaging with MR cholangiography. Radiology 2014; 274:723-33. [PMID: 25302831 DOI: 10.1148/radiol.14132960] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To evaluate the diagnostic performance of magnetic resonance (MR) imaging with MR cholangiopancreatography (MRCP) in determining the malignant potential and surgical resectability of pancreas intraductal papillary mucinous neoplasms (IPMNs). MATERIALS AND METHODS Institutional review board approval was obtained, and the requirement for informed consent was waived. Ninety-eight patients with pathologically proved pancreas IPMNs who underwent MR imaging with MRCP comprised the study population. MR images were analyzed for findings suggestive of high-risk stigmata or worrisome features, as proposed by the international consensus guidelines 2012. Interobserver agreement between two experienced observers (observers 1 and 2) and one inexperienced observer (observer 3) was assessed. Diagnostic performance of MR imaging in the evaluation of the malignant potential and surgical resectability of IPMNs was analyzed in these three observers by using receiver operating curve analysis. RESULTS MR imaging with MRCP showed sensitivity of 83% (35/42), 79% (33/42), and 90% (38/42); specificity of 80% (41/51), 51% (26/51), and 24% (12/51); and accuracy of 82% (76/93), 63% (59/93), and 54% (50/93) for observers 1, 2, and 3, respectively, in the evaluation of the malignant potential of pancreas IPMNs when at least one worrisome feature was present. Interobserver agreement in the detection of intramural nodules (κ = 0.349-0.574), enhanced solid components (κ = 0.318-0.574), and measurement of main pancreatic duct diameter (intraclass correlation coefficient = 0.9477) was fair to high. The respective sensitivity, specificity, and accuracy in determination of surgical resectability were 95% (81/85), 99% (84/85), and 88% (75/85); 69% (9/13), 69% (9/13), and 54% (7/13); and 92% (90/98), 95% (93/98), and 84% (82/98) for observers 1, 2, and 3. CONCLUSION MR imaging with MRCP is a useful modality in the evaluation of the malignant potential and resectability of IPMNs, with high sensitivity and moderate specificity in the experienced radiologists but relatively low specificity in the inexperienced radiology trainee.
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Affiliation(s)
- Seong Ho Kim
- From the Department of Radiology (S.H.K., J.M.L., J.H.B., J.H.K., J.K.H., B.I.C.) and Institute of Radiation Medicine (J.M.L., J.H.K., J.K.H., B.I.C.), Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea; and Department of Radiology, Research Institute and Hospital of National Cancer Center, Goyang, Republic of Korea (E.S.L.)
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Magnetic resonance imaging of less common pancreatic malignancies and pancreatic tumors with malignant potential. Eur J Radiol Open 2014; 1:49-59. [PMID: 26937427 PMCID: PMC4750607 DOI: 10.1016/j.ejro.2014.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 09/16/2014] [Accepted: 09/17/2014] [Indexed: 02/07/2023] Open
Abstract
Pancreatic tumors are an increasingly common finding in abdominal imaging. Various kinds of pathologies of the pancreas are well known, but it often remains difficult to classify the lesions radiologically in respect of type and grade of malignancy. Magnetic resonance imaging (MRI) is the method of choice for the evaluation of pancreatic pathologies due to its superior soft tissue contrast. In this article we present a selection of less common malignant and potentially malignant pancreatic neoplasms with their characteristic appearance on established MRI sequences with and without contrast enhancement.
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Santa LGDL, Retortillo JAP, Miguel AC, Klein LM. Radiology of pancreatic neoplasms: An update. World J Gastrointest Oncol 2014; 6:330-343. [PMID: 25232458 PMCID: PMC4163731 DOI: 10.4251/wjgo.v6.i9.330] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 12/13/2013] [Indexed: 02/05/2023] Open
Abstract
Diagnostic imaging is an important tool to evaluate pancreatic neoplasms. We describe the imaging features of pancreatic malignancies and their benign mimics. Accurate detection and staging are essential for ensuring appropriate selection of patients who will benefit from surgery and for preventing unnecessary surgeries in patients with unresectable disease. Ultrasound, multidetector computed tomography with multiplanar reconstruction and magnetic resonance imaging can help to do a correct diagnosis. Radiologists should be aware of the wide variety of anatomic variants and pathologic conditions that may mimic pancreatic neoplasms. The knowledge of the most important characteristic key findings may facilitate the right diagnosis.
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46
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What to do for the incidental pancreatic cystic lesion? Surg Oncol 2014; 23:117-25. [DOI: 10.1016/j.suronc.2014.04.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 03/09/2014] [Accepted: 04/11/2014] [Indexed: 02/07/2023]
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47
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The utilization of imaging features in the management of intraductal papillary mucinous neoplasms. Gastroenterol Res Pract 2014; 2014:765451. [PMID: 25202326 PMCID: PMC4151493 DOI: 10.1155/2014/765451] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 07/19/2014] [Accepted: 07/24/2014] [Indexed: 12/21/2022] Open
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) represent a group of cystic pancreatic neoplasms with large range of clinical behaviours, ranging from low-grade dysplasia or borderline lesions to invasive carcinomas. They can be grouped into lesions originating from the main pancreatic duct, main duct IPMNs (MD-IPMNs), and lesions which arise from secondary branches of parenchyma, denominated branch-duct IPMNs (BD-IPMNs). Management of these cystic lesions is essentially based on clinical and radiological features. The latter have been very well described in the last fifteen years, with many studies published in literature showing the main radiological features of IPMNs. Currently, the goal of imaging modalities is to identify "high-risk stigmata" or "worrisome feature" in the evaluation of pancreatic cysts. Marked dilatation of the main duct (>1 cm), large size (3-5 cm), and intramural nodules have been associated with increased risk of degeneration. BD-IPMNs could be observed as microcystic or macrocystic in appearance, with or without communication with main duct. Their imaging features are frequently overlapped with cystic neoplasms. The risk of progression for secondary IPMNs is lower, and subsequently an imaging based follow-up is very often proposed for these lesions.
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48
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Buscarini E, Pezzilli R, Cannizzaro R, De Angelis C, Gion M, Morana G, Zamboni G, Arcidiacono P, Balzano G, Barresi L, Basso D, Bocus P, Calculli L, Capurso G, Canzonieri V, Casadei R, Crippa S, D'Onofrio M, Frulloni L, Fusaroli P, Manfredi G, Pacchioni D, Pasquali C, Rocca R, Ventrucci M, Venturini S, Villanacci V, Zerbi A, Falconi M. Italian consensus guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms. Dig Liver Dis 2014; 46:479-93. [PMID: 24809235 DOI: 10.1016/j.dld.2013.12.019] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 12/07/2013] [Accepted: 12/30/2013] [Indexed: 12/11/2022]
Abstract
This report contains clinically oriented guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms in patients fit for treatment. The statements were elaborated by working groups of experts by searching and analysing the literature, and then underwent a consensus process using a modified Delphi procedure. The statements report recommendations regarding the most appropriate use and timing of various imaging techniques and of endoscopic ultrasound, the role of circulating and intracystic markers and the pathologic evaluation for the diagnosis and follow-up of cystic pancreatic neoplasms.
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Affiliation(s)
| | | | | | - Raffaele Pezzilli
- Pancreas Unit, Department of Digestive Diseases and Internal Medicine, S. Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Claudio De Angelis
- Gastroenterology and Hepatology Department, A.O. San Giovanni Battista/Molinette, University of Turin, Turin, Italy
| | - Massimo Gion
- Department of Clinical Pathology, AULSS 12, Venice, Italy
| | - Giovanni Morana
- Department of Diagnostic Radiology, Ospedale Cà Foncello, Treviso, Italy
| | | | - Paolo Arcidiacono
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute, Italy
| | - Gianpaolo Balzano
- Department of Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Luca Barresi
- Gastroenterology and Endoscopy Unit, ISMETT, Palermo, Italy
| | - Daniela Basso
- Department of Laboratory Medicine, University Hospital, Padua, Italy
| | - Paolo Bocus
- Gastroenterology Unit, Ospedale Sacro Cuore-Don Calabria, Negrar, Verona, Italy
| | - Lucia Calculli
- Department of Radiology, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Gabriele Capurso
- Digestive and Liver Disease Unit, Faculty of Medicine and Psychology, Sapienza University of Rome at S. Andrea Hospital, Rome, Italy
| | | | - Riccardo Casadei
- Department of Surgery, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Stefano Crippa
- Department of Surgery, Pancreas Unit, Università Politecnica delle Marche, Ancona, Italy
| | - Mirko D'Onofrio
- Department of Radiology, University Hospital G.B. Rossi, University of Verona, Verona, Italy
| | - Luca Frulloni
- Department of Surgical and Gastroenterological Sciences, University of Verona, Verona, Italy
| | - Pietro Fusaroli
- Department of Clinical Medicine, University of Bologna, Bologna, Italy
| | | | | | - Claudio Pasquali
- Surgery Unit IV, Department of Medical and Surgical Sciences, University of Padua, Padua, Italy
| | - Rodolfo Rocca
- Gastroenterology Unit, Mauriziano Hospital, Turin, Italy
| | - Maurizio Ventrucci
- Department of Internal Medicine and Gastroenterology, Bentivoglio Hospital, Bologna, Italy
| | - Silvia Venturini
- Department of Diagnostic Radiology, Ospedale Cà Foncello, Treviso, Italy
| | | | - Alessandro Zerbi
- Pancreatic Surgery, Department of Surgery, Humanitas Clinical and Research Center, Milan, Italy
| | - Massimo Falconi
- Department of Surgery, Pancreas Unit, Università Politecnica delle Marche, Ancona, Italy
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Iatrogenic pancreatitis in patients with IPMN after ERCP: incidence and predictive signs. ACTA ACUST UNITED AC 2014; 39:949-54. [DOI: 10.1007/s00261-014-0122-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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50
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Enestvedt BK, Ahmad N. To cease or 'de-cyst'? The evaluation and management of pancreatic cystic lesions. Curr Gastroenterol Rep 2014; 15:348. [PMID: 24014118 DOI: 10.1007/s11894-013-0348-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Due to the widespread use of cross-sectional imaging and advances in imaging technology, pancreatic cystic lesions are increasingly being detected. The diagnosis and management of such cysts remains challenging and continues to evolve. Different pancreatic cyst types have varying malignant potential. Thus, accurate cyst characterization is essential to appropriate management; the most clinically important distinction is differentiating mucinous lesions, which have malignant potential and may benefit from surgical resection, from non-mucinous cystic lesions. Endoscopic ultrasound with fine needle aspiration with cytologic, chemical,, and tumor marker analysis appears to be the best currently available method for accurately characterizing a cyst's malignant potential, and therefore impacts the most important management decision for a pancreatic cyst-continued surveillance or surgical resection.
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Affiliation(s)
- Brintha K Enestvedt
- Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, L461, Portland, OR 97239, USA.
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