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Minelli C, Balducci F, Cavalleri C, Milanetto AC, Ferrara F, Crimì F, Quaia E, Vernuccio F. Intraductal papillary mucinous neoplasms of the pancreas: Uncommon imaging presentation, evolution and comparison of guidelines. Eur J Radiol Open 2023; 11:100531. [PMID: 37920680 PMCID: PMC10618428 DOI: 10.1016/j.ejro.2023.100531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/29/2023] [Accepted: 10/10/2023] [Indexed: 11/04/2023] Open
Abstract
Pancreatic cystic lesions are often asymptomatic, incidentally detected and include a range of entities with varying degrees of concern for malignancy. Among these, intraductal papillary mucinous neoplasms (IPMN) are considered premalignant pancreatic lesions, with a broad pathological spectrum ranging from lesions without dysplasia, which can be managed conservatively, to malignant lesions that require surgical resection. The increasing use of CT and MRI has led to increased recognition of this entity incidentally, with branch-duct IPMN representing the most common subtype and the most challenging lesions in terms of patient management. The main imaging modality involved in diagnosis and surveillance of IPMN is MRI. Radiologists play an important role in the management of patients with IPMN, including lesion detection, characterization, follow-up and prognostication, allowing early MRI identification of features that are concerning for malignancy. The main aim of this pictorial review is to illustrate MRI features of IPMN and to discuss risk stratification scores based on different guidelines, with a main focus on branch-duct IPMN. The secondary aims include the presentation of common and uncommon imaging evolution of BD-IPMN as well as the discussion on current controversies on the appropriate management of IPMN.
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Affiliation(s)
- Chiara Minelli
- Institute of Radiology, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Federico Balducci
- Institute of Radiology, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Cristina Cavalleri
- Institute of Radiology, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Anna Caterina Milanetto
- Chirurgia Generale 3, Department of Surgery, Oncology and Gastroenterology - University of Padova, 35128, Padova, Italy
| | - Francesco Ferrara
- Gastroenterology Unit - University Hospital of Padova, 35128 Padova, Italy
| | - Filippo Crimì
- Institute of Radiology, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Emilio Quaia
- Institute of Radiology, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Federica Vernuccio
- Department of Radiology, University Hospital of Padova, 35128 Padova, Italy
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Xu JH, Ni CY, Zhuang YY, Li L, Lin Y, Xia ZS, Wu WR, Chen QK, Zhong W. Acute pancreatitis in intraductal papillary mucinous neoplasm: a single-center retrospective cohort study with systematic review and meta-analysis. BMC Gastroenterol 2023; 23:424. [PMID: 38041073 PMCID: PMC10690977 DOI: 10.1186/s12876-023-02972-4] [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: 02/22/2023] [Accepted: 09/26/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Intraductal papillary mucinous neoplasm (IPMN) is a cystic tumor of the pancreas arising from abnormal papillary proliferation of ductal epithelial cells, and is a precancerous lesion of pancreatic malignancy. This study aimed to evaluate associations between acute pancreatitis (AP) and histologic subtypes of IPMN. METHODS In the clinical study, patients with IPMN confirmed by surgical resection specimens at our institute between 2009 and 2021 were eligible for inclusion. Associations and predictive accuracy of AP on the presence of HGD were determined by logistic regressions. In addition, a systematic review and meta-analysis was conducted through literatures upon search in PubMed, Embase, CENTRAL, China National Knowledge Infrastructure (CKNI), and Wanfang database, up to June, 2023. Pooled effects of the associations between AP and HGD and intestinal epithelial subtype subtype, shown as odds ratios (ORs) with 95% confidence intervals (CIs), were calculated using random effects model. RESULTS The retrospective cohort study included 47 patients (32 males, 15 females) diagnosed with IPMN at our center between 2009 and 2021, including 11 cases with AP (median 62 years) and 36 cases (median 64.5 years) without. Accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of AP in predicting HGD were 78.7%, 57.1%, 82.5%, 36.4%, and 91.7%, respectively. Univariate logistic regression analysis showed that AP group had greater odds of presence of HGD (OR: 6.29,95% CI: 1.14-34.57) than non-AP group. Meta-analysis of five case-control studies in the literature included 930 patients and showed that AP-IPMN patients had higher odds for HGD (OR: 2.13, 95% CI 1.38-3.29) and intestinal epithelial subtype (OR: 5.38, 95% CI: 3.50-8.27) compared to non-AP IPMN. CONCLUSIONS AP is predictive of malignancy in patients with IPMN.
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Affiliation(s)
- Ji-Hao Xu
- Department of Gastroenterology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang Xi Road, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Chu-Yan Ni
- Department of Gastroenterology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang Xi Road, Guangzhou, 510120, Guangdong, People's Republic of China
- Department of Gastroenterology, Longgang District People's Hospital of Shenzhen, Central City of Longgang District, No.53 Aixin Road, Shenzhen City, 518172, Guangdong, People's Republic of China
| | - Yan-Yan Zhuang
- Department of Gastroenterology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang Xi Road, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Li Li
- Department of Emergency, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang Xi Road, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Ying Lin
- Department of Gastroenterology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang Xi Road, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Zhong-Sheng Xia
- Department of Gastroenterology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang Xi Road, Guangzhou, 510120, Guangdong, People's Republic of China.
| | - Wei-Rong Wu
- Department of Gastroenterology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang Xi Road, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Qi-Kui Chen
- Department of Gastroenterology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang Xi Road, Guangzhou, 510120, Guangdong, People's Republic of China
| | - Wa Zhong
- Department of Gastroenterology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, 107 Yan Jiang Xi Road, Guangzhou, 510120, Guangdong, People's Republic of China.
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Triantopoulou C, Gourtsoyianni S, Karakaxas D, Delis S. Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Challenging Diagnosis. Diagnostics (Basel) 2023; 13:2015. [PMID: 37370909 DOI: 10.3390/diagnostics13122015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/31/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023] Open
Abstract
Intraductal papillary mucinous neoplasm of the pancreas (IPMN) was classified as a distinct entity from mucinous cystic neoplasm by the WHO in 1995. It represents a mucin-producing tumor that originates from the ductal epithelium and can evolve from slight dysplasia to invasive carcinoma. In addition, different aspects of tumor progression may be seen in the same lesion. Three types are recognized, the branch duct variant, the main duct variant, which shows a much higher prevalence for malignancy, and the mixed-type variant, which combines branch and main duct characteristics. Advances in cross-sectional imaging have led to an increased rate of IPMN detection. The main imaging characteristic of IPMN is the dilatation of the pancreatic duct without the presence of an obstructing lesion. The diagnosis of a branch duct IPMN is based on the proof of its communication with the main pancreatic duct on MRI-MRCP examination. Early identification by imaging of the so-called worrisome features or predictors for malignancy is an important and challenging task. In this review, we will present recent imaging advances in the diagnosis and characterization of different types of IPMNs, as well as imaging tools available for early recognition of worrisome features for malignancy. A critical appraisal of current IPMN management guidelines from both a radiologist's and surgeon's perspective will be made. Special mention is made of complications that might arise during the course of IPMNs as well as concomitant pancreatic neoplasms including pancreatic adenocarcinoma and pancreatic endocrine neoplasms. Finally, recent research on prognostic and predictive biomarkers including radiomics will be discussed.
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Affiliation(s)
| | - Sofia Gourtsoyianni
- 1st Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Areteion Hospital, 11528 Athens, Greece
| | - Dimitriοs Karakaxas
- Department of Surgery, Konstantopouleio General Hospital, 14233 Athens, Greece
| | - Spiros Delis
- Department of Surgery, Konstantopouleio General Hospital, 14233 Athens, Greece
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Alwahbi O, Ghumman Z, van der Pol CB, Patlas M, Gopee-Ramanan P. Pancreatic Cystic Lesions: Review of the Current State of Diagnosis and Surveillance. Can Assoc Radiol J 2022:8465371221130524. [PMID: 36220377 DOI: 10.1177/08465371221130524] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pancreatic cystic lesions (PCLs) are both common and often incidental. These encompass a range of pathologies with varying degrees of concern for malignancy. Although establishing a diagnosis is helpful for determining malignant potential, many PCLs are either too small to characterize or demonstrate nonspecific morphologic features. The most salient modalities involved in diagnosis and surveillance are magnetic resonance imaging, multidetector computerized tomography, and endoscopic ultrasound. Fine needle aspiration has a role in conjunction with molecular markers as a diagnostic tool, particularly for identifying malignant lesions. Although several major consensus guidelines exist internationally, there remains uncertainty in establishing the strength of the association between all PCLs and pancreatic adenocarcinoma, and in showing a benefit from extended periods of imaging surveillance. No consensus exists between the major guidelines, particularly regarding surveillance duration, frequency, or endpoints. This review paper discusses PCL subtypes, diagnosis, and compares the major consensus guidelines with considerations for local adaptability along with questions regarding current and future priorities for research.
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Affiliation(s)
- Omar Alwahbi
- Department of Radiology, 62703McMaster University Health Sciences Centre (HSC - 3N26), Hamilton, ON, Canada
| | - Zonia Ghumman
- Department of Radiology, 62703McMaster University Health Sciences Centre (HSC - 3N26), Hamilton, ON, Canada.,Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Christian B van der Pol
- Department of Radiology, 62703McMaster University Health Sciences Centre (HSC - 3N26), Hamilton, ON, Canada.,Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Michael Patlas
- Department of Radiology, 62703McMaster University Health Sciences Centre (HSC - 3N26), Hamilton, ON, Canada.,Hamilton General Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Prasaanthan Gopee-Ramanan
- Department of Radiology, 62703McMaster University Health Sciences Centre (HSC - 3N26), Hamilton, ON, Canada.,Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, ON, Canada
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5
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Zhao B, Zhao B, Chen F. Diagnostic value of serum carbohydrate antigen 19-9 in pancreatic cancer: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2022; 34:891-904. [PMID: 35913776 DOI: 10.1097/meg.0000000000002415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Carbohydrate antigen 19-9 (CA19-9) is the most widely used serum biomarker for detecting pancreatic cancer (PC). Since early diagnosis is important for improving PC prognosis, a comprehensive understanding of the diagnostic performance of CA19-9 is critical. This study focused on comprehensive evaluation of the efficacy of CA19-9 in PC diagnosis. Literature research was based on the seven databases. Studies released from January 2002 to January 2022 focused on the efficacy of CA19-9 in the detection of PC were included. Summarized sensitivity, specificity, and sROC/accuracy of discrimination (AUC) were estimated. Potential publication bias was measured with Funnel plot and Egger's test. Meta-regression was performed to detect possible causes of heterogeneity. Subgroup analysis was used to assess the diagnostic efficacy of CA19-9 under different conditions. The study is registered on PROSPERO (CRD42021253861). Seventy-nine studies containing 20 991 participants who met the criteria were included. The pooled sensitivity, specificity, and AUC of CA19-9 in diagnose PC were 72% (95% CI, 71-73%), 86% (95% CI, 85-86%), and 0.8474 (95% CI, 0.8272-0.8676). Subgroup analysis suggested that the diagnostic efficiency of CA19-9 in studies with healthy controls was the highest, followed by intraductal papillary mucinous neoplasm, in pancreatitis and diabetes were consistent with the overall result. Our analysis showed that serum CA19-9 had high and stable diagnostic efficacy for PC (not affected by diabetes). Subgroup analysis showed that serum CA19-9 yielded highest effectiveness in the diagnosis of pancreatic precancerous lesions, which indicated an irreplaceable clinical value in the early detection and warning value for PC.
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Affiliation(s)
- Boqiang Zhao
- Xi'an Jiaotong University Health Science Center, Xi'an, China
- The First School of Clinical Medicine, Xi'an, China
| | - Boyue Zhao
- Xi'an Jiaotong University Health Science Center, Xi'an, China
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an, China
| | - Fangyao Chen
- Xi'an Jiaotong University Health Science Center, Xi'an, China
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an, China
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6
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de la Fuente J, Lui J, Lennon RJ, Chatterjee A, Graham RP, Zhang L, Kendrick ML, Truty MJ, Cleary SP, Smoot RL, Nagorney DM, Gleeson FC, Levy MJ, Chandrasekhara V, Pearson RK, Petersen BT, Vege SS, Chari ST, Majumder S. Pancreatic Cancer is More Frequently Early Stage at Diagnosis in Surgically Resected Intraductal Papillary Mucinous Neoplasms With Preoperative Surveillance. GASTRO HEP ADVANCES 2022; 1:1099-1107. [PMID: 39131265 PMCID: PMC11308491 DOI: 10.1016/j.gastha.2022.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 07/06/2022] [Indexed: 08/13/2024]
Abstract
Background and Aims Management of intraductal papillary mucinous neoplasms (IPMNs) relies on clinical and imaging features to select patients for either pancreatectomy or periodic image-based surveillance. We aimed to compare outcomes in patients with IPMNs who underwent surgery at diagnosis with those who underwent surgery after a period of surveillance and identify preoperative clinical and imaging features associated with advanced neoplasia. Methods Patients with surgically resected IPMN (n = 450) were divided into 2 groups: "immediate surgery": resection within 6 months of IPMN detection, and "surveillance surgery": resection after surveillance >6 months. Survival was analyzed with Kaplan-Meier estimates and Cox proportional hazard models. Results Pancreatic cancers in the surveillance surgery group (n = 135) was more frequently stage I compared with the immediate surgery group (9/13, 69.2% vs 41/110, 37.3%; P = .027). Among Fukuoka "worrisome features," only main pancreatic duct dilation 5-9 mm (odds ratio [OR] = 3.12, 95% confidence interval [CI]: 1.72-5.68; P < .001) and serum CA 19-9≥ 35 U/mL (OR = 2.82, 95% CI: 1.31-6.06; P = .008) were significantly associated with advanced neoplasia. In addition, smoking history was associated with increased risk of advanced neoplasia (OR = 2.05, 95% CI: 1.23-3.43). Occurrence of future cancer was 16-fold higher in IPMN with high-grade dysplasia when compared with low-grade dysplasia (hazard ratio: 16.5; 95% CI: 4.19-64.7). Conclusion Surveillance-detected pancreatic cancers in patients with IPMNs are more frequently stage I, and IPMN-HGD on surgical pathology is associated with significant risk of future pancreatic cancer. In addition to known "high-risk" features, main pancreatic duct dilation 5-9 mm, CA 19-9 elevation, and smoking history are significantly associated with advanced neoplasia.
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Affiliation(s)
- Jaime de la Fuente
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Jacob Lui
- Department of Internal Medicine, Columbia University Irving Medical Center and the Vagelos College of Physicians and Surgeons, New York, New York
| | - Ryan J. Lennon
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester Mayo Clinic, Rochester, Minnesota
| | - Arjun Chatterjee
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Rondell P. Graham
- Division of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Lizhi Zhang
- Division of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Michael L. Kendrick
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mark J. Truty
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sean P. Cleary
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Rory L. Smoot
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - David M. Nagorney
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, Minnesota
| | - Ferga C. Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michael J. Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Randall K. Pearson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Bret T. Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Santhi S. Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Suresh T. Chari
- Department of Gastroenterology and Hepatology, University of Texas MD Anderson, Houston, Texas
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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7
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Intraductal Papillary Mucinous Neoplasms (IPMN) of the Pancreas: an Update in Definition, Time to Progression, and Surgical Management. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03394-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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8
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[Diagnostics and clinical management of premalignant diseases of the pancreas]. Internist (Berl) 2022; 63:401-413. [PMID: 35234978 DOI: 10.1007/s00108-022-01308-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
Abstract
Pancreatic cancer is one of the most aggressive solid tumors and still has a poor prognosis. A delayed diagnosis at advanced stages and a poor response to systemic treatment frequently make a curative treatment impossible. Therefore, the identification of high-risk patients and screening them regularly is the most promising approach to improve the prognosis. Chronic pancreatitis as well as neoplastic pancreatic cysts can greatly increase the risk of developing pancreatic cancer. Furthermore, familial syndromes and germline mutations also confer an increased risk for development of pancreatic cancer. This article provides an overview of the various premalignant diseases of the pancreas. The value of the various imaging modalities, such as magnetic resonance imaging and endosonography are particularly discussed as well as the screening interval and the indications for surgical treatment are explained.
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Das KK, Mullady DK. Main Pancreatic Duct Dilation in IPMN: When (and Where) to Get "Worried"? Clin Gastroenterol Hepatol 2022; 20:272-275. [PMID: 33581356 DOI: 10.1016/j.cgh.2021.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Koushik K Das
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel K Mullady
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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10
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Buerlein RCD, Shami VM. Management of pancreatic cysts and guidelines: what the gastroenterologist needs to know. Ther Adv Gastrointest Endosc 2021; 14:26317745211045769. [PMID: 34589706 PMCID: PMC8474323 DOI: 10.1177/26317745211045769] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/25/2021] [Indexed: 12/15/2022] Open
Abstract
The prevalence of pancreatic cysts has increased significantly over the last
decade, partly secondary to increased quality and frequency of cross-sectional
imaging. While the majority never progress to cancer, a small number will and
need to be followed. The management of pancreatic cysts can be both confusing
and intimidating due to the multiple guidelines with varying recommendations.
Despite the differences in the specifics of the guidelines, they all agree on
several high-risk features that should get the attention of any clinician when
assessing a pancreatic cyst: presence of a mural nodule or solid component,
dilation of the main pancreatic duct (or presence of main duct intraductal
papillary mucinous neoplasm), pancreatic cyst size ⩾3–4 cm, or positive cytology
on pancreatic cyst fluid aspiration. Other important criteria to consider
include rapid cyst growth (⩾5 mm/year), elevated serum carbohydrate antigen 19-9
levels, new-onset diabetes mellitus, or acute pancreatitis thought to be related
to the cystic lesion.
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Affiliation(s)
| | - Vanessa M Shami
- University of Virginia Digestive Health, 1215 Lee Street, Charlottesville, VA 22903, USA
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11
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Assessment of Malignancy Potential in Intraductal Papillary Mucinous Neoplasms of the Pancreas on MDCT. Acad Radiol 2021; 28:679-686. [PMID: 32591278 DOI: 10.1016/j.acra.2020.03.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/23/2020] [Accepted: 03/24/2020] [Indexed: 12/19/2022]
Abstract
RATIONALE AND OBJECTIVE To assess the malignancy potential of intraduct papillary mucinous neoplasms (IPMNs) on multidetector-row computerized tomography according to the 2012 International Consensus Guidelines (ICG). MATERIALS AND METHODS This study retrospectively collected IPMNs confirmed by surgery from 2016 to 2019. The imaging findings of IPMNs were analyzed. IPMNs were classified as malignancy in the presence of high-grade dysplasia or invasive carcinoma and began in the presence of low- and intermediate-grade dysplasia. RESULTS A total of 207 patients (mean age: 63.7 ± 7.9 years) were included, and the prevalence of malignancy was 28.0% (58 of 207). According to the 2012 ICG, the imaging findings of IPMNs were divided into worrisome features (WFs) and high-risk stigmata (HRS). The malignancy of IPMN with only one WF was relatively low (1.4%, 3 of 207). In multivariate regression analyses, the independent factors of IPMNs were enhanced mural nodule ≥5 mm (odds ratio [OR] = 19.5, 95% confidence interval [CI] 6.8-55.4), abrupt change in the main pancreatic duct caliber with distal pancreatic atrophy (OR = 4.6, 95%CI 1.67-12.71), and thickened enhanced cyst walls (OR = 2.9, 95%CI 1.1-8.2). When the presence of more than two WFs or HRS (score ≥ 3) was regarded as indicating the malignancy potential of IPMNs on multidetector-row computerized tomography, the sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) were 89.7%, 75.8%, 79.7%, 59.1%, and 95.0%, respectively. CONCLUSION According to the ICG in 2012, patients with IPMNs with only one WF have a low risk for malignancy, and the presence of at least two WFs or any HRS (score ≥3) suggests malignant IPMNs.
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Wu YA, Oba A, Beaty L, Colborn KL, Rodriguez Franco S, Harnke B, Meguid C, Negrini D, Valente R, Ahrendt S, Schulick RD, Del Chiaro M. Ductal Dilatation of ≥5 mm in Intraductal Papillary Mucinous Neoplasm Should Trigger the Consideration for Pancreatectomy: A Meta-Analysis and Systematic Review of Resected Cases. Cancers (Basel) 2021; 13:cancers13092031. [PMID: 33922344 PMCID: PMC8122854 DOI: 10.3390/cancers13092031] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Intraductal papillary mucinous neoplasms (IPMN) are common but difficult to manage since accurate tools for diagnosing malignancy are unavailable. This study evaluates the diagnostic value of main pancreatic duct (MPD) diameter for detecting IPMN malignancy, using a meta-analysis of published data. The result suggests that malignancy is highly prevalent in IPMN with ductal dilatation of >5 mm. Abstract Intraductal papillary mucinous neoplasms (IPMN) are common but difficult to manage since accurate tools for diagnosing malignancy are unavailable. This study tests the diagnostic value of the main pancreatic duct (MPD) diameter for detecting IPMN malignancy using a meta-analysis of published data of resected IPMNs. Collected from a comprehensive literature search, the articles included in this analysis must report malignancy cases (high-grade dysplasia (HGD) and invasive carcinoma (IC)) and MPD diameter so that two MPD cut-offs could be created. The sensitivity, specificity, and odds ratios of the two cutoffs for predicting malignancy were calculated. A review of 1493 articles yielded 20 retrospective studies with 3982 resected cases. A cutoff of ≥5 mm is more sensitive than the ≥10 mm cutoff and has pooled sensitivity of 72.20% and 75.60% for classification of HGD and IC, respectively. Both MPD cutoffs of ≥5 mm and ≥10 mm were associated with malignancy (OR = 4.36 (95% CI: 2.82, 6.75) vs. OR = 3.18 (95% CI: 2.25, 4.49), respectively). The odds of HGD and IC for patients with MPD ≥5 mm were 5.66 (95% CI: 3.02, 10.62) and 7.40 (95% CI: 4.95, 11.06), respectively. OR of HGD and IC for MPD ≥10 mm cutoff were 4.36 (95% CI: 3.20, 5.93) and 4.75 (95% CI: 2.39, 9.45), respectively. IPMN with MPD of >5 mm could very likely be malignant. In selected IPMN patients, pancreatectomy should be considered when MPD is >5 mm.
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Affiliation(s)
- Y.H. Andrew Wu
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
| | - Atsushi Oba
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan
| | - Laurel Beaty
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Kathryn L. Colborn
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Surgical Outcomes and Applied Research Program, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Salvador Rodriguez Franco
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- The Heart Institute, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Ben Harnke
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA;
| | - Cheryl Meguid
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
| | - Daniel Negrini
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Anesthesiology, Federal University of the State of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Roberto Valente
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Surgery and Perioperative Sciences, Umeå University Hospital, 907 37 Umeå, Sweden
| | - Steven Ahrendt
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- University of Colorado Cancer Center, Aurora, CO 80045, USA
| | - Richard D. Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- University of Colorado Cancer Center, Aurora, CO 80045, USA
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- University of Colorado Cancer Center, Aurora, CO 80045, USA
- Correspondence:
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13
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Li B, Shi X, Gao S, Shen S, Bian Y, Cao K, Pan Y, Zhang G, Jiang H, Li G, Guo S, Jin G. Nomogram for the Prediction of High-Grade Dysplasia and Invasive Carcinoma in Patients With Intraductal Papillary Mucinous Neoplasms of the Pancreas Based on Variables of Noninvasive Examination. Front Oncol 2021; 11:609187. [PMID: 33767983 PMCID: PMC7985057 DOI: 10.3389/fonc.2021.609187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 02/02/2021] [Indexed: 12/12/2022] Open
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) are a heterogeneous group of neoplasms and represent the most common identifiable precursor lesions of pancreatic cancer. Clinical decision-making of the risk for malignant disease, including high-grade dysplasia and invasive carcinoma, is challenging. Moreover, discordance on the indication for resection exists between the contemporary guidelines. Furthermore, most of the current nomogram models for predicting malignant disease depend on endoscopic ultrasonography to evaluate the precise size of mural nodules. Thus, this study aimed to propose a model to predict malignant disease using variables from a noninvasive examination. We evaluated patients who underwent resection of pathologically confirmed IPMNs between November 2010 and December 2018 and had preoperative clinical data available for review. Based on binary multivariable logistic regression analysis, we devised a nomogram model to predict malignant IPMNs. The area under the receiver operating characteristics curve (AUC) was used to evaluate the discrimination power of the model. Of the 333 patients who underwent resection of IPMNs, 198 (59.5%) had benign and 135 (40.5%) had malignant IPMNs. Multivariable logistic regression analysis showed that cyst size, cyst location, cyst wall enhancement, multicystic lesion, diameter of main pancreatic duct, neutrophil-to-lymphocyte ratio, serum carbohydrate antigen 19-9, and carcinoembryonic antigen were significantly associated with malignancy. The nomogram, constructed based on these variables, showed excellent discrimination power with an AUC of 0.859 (95% CI: 0.818–0.900, P < 0.001). In conclusion, we have developed a nomogram consisting of a combination of cross-sectional imaging features and blood markers, variables that can readily be obtained by noninvasive examinations during the surveillance period, which can distinguish benign from malignant IPMNs. Nevertheless, external validation is warranted.
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Affiliation(s)
- Bo Li
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China.,Department of General Surgery, Beidaihe Rehabilitation and Recuperation Center of PLA, Qinhuangdao, China
| | - Xiaohan Shi
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Suizhi Gao
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Shuo Shen
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Yun Bian
- Department of Radiology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Kai Cao
- Department of Radiology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Yaqi Pan
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Guoxiao Zhang
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Hui Jiang
- Department of Pathology, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Gang Li
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Shiwei Guo
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
| | - Gang Jin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University, Shanghai, China
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14
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Cui S, Tang T, Su Q, Wang Y, Shu Z, Yang W, Gong X. Radiomic nomogram based on MRI to predict grade of branching type intraductal papillary mucinous neoplasms of the pancreas: a multicenter study. Cancer Imaging 2021; 21:26. [PMID: 33750453 PMCID: PMC7942000 DOI: 10.1186/s40644-021-00395-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 02/26/2021] [Indexed: 12/15/2022] Open
Abstract
Background Accurate diagnosis of high-grade branching type intraductal papillary mucinous neoplasms (BD-IPMNs) is challenging in clinical setting. We aimed to construct and validate a nomogram combining clinical characteristics and radiomic features for the preoperative prediction of low and high-grade in BD-IPMNs. Methods Two hundred and two patients from three medical centers were enrolled. The high-grade BD-IPMN group comprised patients with high-grade dysplasia and invasive carcinoma in BD-IPMN (n = 50). The training cohort comprised patients from the first medical center (n = 103), and the external independent validation cohorts comprised patients from the second and third medical centers (n = 48 and 51). Within 3 months prior to surgery, all patients were subjected to magnetic resonance examination. The volume of interest was delineated on T1-weighted (T1-w) imaging, T2-weighted (T2-w) imaging, and contrast-enhanced T1-weighted (CET1-w) imaging, respectively, on each tumor slice. Quantitative image features were extracted using MITK software (G.E.). The Mann-Whitney U test or independent-sample t-test, and LASSO regression, were applied for data dimension reduction, after which a radiomic signature was constructed for grade assessment. Based on the training cohort, we developed a combined nomogram model incorporating clinical variables and the radiomic signature. Decision curve analysis (DCA), a receiver operating characteristic curve (ROC), a calibration curve, and the area under the ROC curve (AUC) were used to evaluate the utility of the constructed model based on the external independent validation cohorts. Results To predict tumor grade, we developed a nine-feature-combined radiomic signature. For the radiomic signature, the AUC values of high-grade disease were 0.836 in the training cohort, 0.811 in external validation cohort 1, and 0.822 in external validation cohort 2. The CA19–9 level and main pancreatic duct size were identified as independent parameters of high-grade of BD-IPMNs using multivariate logistic regression analysis. The CA19–9 level and main pancreatic duct size were then used to construct the radiomic nomogram. Using the radiomic nomogram, the high-grade disease-associated AUC values were 0.903 (training cohort), 0.884 (external validation cohort 1), and 0.876 (external validation cohort 2). The clinical utility of the developed nomogram was verified using the calibration curve and DCA. Conclusions The developed radiomic nomogram model could effectively distinguish high-grade patients with BD-IPMNs preoperatively. This preoperative identification might improve treatment methods and promote personalized therapy in patients with BD-IPMNs. Supplementary Information The online version contains supplementary material available at 10.1186/s40644-021-00395-6.
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Affiliation(s)
- Sijia Cui
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Hangzhou, 310000, China.,The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Tianyu Tang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China
| | - Qiuming Su
- Department of General Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yajie Wang
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Hangzhou, 310000, China
| | - Zhenyu Shu
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Hangzhou, 310000, China
| | - Wei Yang
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Hangzhou, 310000, China.,Bengbu Medical College, Bengbu, 233000, China
| | - Xiangyang Gong
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Hangzhou, 310000, China. .,Institute of Artificial Intelligence and Remote Imaging, Hangzhou Medical College, Hangzhou, China.
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15
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Haeberle L, Schramm M, Goering W, Frohn L, Driescher C, Hartwig W, Preissinger-Heinzel HK, Beyna T, Neuhaus H, Fuchs K, Keitel-Anselmino V, Knoefel WT, Esposito I. Molecular analysis of cyst fluids improves the diagnostic accuracy of pre-operative assessment of pancreatic cystic lesions. Sci Rep 2021; 11:2901. [PMID: 33536452 PMCID: PMC7858638 DOI: 10.1038/s41598-021-81065-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 12/24/2020] [Indexed: 12/18/2022] Open
Abstract
Pancreatic cystic lesions (PCL) are increasingly diagnosed. Endoscopic ultrasound fine-needle aspiration (EUS-FNA) cytology is often used for diagnostic confirmation but can be inconclusive. In this study, the role of molecular analyses in the pre-operative diagnostics of PCL is evaluated. Targeted Next Generation Sequencing (NGS) applied on cytology smears was retrospectively evaluated in a cohort of 37 resected PCL. Usefulness of NGS on fresh cyst fluids was tested in a prospective cohort of patients with newly diagnosed PCL (n = 71). In the retrospective cohort, cytology plus NGS displayed higher sensitivity (94.1% vs. 87.1%) and specificity (100% vs. 50%) than cytology alone for the detection of mucinous neoplasms. In the prospective cohort, sensitivity and specificity of conventional cytology alone were 54.2% and 100% for the detection of mucinous neoplasia and 50.0% and 100% for the detection of high-grade dysplasia, respectively. Adding NGS, all lesions which underwent histopathologic verification (12/71, 17%) could be classified without false positive or false negative results regarding the detection of mucinous neoplasm so far. NGS analysis of cfDNA in PCL fluids is feasible and can increase diagnostic accuracy in the detection of mucinous neoplasms compared to cytology alone. However, algorithms for the detection of high-risk lesions need further improvement.
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Affiliation(s)
- Lena Haeberle
- Institute of Pathology, Heinrich-Heine University and University Hospital of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Martin Schramm
- Institute of Pathology, Heinrich-Heine University and University Hospital of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Wolfgang Goering
- Institute of Pathology, Heinrich-Heine University and University Hospital of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Lisa Frohn
- Institute of Pathology, Heinrich-Heine University and University Hospital of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Caroline Driescher
- Institute of Pathology, Heinrich-Heine University and University Hospital of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany
| | - Werner Hartwig
- Department of Surgery, Evangelisches Krankenhaus, Duesseldorf, Germany
| | | | - Torsten Beyna
- Department of Internal Medicine, Evangelisches Krankenhaus, Duesseldorf, Germany
| | - Horst Neuhaus
- Department of Internal Medicine, Evangelisches Krankenhaus, Duesseldorf, Germany
| | - Katharina Fuchs
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, Heinrich-Heine University and University Hospital of Duesseldorf, Duesseldorf, Germany
| | - Verena Keitel-Anselmino
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, Heinrich-Heine University and University Hospital of Duesseldorf, Duesseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of Visceral, Thoracic and Pediatric Surgery, Heinrich-Heine University and University Hospital of Duesseldorf, Duesseldorf, Germany
| | - Irene Esposito
- Institute of Pathology, Heinrich-Heine University and University Hospital of Duesseldorf, Moorenstr. 5, 40225, Duesseldorf, Germany.
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16
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Regenet N, Sauvanet A, Muscari F, Meunier B, Mariette C, Adham M, Moutardier V, Delpero JR, Regimbeau JM, Pessaux P, Paye F, Sa Cunha A, Ansquer C. The value of 18F-FDG positron emission tomography to differentiate benign from malignant intraductal papillary mucinous neoplasms: A prospective multicenter study. J Visc Surg 2020; 157:387-394. [DOI: 10.1016/j.jviscsurg.2020.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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17
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Fujiyama Y, Kumamoto Y, Nishizawa N, Nakamoto S, Harada H, Yokota K, Tanaka Y, Igarashi K, Oiki H, Okuwaki K, Iwai T, Kajita S, Takahashi H, Tajima H, Kaizu T, Sasaki J, Watanabe M, Yamashita K. Promoter DNA Hypermethylation of the Cysteine Dioxygenase 1 (CDO1) Gene in Intraductal Papillary Mucinous Neoplasm (IPMN). Ann Surg Oncol 2020; 27:4007-4016. [PMID: 32144623 DOI: 10.1245/s10434-020-08291-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasm (IPMN) involves adenoma (IPMA), a precancerous lesion, cancer (IPMC) including high-grade dysplasia (HGD), and invasive carcinoma (IC). DNA markers of IPMN are required for detection of invasive disease, and cysteine dioxygenase 1 (CDO1) gene promoter hypermethylation is a potential candidate. However, it has never been investigated in the context of IPMN. PATIENTS AND METHODS A total of 107 IPMN tumor tissues, including 41 IPMC and 66 IPMA, were studied. CDO1 promoter methylation was quantified using TaqMan quantitative methylation-specific polymerase chain reaction (qMSP) in patients with IPMN and other pancreatic cystic disorders after pancreatectomy. RESULTS The methylation values (TaqMeth Vs) of CDO1 increased when noncancerous pancreas tissues were compared with IPMA and HGD (p < 0.0001). Among IPMC, the TaqMeth Vs in IC were not significantly higher than in HGD. The TaqMeth Vs of the solid tumors were higher than those of the cystic tumors (p = 0.0016), which were in turn higher than the corresponding noncancerous tissues (p < 0.0001). Prognostic analysis revealed that high TaqMeth Vs (≥ 14.1) resulted in a poorer prognosis than low TaqMeth Vs (< 14.1) (p < 0.0001). In other pancreatic cystic diseases, only malignant mucinous cystic neoplasm showed DNA hypermethylation of its promoter. A pilot study in pancreatic juice confirmed methylation in all IPMN samples but not in benign pancreatic diseases (p = 0.0277). CONCLUSIONS CDO1 promoter hypermethylation is extremely specific to IPMN and may accumulate with IPMN tumor progression during the adenoma-carcinoma sequence. It might be a promising candidate as a diagnostic marker of pancreatic cystic diseases.
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Affiliation(s)
- Yoshiki Fujiyama
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yusuke Kumamoto
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Nobuyuki Nishizawa
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Shuji Nakamoto
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Hiroki Harada
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Kazuko Yokota
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yoko Tanaka
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Kazuharu Igarashi
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Hironobu Oiki
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Kosuke Okuwaki
- Department of Gastroenterology, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Sabine Kajita
- Department of Pathology, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Hiroyuki Takahashi
- Department of Pathology, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Hiroshi Tajima
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Takashi Kaizu
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Jiichiro Sasaki
- Multidisciplinary Cancer Care and Treatment Center, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Masahiko Watanabe
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Keishi Yamashita
- Department of Surgery, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan. .,Division of Advanced Surgical Oncology, Research and Development Center for New Medical Frontiers, Kitasato University School of Medicine, Kitasato 1-15-1, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan.
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18
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Main duct and mixed type intraductal papillary mucinous neoplasms without enhancing mural nodules: Duct diameter of less than 10 mm and segmental dilatation of main pancreatic duct are findings support surveillance rather than immediate surgery. Pancreatology 2019; 19:1054-1060. [PMID: 31611130 DOI: 10.1016/j.pan.2019.09.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/14/2019] [Accepted: 09/22/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The guidelines for pancreatic intraductal papillary mucinous neoplasms (IPMNs) recommend surgical resection of all main-duct (MD) and mixed-type IPMNs in surgically fit patients. We conducted this study to identify the rates of high-grade dysplasia (HGD) and invasive carcinoma according to the morphological features of the main pancreatic duct (MPD) in patients with MD and mixed IPMN. METHODS We performed a retrospective study of 259 patients with histologically proven MD and mixed-type IPMNs who underwent surgery at six academic institutions. RESULTS The rate of HGD and invasive carcinoma was 11.1% (24/216) in patients without enhancing mural nodules (MNs) and 69.8% (30/43) in patients with MNs. Multivariate analysis showed that MPD diameter of ≥10 mm [odds ratio (OR), 2.5; 95% confidence interval (CI), 1.155-5.505; P = 0.02], diffuse MPD dilatation (OR, 3.2; 95% CI, 1.152-8.998; P = 0.02), and presence of enhancing MNs in MPD (OR, 9.6; 95% CI, 3.928-23.833, P < 0.0001) were significant predictors of HGD and invasive carcinoma. Of the 216 patients without enhancing MNs, 79 patients (36.6%) having both segmental MPD dilatation and MPD diameter of <10 mm showed significantly lower rates of HGD and invasive carcinoma (3/79, 3.8%) than patients having both diffuse MPD dilatation and MPD diameter ≥10 mm (9/36, 25%, P = 0.001). CONCLUSIONS MD and mixed-type IPMNs having segmental MPD dilatation with MPD dilation <10 mm and no enhancing MNs on imaging showed a significantly lower rate of HGD and invasive carcinoma, and watchful follow-up instead of immediate surgical resection might be possible in these patients.
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19
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Tanaka M, Heckler M, Liu B, Heger U, Hackert T, Michalski CW. Cytologic Analysis of Pancreatic Juice Increases Specificity of Detection of Malignant IPMN-A Systematic Review. Clin Gastroenterol Hepatol 2019; 17:2199-2211.e21. [PMID: 30630102 DOI: 10.1016/j.cgh.2018.12.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 12/25/2018] [Accepted: 12/27/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas can progress to cancer. Biomarkers have been identified that were reported to increase the accuracy of identification of malignant lesions; we performed a systematic review of the accuracy of these markers. METHODS We performed a systematic review of published studies on biomarkers of malignant IPMNs by searching MEDLINE and Web of Science databases from January 2005 through December 2017. Our methods were developed based on the Meta-analysis Of Observational Studies in Epidemiology guidelines. Pooled sensitivity, specificity, receiver operating characteristic curves, and their respective areas under the curve (AUC) were calculated from groups of markers (cell-, protein-, or DNA-based) measured in samples collected before and after surgery. A hypothetical test model was developed to determine how to meaningfully amend the revised Fukuoka guidelines, focusing on increasing test specificity for patients with IPMNs that have worrisome features. RESULTS We collected data from 193 published studies, comprising 12,297 patients, that analyzed 7 preoperative and 21 postoperative markers of IPMNs. The 3 biomarkers that identified malignant IPMNs with the largest AUC values were pancreatic juice cytology (AUC, 0.84; sensitivity, 0.54; specificity, 0.91), serum protein carbohydrate antigen 19-9 (AUC, 0.81; sensitivity, 0.45; specificity, 0.90), and cyst fluid cytology (AUC, 0.82; sensitivity, 0.57; specificity, 0.84). A combination of cytologic and immunohistochemical analysis of MUC1 and MUC2 in pancreatic juice samples identified malignant IPMNs with the largest AUC and sensitivity values (AUC, 0.85; sensitivity, 0.85; specificity, 0.65). In a test model, inclusion of cytologic analysis of pancreatic juice in the guideline algorithm significantly increased the specificity of detection of malignant IPMNs. CONCLUSIONS In a systematic review, we found cytologic analysis of pancreatic juice to have the greatest effect in increasing the specificity of detection of malignant IPMNs. We propose addition of this test to the Fukuoka guidelines for assessment of patients with IPMNs with worrisome features.
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Affiliation(s)
- Masayuki Tanaka
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld, Germany
| | - Max Heckler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld, Germany
| | - Bing Liu
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld, Germany
| | - Ulrike Heger
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld, Germany.
| | - Christoph W Michalski
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld, Germany; Department of Surgery, Halle University Hospital, Martin Luther University Halle-Wittenberg, Halle, Germany
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20
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Kerlakian S, Dhar VK, Abbott DE, Kooby DA, Merchant NB, Kim HJ, Martin RC, Scoggins CR, Bentrem DJ, Weber SM, Maithel SK, Ahmad SA, Patel SH. Cyst location and presence of high grade dysplasia or invasive cancer in intraductal papillary mucinous neoplasms of the pancreas: a seven institution study from the central pancreas consortium. HPB (Oxford) 2019; 21:482-488. [PMID: 30361110 DOI: 10.1016/j.hpb.2018.09.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 09/04/2018] [Accepted: 09/27/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Traditionally, intraductal papillary mucinous neoplasms (IPMNs) of the pancreas with "high risk stigmata" (HRS) or "worrisome features" (WF) are referred for resection. We aim to assess if IPMN location is predictive of harboring either high grade dysplasia (HGD) or invasive cancer (IC). METHODS Patients undergoing resection for IPMN from seven institutions between 2000 and 2015 (n = 275) were analyzed. HRS and WF were defined by the 2012 Fukuoka international consensus guidelines. RESULTS 168 (61%) patients had head/uncinate cysts, while 107 (39%) had neck/body/tail cysts. No differences were noted between groups with regard to age, duct type, cyst size, or presence of at least one WF. Patients with cysts in the head/uncinate were more often male (55% vs. 40%), had at least one HRS (24% vs. 11%), and more often harbored HGD or IC(49% vs. 27%)[all p < 0.05]. On multivariate analysis, only cyst location in the head/uncinate remained associated with presence of HGD or IC(odds ratio 4.76, p = 0.02). DISCUSSION Cyst location is predictive of HGD or IC in patients with IPMNs. Head/uncinated cysts are more likely to harbor malignancy compared to those of the neck/body/tail. Additional studies are needed to confirm these findings, however, cyst location should be considered part of the decision making process for surveillance vs. resection for IPMNs.
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Affiliation(s)
- Stephanie Kerlakian
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Vikrom K Dhar
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David A Kooby
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Nipun B Merchant
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hong J Kim
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Robert C Martin
- Department of Surgery, University of Louisville College of Medicine, Louisville, KY, USA
| | - Charles R Scoggins
- Department of Surgery, University of Louisville College of Medicine, Louisville, KY, USA
| | - David J Bentrem
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Shishir K Maithel
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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21
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Marchegiani G, Andrianello S, Morbin G, Secchettin E, D'Onofrio M, De Robertis R, Malleo G, Bassi C, Salvia R. Importance of main pancreatic duct dilatation in IPMN undergoing surveillance. Br J Surg 2018; 105:1825-1834. [PMID: 30106195 DOI: 10.1002/bjs.10948] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/09/2018] [Accepted: 06/14/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The association between risk of pancreatic cancer and a dilated main pancreatic duct (MPD) in intraductal papillary mucinous neoplasm (IPMN) is debated. The aim of this study was to assess the role of MPD size in predicting pancreatic cancer in resected IPMNs and those kept under surveillance. METHODS All patients with IPMN referred to the Pancreas Institute, University of Verona Hospital Trust, from 2006 to 2016 were included. The primary endpoint was the occurrence of malignancy detected at surgery or during follow-up. RESULTS The final cohort consisted of 1688 patients with a median follow-up of 60 months. Main pancreatic duct dilatation was associated with other features of malignancy in both the resected and surveillance groups. In patients who underwent resection, only a MPD of at least 10 mm was an independent predictor of malignancy. In patients kept under surveillance, MPD dilatation was not associated with malignancy. Fifteen of 71 patients (21 per cent) with malignancy in the resection cohort had a dilated MPD alone, whereas only one of 30 (3 per cent) under surveillance with MPD dilatation alone developed malignancy. Patients with a dilated MPD and other worrisome features had an increased 5-year cumulative incidence of malignancy compared with those with a non-dilated duct (11 versus 1·2 per cent; P < 0·001); however, the risk of malignancy was not significantly increased in patients with a dilated MPD alone (4 versus 1·2 per cent; P = 0·448). CONCLUSION In patients under surveillance, a dilated MPD alone was not associated with an increased incidence of malignancy in IPMN.
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Affiliation(s)
- G Marchegiani
- Department of Surgery and Oncology, General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - S Andrianello
- Department of Surgery and Oncology, General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - G Morbin
- Department of Surgery and Oncology, General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - E Secchettin
- Department of Surgery and Oncology, General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - M D'Onofrio
- Department of Radiology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - R De Robertis
- Department of Radiology, Casa di Cura Pederzoli, Peschiera del Garda, Italy
| | - G Malleo
- Department of Surgery and Oncology, General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - C Bassi
- Department of Surgery and Oncology, General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - R Salvia
- Department of Surgery and Oncology, General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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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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23
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Elta GH, Enestvedt BK, Sauer BG, Lennon AM. ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts. Am J Gastroenterol 2018; 113:464-479. [PMID: 29485131 DOI: 10.1038/ajg.2018.14] [Citation(s) in RCA: 376] [Impact Index Per Article: 62.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 01/05/2018] [Indexed: 02/07/2023]
Abstract
Pancreatic cysts are very common with the majority incidentally identified. There are several types of pancreatic cysts; some types can contain cancer or have malignant potential, whereas others are benign. However, even the types of cysts with malignant potential rarely progress to cancer. At the present time, the only viable treatment for pancreatic cysts is surgical excision, which is associated with a high morbidity and occasional mortality. The small risk of malignant transformation, the high risks of surgical treatment, and the lack of high-quality prospective studies have led to contradictory recommendations for their immediate management and for their surveillance. This guideline will provide a practical approach to pancreatic cyst management and recommendations for cyst surveillance for the general gastroenterologist.
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Affiliation(s)
- Grace H Elta
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Brintha K Enestvedt
- Division of Gastroenterology, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Bryan G Sauer
- Division of Gastroenterology, University of Virginia, Charlottesville, Virginia, USA
| | - Anne Marie Lennon
- Division of Gastroenterology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Khoury RE, Kabir C, Maker VK, Banulescu M, Wasserman M, Maker AV. What is the Incidence of Malignancy in Resected Intraductal Papillary Mucinous Neoplasms? An Analysis of Over 100 US Institutions in a Single Year. Ann Surg Oncol 2018; 25:1746-1751. [PMID: 29560572 DOI: 10.1245/s10434-018-6425-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND A subset of intraductal papillary mucinous neoplasms (IPMNs) will progress to invasive adenocarcinoma, however identifying invasive from non-invasive disease preoperatively remains challenging. The rate of malignancy in resected IPMNs in the US remains unclear. OBJECTIVE We aimed to determine the rate of malignancy and factors associated with high-risk pathology in resected IPMNs. METHODS The most recent annual cohort of patients undergoing pancreatectomy included in the American College of Surgeons National Surgical Quality Improvement Program were assessed, and contributions of demographics, preoperative laboratory values, and outcome data to level of IPMN dysplasia were analyzed. The main outcomes were incidence of invasive carcinoma or high-grade dysplasia. RESULTS Of 5025 pancreatectomies in 1 year, 478 patients underwent pancreatectomy for IPMN. Invasive carcinoma/high-grade dysplasia was identified in 23% of resected lesions, and there was no difference in patient characteristics or type of resection performed in patients with invasive versus non-invasive pathology. Patients with invasive IPMNs presented significantly more often with high liver function tests, >10% weight loss, clinical jaundice and stent placement, and were more likely to undergo an open operation (p = 0.03). There were no differences in perioperative outcomes. Adjusted logistic regression identified an association between invasive disease and non-soft pancreatic gland texture (odds ratio 0.19, 95% confidence interval 0.05-0.68, p < 0.01). CONCLUSIONS Approximately 10% of all pancreatectomies in the US are for IPMNs. In these patients, treated after the revised international consensus guidelines, only 23% of IPMNs contained invasive or high-grade histology. Resections carried similar morbidity regardless of pathology. Improved biomarkers are needed to aid in surgical selection.
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Affiliation(s)
- Rym El Khoury
- Division of Surgical Oncology, Department of Surgery, University of Illinois at Chicago, 835 S. Wolcott St. MC790, Chicago, IL, 60612, USA.,Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Christopher Kabir
- Advocate Research Institute, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Vijay K Maker
- Division of Surgical Oncology, Department of Surgery, University of Illinois at Chicago, 835 S. Wolcott St. MC790, Chicago, IL, 60612, USA.,Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Mihaela Banulescu
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Margaret Wasserman
- Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of Illinois at Chicago, 835 S. Wolcott St. MC790, Chicago, IL, 60612, USA. .,Department of Surgery, Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
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25
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Heckler M, Brieger L, Heger U, Pausch T, Tjaden C, Kaiser J, Tanaka M, Hackert T, Michalski CW. Predictive performance of factors associated with malignancy in intraductal papillary mucinous neoplasia of the pancreas. BJS Open 2018; 2:13-24. [PMID: 29951625 PMCID: PMC5989990 DOI: 10.1002/bjs5.38] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 11/17/2017] [Indexed: 12/17/2022] Open
Abstract
Background Estimation of the risk of malignancy in intraductal papillary mucinous neoplasia (IPMN) of the pancreas is a clinical challenge. Several routinely used clinical factors form the basis of the current consensus guidelines. This study aimed to determine the predictive values of the most commonly assessed risk factors. Methods A meta-analysis of individual risk factors of malignancy in IPMN was performed. Contingency tables were derived from these data, and sensitivity, specificity, negative and positive predictive values, and diagnostic odds ratios (DOR) were determined. Hierarchical summary receiver operating characteristic (HSROC) curves for each factor were calculated and the respective area under the curve (AUC) was assessed. Results A total of 3443 studies were screened initially. Analysis of recent literature revealed 60 studies with 13 relevant risk factors including clinical, serological and radiological parameters. The largest area under the HSROC curve was found for weight loss (0·84) and jaundice/raised bilirubin level (0·80), followed by increased carcinoembryonic antigen (CEA) (0·79) or carbohydrate antigen (CA) 19-9 (0·78) levels. The most sensitive factors were patient age (71 per cent) and mural nodules (65 per cent), and jaundice/raised bilirubin level (97 per cent) and increased CEA level (95 per cent) were most specific. None of the analysed factors reached a positive or negative level of prediction beyond 90 per cent. Conclusion None of the established criteria safely distinguishes malignant from non-malignant lesions.
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Affiliation(s)
- M Heckler
- Department of Surgery Heidelberg University Hospital Im Neuenheimer Feld 110, 69120 Heidelberg Germany
| | - L Brieger
- Department of Surgery Heidelberg University Hospital Im Neuenheimer Feld 110, 69120 Heidelberg Germany
| | - U Heger
- Department of Surgery Heidelberg University Hospital Im Neuenheimer Feld 110, 69120 Heidelberg Germany
| | - T Pausch
- Department of Surgery Heidelberg University Hospital Im Neuenheimer Feld 110, 69120 Heidelberg Germany
| | - C Tjaden
- Department of Surgery Heidelberg University Hospital Im Neuenheimer Feld 110, 69120 Heidelberg Germany
| | - J Kaiser
- Department of Surgery Heidelberg University Hospital Im Neuenheimer Feld 110, 69120 Heidelberg Germany
| | - M Tanaka
- Department of Surgery Heidelberg University Hospital Im Neuenheimer Feld 110, 69120 Heidelberg Germany
| | - T Hackert
- Department of Surgery Heidelberg University Hospital Im Neuenheimer Feld 110, 69120 Heidelberg Germany
| | - C W Michalski
- Department of Surgery Heidelberg University Hospital Im Neuenheimer Feld 110, 69120 Heidelberg Germany
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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: 19] [Impact Index Per Article: 2.7] [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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Girometti R, Pravisani R, Intini SG, Isola M, Cereser L, Risaliti A, Zuiani C. Evolution of incidental branch-duct intraductal papillary mucinous neoplasms of the pancreas: A study with magnetic resonance imaging cholangiopancreatography. World J Gastroenterol 2016; 22:9562-9570. [PMID: 27920477 PMCID: PMC5116600 DOI: 10.3748/wjg.v22.i43.9562] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/28/2016] [Accepted: 10/27/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the type and timing of evolution of incidentally found branch-duct intraductal papillary mucinous neoplasms (bd-IPMN) of the pancreas addressed to magnetic resonance imaging cholangiopancreatography (MRCP) follow-up.
METHODS We retrospectively evaluated 72 patients who underwent, over the period 2006-2016, a total of 318 MRCPs (mean 4.4) to follow-up incidental, presumed bd-IPMN without signs of malignancy, found or confirmed at a baseline MRCP examination. Median follow-up time was 48.5 mo (range 13-95 mo). MRCPs were acquired on 1.5T and/or 3.0T systems using 2D and/or 3D technique. Image analysis assessed the rates of occurrence over the follow-up of the following outcomes: (1) imaging evolution, defined as any change in cysts number and/or size and/or appearance; and (2) alert findings, defined as worrisome features and/or high risk stigmata (e.g., thick septa, parietal thickening, mural nodules and involvement of the main pancreatic duct). Time to outcomes was described with the Kaplan-Meir approach. Cox regression model was used to investigate clinical or initial MRCP findings predicting cysts changes.
RESULTS We found a total of 343 cysts (per-patient mean 5.1) with average size of 8.5 mm (range 5-25 mm). Imaging evolution was observed in 32/72 patients (44.4%; 95%CI: 32-9-56.6), involving 47/343 cysts (13.7%). There was a main trend towards small (< 10 mm) increase and/or decrease of cysts size at a median time of 22.5 mo. Alert findings developed in 6/72 patients (8.3%; 95%CI: 3.4-17.9) over a wide interval of time (13-63 mo). No malignancy was found on endoscopic ultrasound with fine-needle aspiration (5/6 cases) or surgery (1/6 cases). No clinical or initial MRCP features were significantly associated with changes in bd-IPMN appearance (P > 0.01).
CONCLUSION Changes in MRCP appearance of incidental bd-IPNM were frequent over the follow-up (44.4%), with relatively rare (8.3%) occurrence of non-malignant alert findings that prompted further diagnostic steps. Changes occurred at a wide interval of time and were unpredictable, suggesting that imaging follow-up should be not discontinued, though MRCPs might be considerably delayed without a significant risk of missing malignancy.
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28
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Cao S, Hu Y, Gao X, Liao Q, Zhao Y. Serum Carbohydrate Antigen 19-9 in Differential Diagnosis of Benign and Malignant Pancreatic Cystic Neoplasms: A Meta-Analysis. PLoS One 2016; 11:e0166406. [PMID: 27835676 PMCID: PMC5105948 DOI: 10.1371/journal.pone.0166406] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 10/30/2016] [Indexed: 12/12/2022] Open
Abstract
Background Using serum carbohydrate antigen 19–9 (CA 19–9) in discriminating between benign and malignant pancreatic disease remains controversial. We aim to evaluate the diagnostic value of serum CA 19–9 in predicting malignant pancreatic cystic lesions. Methods Eligible studies were identified through searching MEDLINE and EMBASE prior to March 2016. Studies were assessed for quality using the Quality Assessment for Studies of Diagnostic Accuracy, 2nd version (QUADAS-2). Pooled sensitivity and specificity with 95% confidence interval (CI) were calculated using random-effects models. Summary receiver operator characteristic (SROC) curves and the area under curve (AUC) were performed. Results A total of thirteen studies including 1437 patients were enrolled in this meta-analysis. The pooled sensitivity and specificity were 0.47(95% CI: 0.35–0.59), and 0.88(95% CI: 0.86–0.91), respectively, and the AUC was 0.87(95% CI, 0.84–0.90). Meta-regression analysis showed that sample size, region and reference standards were not the main sources of heterogeneity. Conclusions Serum CA 19–9 has satisfying pooled specificity while poor pooled sensitivity for discriminating benign from malignant PCNs. It deserves to be widely used as complementary to other clinical diagnostic methods.
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Affiliation(s)
- Shaobo Cao
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Science, Beijing, 100730, China
| | - Ya Hu
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Science, Beijing, 100730, China
| | - Xiang Gao
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Science, Beijing, 100730, China
| | - Quan Liao
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Science, Beijing, 100730, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Science, Beijing, 100730, China
- * E-mail:
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29
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Abstract
In this article, we aimed to review the literature on the clinics and management of intraductal papillary mucinous neoplasm (IPMN). Intraductal papillary mucinous neoplasm of the pancreas is a mucin-producing cystic mass originating from the pancreatic ductal system. Approximately 25% of the pancreatic neoplasms resected surgically and 50% of pancreatic cysts detected incidentally are IPMNs. They can be benign or malignant in character, while malignant transformation of benign forms can be encountered. It is important to determine IPMNs in the early stages, implementation of appropriate treatment approaches, and follow-up to provide better prognosis. We reviewed the studies published in the English medical literature through PubMed and summarized the clinical features and current approaches to the treatment and follow-up of the IPMN. Due to the recent advances and widespread implementation of radiological imaging techniques, the incidental detection rate of IPMNs has increased significantly. The effective treatment of the disease is possible via the detailed diagnosis of the disease, determination of the prognostic factors, and a multidisciplinary approach. Recent literature also emphasized the molecular profile determination approaches for assessment of prognosis of patients with IPMN. Current knowledge on IPMN, a clinically important epidemiologic problem, shows that the treatment should be personalized considering the prognostic features and life expectancy of the patient.
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30
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Development and Potential Utility of a New Scoring Formula for Prediction of Malignant Intraductal Papillary Mucinous Neoplasm of the Pancreas. Pancreas 2016; 45:1227-32. [PMID: 27171512 DOI: 10.1097/mpa.0000000000000649] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE A simple system is needed to determine whether surgery is indicated in cases of intraductal papillary mucinous neoplasm (IPMN). METHODS We conducted a retrospective study to identify factors predictive of malignant IPMN and thus simplify the treatment decision-making process. Ninety-six consecutive patients treated surgically for IPMN at Kyorin University Hospital (Tokyo, Japan) between 1994 and 2014 were included. Univariate and multivariate analyses were used to identify preoperative factors predictive of malignancy. A simple scoring formula was derived from the regression equation. RESULTS Twenty-two (23%) of the IPMNs were malignant, and 74 (77%) were benign. Pancreatic head tumor, cyst diameter of 47 mm or greater, and mural nodule diameter of 9 mm or greater were identified as significant predictors of malignant IPMN. The following scoring formula was developed: 4 × tumor location (pancreatic head, 1; pancreatic body or tail, 0) + 3 × cyst diameter (≥47 mm, 1; <47 mm, 0) + 6 × mural nodule diameter (≥9 mm, 1; <9 mm, 0); the area under the receiver operating characteristic curve was 0.970. At a cutoff of 8 points, the diagnostic accuracy was excellent (sensitivity, 90.9%; specificity, 95.9%; accuracy, 94.8%). CONCLUSIONS Our scoring system has potential as a simple screening tool for the identification of malignant IPMN.
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Serum tumor markers not useful in screening patients with pancreatic mucinous cystic lesions associated with malignant changes. Hepatobiliary Pancreat Dis Int 2016; 15:553-557. [PMID: 27733327 DOI: 10.1016/s1499-3872(16)60076-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Serum cancer antigen 19-9 (CA19-9) provides additional information about mucinous cystic pancreatic neoplasm (MPN). This study was undertaken to assess both CA19-9 and carcinoembryonic antigen (CEA) serum concentrations in consecutive patients affected by MPNs and other chronic benign and malignant pancreatic diseases. We also evaluated whether serum CA19-9 and CEA determinations provide additional information such as the presence of invasive carcinoma in MPN patients. METHODS Serum CA19-9 and CEA from 91 patients with pancreatic diseases were tested by commercially available kits at the time of diagnosis. The upper reference limit of serum CA19-9 was 37 U/mL and that of serum CEA was 3 ng/mL. RESULTS Thirty-five patients was diagnosed with chronic pancreatitis (CP), 32 with MPN, and 24 with pancreatic ductal adenocarcinoma (PDAC) confirmed histologically. Surgery was carried out in 5 CP patients, in 10 MPN patients (7 of them had severe dysplasia), and in 9 PDAC patients. Serum CA19-9 activity was high in 12 (34.3%) CP patients, in 7 (21.9%) MPN patients, and in 12 (50.0%) PDAC patients (P=0.089). High serum CEA concentrations were noted in 6 (17.1%) CP patients, in 6 (18.8%) MPN patients, and in 12 (50.0%) PDAC patients (P=0.010). In the 7 MPN patients associated with histologically confirmed severe dysplasia, 3 (42.9%) patients had elevated serum activity of serum CA19-9, and 2 (28.6%) patients had high levels of CEA. CONCLUSION Serum determination of oncological markers is not useful in selecting MPN patients with malignant changes.
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Kim YI, Shin SH, Song KB, Hwang DW, Lee JH, Park KM, Lee YJ, Kim SC. Branch duct intraductal papillary mucinous neoplasm of the pancreas: single-center experience with 324 patients who underwent surgical resection. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2015; 19:113-20. [PMID: 26379733 PMCID: PMC4568594 DOI: 10.14701/kjhbps.2015.19.3.113] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 08/07/2015] [Accepted: 08/15/2015] [Indexed: 12/30/2022]
Abstract
Backgrounds/Aims International treatment guidelines for branch duct intraductal papillary mucinous neoplasm (BD-IPMN) of the pancreas have been proposed, for features associated with malignancy and invasiveness. We investigated the clinicopathological characteristics that are predictive of malignancy or invasiveness and disease recurrence. Methods A review of 324 patients with resected and pathologically confirmed BD-IPMN, between March 1997 and December 2013, was conducted. Results There were 144 (44.4%) low grade dysplasia (LGD), 138 (42.6%) intermediate grade dysplasia (IMGD), 17 (5.3%) high grade dysplasia (HGD), and 25 (7.7%) invasive carcinoma (invIPMC) cases. The 5-year survival rates were 98.1% for LGD, 95.3% for IMGD, 100% for HGD, and 71.8% for invIPMC. Through a univariate analysis, the male sex was associated with malignancy, and CA19-9 was related to both malignant and invasive IPMN. The high risk or worrisome features of the international guidelines were associated with both malignant and invasive IPMN: the total bilirubin of the head/uncinate lesion, tumor size, mural nodule, and the size of the main pancreatic duct (MPD). Through a multivariate analysis, the male sex, elevated CA19-9, mural nodule, and dilated MPD diameter were independently correlated with the malignant IPMN. The elevated CA19-9 and dilated MPD diameter were also correlated with invasive carcinoma. The patient age and the initial pathological diagnosis were strongly associated with disease recurrence following surgical resection. Conclusions The high risk or worrisome features in the current treatment guidelines for BD-IPMN are confined to the morphological characteristics of the disease. Patient factors and biological features should also be considered in order to develop optimal therapeutic or surveillance strategies.
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Affiliation(s)
- Young Il Kim
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Hyun Shin
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki Byung Song
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Wook Hwang
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Hoon Lee
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kwang-Min Park
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Joo Lee
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Song Cheol Kim
- Division of Hepato-Biliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Acute pancreatitis in intraductal papillary mucinous neoplasms: A common predictor of malignant intestinal subtype. Surgery 2015; 158:1219-25. [PMID: 26077509 DOI: 10.1016/j.surg.2015.04.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 04/14/2015] [Accepted: 04/22/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute pancreatitis (AP) is a common presenting symptom of intraductal papillary mucinous neoplasms (IPMN). Our objective was to evaluate the clinical and pathologic features of IPMN that present with AP. We hypothesized that the intestinal epithelial subtype, which produces a highly viscous mucin containing MUC2 glycoprotein, is associated with the development of AP. METHODS We performed a case-control study, evaluating 325 patients with IPMN resected at our institution. Clinicopathologic features were assessed for patients with and without a history of AP and compared between the 2 groups. RESULTS A history of AP was found in 69 patients (21%). Of those, 33 (48%) experienced a single episode, and some patients had as many as 10 distinct attacks. Three patients presented with necrotizing pancreatitis requiring operative debridement. After resection, recurrent AP occurred in only 14%. A history of AP was associated with younger age (61 vs 70, P < .001), main duct involvement (odds ratio [OR] 1.73, 95% confidence interval [95% CI] 1.00-3.01; P = .049), intestinal subtype (OR 4.84, 95% CI 2.71-8.67; P < .001), and high-grade dysplasia (OR 1.82, 95% CI 1.07-3.11; P = .028). On multivariate analysis, AP was an independent predictor of intestinal subtype (OR 4.69, 95% CI 2.48-8.84, P < .001), malignancy (OR 1.97, 95% CI 1.07-3.63, P = .029), and main duct involvement (OR 1.87, 95% CI 1.02-3.43, P = .044). CONCLUSION AP is a frequent presenting symptom of IPMN. These patients are younger and have greater odds of harboring malignant intestinal-type IPMN involving the main pancreatic duct.
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Chang YT, Tien YW, Jeng YM, Yang CY, Liang PC, Wong JM, Chang MC. Overweight increases the risk of malignancy in patients with pancreatic mucinous cystic neoplasms. Medicine (Baltimore) 2015; 94:e797. [PMID: 25997051 PMCID: PMC4602873 DOI: 10.1097/md.0000000000000797] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Distinguishing between benign and malignant pancreatic cysts remains a clinical challenge. The aim of this study was to investigate the influence of body mass index (BMI) and preoperative clinical and cyst features, as described by the International Consensus Guidelines, on malignancy in patients with pancreatic mucinous cystic neoplasms (PMCNs).A retrospective cohort study was performed on patients with PMCNs who underwent surgical resection between January 1994 and June 2014. Preoperative BMI, clinical demographic data, cystic features, tumor markers, and surgical pathology results were analyzed. Predictors of malignancy were determined by univariate and multivariate analysis using logistic regression.One hundred sixty-four cases of PMCNs, including 106 intraductal papillary mucinous neoplasms (IPMNs) and 58 mucinous cystic neoplasms (MCNs), were analyzed. On univariate analysis, older age (P = 0.008), male sex (P = 0.007), high-risk stigmata (P = 0.007), diabetes mellitus (DM; P = 0.008), and BMI >25 (P < 0.001) were associated with malignancy. Multivariate analysis found that BMI >25 (odds ratio, 3.99; 95% confidence interval: 1.60-10) was an independent predictor of malignancy. In subgroup analysis, BMI >25 was an independent predictor of malignancy in IPMNs but not in MCNs.Overweight patients with IPMNs have a higher risk of malignancy and should be followed closely or undergo resection. The operative strategy for PMCNs should consider cyst-related and patient-related risk factors.
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Affiliation(s)
- Yu-Ting Chang
- From the Departments of Internal Medicine (YTC, JMW, M-CC), Surgery (YWT, C-YY), Pathology (YMJ) and Medical Image (P-CL), National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
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Scheiman JM, Hwang JH, Moayyedi P. American gastroenterological association technical review on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015; 148:824-48.e22. [PMID: 25805376 DOI: 10.1053/j.gastro.2015.01.014] [Citation(s) in RCA: 273] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- James M Scheiman
- Department of Internal Medicine and Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Joo Ha Hwang
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington
| | - Paul Moayyedi
- Division of Gastroenterology, Hamilton Health Sciences, Farncombe Family Digestive Health Research Institute, McMaster University Hamilton, Ontario, Canada
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Daudé M, Muscari F, Buscail C, Carrère N, Otal P, Selves J, Buscail L, Bournet B. Outcomes of nonresected main-duct intraductal papillary mucinous neoplasms of the pancreas. World J Gastroenterol 2015; 21:2658-2667. [PMID: 25759534 PMCID: PMC4351216 DOI: 10.3748/wjg.v21.i9.2658] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 10/12/2014] [Accepted: 12/08/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare characteristics and outcomes of resected and nonresected main-duct and mixed intraductal papillary mucinous neoplasms of the pancreas (IPMN).
METHODS: Over a 14-year period, 50 patients who did not undergo surgery for resectable main-duct or mixed IPMN, for reasons of precluding comorbidities, age and/or refusal, were compared with 74 patients who underwent resection to assess differences in rates of survival, recurrence/occurrence of malignancy, and prognostic factors. All study participants had dilatation of the main pancreatic duct by ≥ 5 mm, with or without dilatation of the branch ducts. Some of the nonsurgical patients showed evidence of mucus upon perendoscopic retrograde cholangiopancreatography or endoscopic ultrasound and/or after fine needle aspiration. For the surgical patients, pathologic analysis of resected specimens confirmed a diagnosis of IPMN with involvement of the main pancreatic duct or of both branch ducts as well as the main pancreatic duct. Clinical and biologic follow-ups were conducted for all patients at least annually, through hospitalization or consultation every six months during the first year of follow-up, together with abdominal imaging analysis (magnetic resonance cholangiopancreatography or computed tomography) and, if necessary, endoscopic ultrasound with or without fine needle aspiration.
RESULTS: The overall five-year survival rate of patients who underwent resection was significantly greater than that for the nonsurgical patients (74% vs 58%; P = 0.019). The parameters of age (< 70 years) and absence of a nodule were associated with better survival (P < 0.05); however, the parameters of main pancreatic duct diameter > 10 mm, branch duct diameter > 30 mm, or presence of extra pancreatic cancers did not significantly influence the prognosis. In the nonsurgical patients, pancreatic malignancy occurred in 36% of cases within a mean time of 33 mo (median: 29 mo; range: 8-141 mo). Comparison of the nonsurgical patients who experienced disease progression with those who did not progress showed no significant differences in age, sex, symptoms, subtype of IPMN, or follow-up period; only the size of the main pancreatic duct was significantly different between these two sub-groups, with the nonsurgical patients who experienced progression showing a greater diameter at the time of diagnosis (> 10 mm).
CONCLUSION: Patients unfit for surgery have a 36% greater risk of developing pancreatic malignancy of the main-duct or mixed IPMN within a median of 2.5 years.
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MESH Headings
- Adenocarcinoma, Mucinous/mortality
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/surgery
- Adenocarcinoma, Mucinous/therapy
- Adenocarcinoma, Papillary/mortality
- Adenocarcinoma, Papillary/pathology
- Adenocarcinoma, Papillary/surgery
- Adenocarcinoma, Papillary/therapy
- Adult
- Aged
- Aged, 80 and over
- Cholangiopancreatography, Endoscopic Retrograde
- Cholangiopancreatography, Magnetic Resonance
- Disease Progression
- Endoscopic Ultrasound-Guided Fine Needle Aspiration
- Endosonography
- Female
- Humans
- Kaplan-Meier Estimate
- Male
- Middle Aged
- Neoplasm Recurrence, Local
- Pancreatectomy/adverse effects
- Pancreatectomy/mortality
- Pancreatic Neoplasms/mortality
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/surgery
- Pancreatic Neoplasms/therapy
- Predictive Value of Tests
- Proportional Hazards Models
- Retrospective Studies
- Risk Factors
- Time Factors
- Tomography, X-Ray Computed
- Treatment Outcome
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Wang W, Zhang L, Chen L, Wei J, Sun Q, Xie Q, Zhou X, Zhou D, Huang P, Yang Q, Xie H, Zhou L, Zheng S. Serum carcinoembryonic antigen and carbohydrate antigen 19-9 for prediction of malignancy and invasiveness in intraductal papillary mucinous neoplasms of the pancreas: A meta-analysis. Biomed Rep 2014; 3:43-50. [PMID: 25469245 DOI: 10.3892/br.2014.376] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 09/16/2014] [Indexed: 12/14/2022] Open
Abstract
The clinical importance of intraductal papillary mucinous neoplasms (IPMN) of the pancreas has been increasing due to the large number of newly diagnosed cases. A meta-analysis was used to assess the accuracy of serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) for the identification of malignant and invasive IPMN. A literature search of PubMed and Web of Knowledge was conducted. Studies included in the analysis addressed the diagnostic accuracy of serum CEA and CA19-9 and pooled estimates of sensitivity, specificity, positive- and negative-likelihood ratios (PLR and NLR), diagnostic odds ratio (DOR) and receiver operating characteristic curves were calculated using random-effects models. Predefined subgroup analysis was performed. Fifteen studies (published between 2001 and 2013) were analyzed, including a total of 1,629 patients. Pooled estimates of CEA in malignant and invasive IPNM prediction were: Pooled sensitivity, 18 and 18%; pooled specificity, 93 and 95%; PLR, 2.83 and 3.54; NLR, 0.89 and 0.89; and DOR, 3.35 and 3.6, respectively. Pooled estimates of CA19-9 in malignant and invasive IPMN prediction were: Pooled sensitivity, 40 and 52%; pooled specificity, 89 and 88%; PLR, 2.93 and 3.78; NLR, 0.74 and 0.6; and DOR, 4.34 and 6.33, respectively. In conclusion, serum CEA has low sensitivity and high specificity for malignant and invasive IPMN. Serum CA19-9 is a useful non-invasive preoperative tool for differentiating between invasive and benign IPMN and should be taken into account in the decision to perform surgery.
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Affiliation(s)
- Weilin Wang
- Key Laboratories of Combined Multi-Organ Transplantation, Ministry of Public Health, and The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China ; Key Laboratories of Organ Transplantation, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Lufei Zhang
- Key Laboratories of Combined Multi-Organ Transplantation, Ministry of Public Health, and The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China ; Key Laboratories of Organ Transplantation, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Linghui Chen
- Key Laboratories of Combined Multi-Organ Transplantation, Ministry of Public Health, and The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China ; Key Laboratories of Organ Transplantation, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Jianfeng Wei
- Key Laboratories of Combined Multi-Organ Transplantation, Ministry of Public Health, and The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China ; Key Laboratories of Organ Transplantation, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Qiang Sun
- Key Laboratories of Combined Multi-Organ Transplantation, Ministry of Public Health, and The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China ; Key Laboratories of Organ Transplantation, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Qingshong Xie
- Key Laboratories of Combined Multi-Organ Transplantation, Ministry of Public Health, and The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China ; Key Laboratories of Organ Transplantation, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Xiaohu Zhou
- Key Laboratories of Combined Multi-Organ Transplantation, Ministry of Public Health, and The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China ; Key Laboratories of Organ Transplantation, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Dongkai Zhou
- Key Laboratories of Combined Multi-Organ Transplantation, Ministry of Public Health, and The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China ; Key Laboratories of Organ Transplantation, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Pengfei Huang
- Key Laboratories of Combined Multi-Organ Transplantation, Ministry of Public Health, and The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China ; Key Laboratories of Organ Transplantation, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Qifan Yang
- Key Laboratories of Combined Multi-Organ Transplantation, Ministry of Public Health, and The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China ; Key Laboratories of Organ Transplantation, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Haiyang Xie
- Key Laboratories of Combined Multi-Organ Transplantation, Ministry of Public Health, and The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Lin Zhou
- Key Laboratories of Combined Multi-Organ Transplantation, Ministry of Public Health, and The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Shusen Zheng
- Key Laboratories of Combined Multi-Organ Transplantation, Ministry of Public Health, and The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China ; Key Laboratories of Organ Transplantation, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
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38
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Roch AM, Parikh JA, Al-Haddad MA, DeWitt JM, Ceppa EP, House MG, Nakeeb A, Schmidt CM. Abnormal serum pancreatic enzymes, but not pancreatitis, are associated with an increased risk of malignancy in patients with intraductal papillary mucinous neoplasms. Surgery 2014; 156:923-9. [DOI: 10.1016/j.surg.2014.07.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 07/16/2014] [Indexed: 12/13/2022]
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Freeny PC, Saunders MD. Moving beyond morphology: new insights into the characterization and management of cystic pancreatic lesions. Radiology 2014; 272:345-63. [PMID: 25058133 DOI: 10.1148/radiol.14131126] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The frequency of detection of cystic pancreatic lesions with cross-sectional imaging, particularly with multidetector computed tomography, magnetic resonance (MR) imaging, and MR cholangiopancreatography, is increasing, and many of these cystic pancreatic lesions are being detected incidentally in asymptomatic patients. Because there is considerable overlap in the cross-sectional imaging findings of cystic pancreatic lesions, and because many of these lesions being detected are smaller than 3 cm in diameter and lack any specific cross-sectional imaging features, it has become difficult to make informed decisions about patient management when the precise diagnosis remains uncertain. This article presents the limitations of cross-sectional imaging in patients with cystic pancreatic lesions, details advances in knowledge of the genomic and epigenomic changes that lead to progression of carcinogenesis, outlines the current understanding of the natural history of mucinous cystic lesions, and includes the current use and future potential of novel tumor markers and molecular analysis to characterize cystic pancreatic lesions more precisely. The need to move beyond cross-sectional imaging morphology and toward the use of new techniques to diagnose these lesions accurately is emphasized. An algorithm that uses these techniques is proposed and will hopefully lead to improved patient management.
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Affiliation(s)
- Patrick C Freeny
- From the Department of Radiology (P.C.F.) and Department of Medicine, Division of Gastroenterology (M.D.S.), University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195
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Efthymiou A, Podas T, Zacharakis E. Endoscopic ultrasound in the diagnosis of pancreatic intraductal papillary mucinous neoplasms. World J Gastroenterol 2014; 20:7785-7793. [PMID: 24976716 PMCID: PMC4069307 DOI: 10.3748/wjg.v20.i24.7785] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 11/29/2013] [Accepted: 02/27/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cystic lesions are increasingly recognised due to the widespread use of different imaging modalities. Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas represent a common, but also heterogeneous group of cystic tumors with a significant malignant potential. These neoplasms must be differentiated from other cystic tumors and properly classified into their different types, main-duct IPMNs vs branch-duct IPMNs. These types have a different malignant potential and therefore, different treatment strategies need to be implemented. Endoscopic ultrasound (EUS) offers the highest resolution of the pancreas and can aid in the differential diagnosis, classification and differentiation between benign and malignant tumors. The addition of EUS fine-needle aspiration can supply further information by obtaining fluid for cytology, measurement of tumor markers and perhaps DNA analysis. Novel techniques, such as the use of contrast and sophisticated equipment, like intraductal probes can provide information regarding malignant features and extent of these neoplasms. Thus, EUS is a valuable tool in the diagnosis and appropriate management of these tumors.
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MESH Headings
- Carcinoma, Pancreatic Ductal/diagnosis
- Carcinoma, Pancreatic Ductal/diagnostic imaging
- Carcinoma, Pancreatic Ductal/epidemiology
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Papillary/diagnosis
- Carcinoma, Papillary/diagnostic imaging
- Carcinoma, Papillary/epidemiology
- Carcinoma, Papillary/pathology
- Diagnosis, Differential
- Endoscopic Ultrasound-Guided Fine Needle Aspiration
- Endosonography
- Humans
- Neoplasms, Cystic, Mucinous, and Serous/diagnosis
- Neoplasms, Cystic, Mucinous, and Serous/diagnostic imaging
- Neoplasms, Cystic, Mucinous, and Serous/epidemiology
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Pancreatic Neoplasms/diagnosis
- Pancreatic Neoplasms/diagnostic imaging
- Pancreatic Neoplasms/epidemiology
- Pancreatic Neoplasms/pathology
- Predictive Value of Tests
- Prognosis
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Abdeljawad K, Vemulapalli KC, Schmidt CM, Dewitt J, Sherman S, Imperiale TF, Al-Haddad M. Prevalence of malignancy in patients with pure main duct intraductal papillary mucinous neoplasms. Gastrointest Endosc 2014; 79:623-9. [PMID: 24094923 DOI: 10.1016/j.gie.2013.08.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 08/20/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND Risk of malignancy in main duct intraductal papillary mucinous neoplasm (MD-IPMN) ranges from 36% to 100% in the literature. Although surgical resection is recommended for all MD-IPMNs, the risk of malignancy based on main pancreatic duct (MPD) size alone remains unclear. OBJECTIVE To assess the prevalence of malignancy in symptomatic and asymptomatic patients with pure MD-IPMN based on MPD size. DESIGN Single-center retrospective study of prospectively collected data. SETTINGS Tertiary referral center. PATIENTS AND INTERVENTIONS Fifty-two patients with pure low-risk MD-IPMN. Clinical, endoscopic, radiographic, and pathologic data were reviewed. MAIN OUTCOME MEASUREMENTS Prevalence of malignancy in patients with pure MD-IPMN based on histopathology of resected lesions. RESULTS Sixteen asymptomatic patients had pure MD-IPMN on surgical pathology, 4 (25%) with malignant disease, compared with 25 of 36 symptomatic patients (69%) with pure MD-IPMN. Logistic regression identified symptoms and MPD size as predictors of malignancy. Receiver operating characteristic curve analysis demonstrated that MPD size (optimal cutoff of 8 mm) produced the greatest area under the curve to discriminate between benign and malignant MD-IPMN (.83; 95% CI, .72-.94). MPD size greater than 8 mm has a relative risk of 2.8 for malignancy (95% CI, 1.6-4.9). LIMITATIONS Retrospective, single-center study at a tertiary referral hospital. Study population included only patients who underwent surgical resection. CONCLUSION Asymptomatic MD-IPMN patients with a duct size of no more than 8 mm have a lower prevalence of malignancy and may represent a distinct group of patients with less aggressive biologic behavior. Further studies are needed to confirm our observations.
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Affiliation(s)
- Khaled Abdeljawad
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Krishna C Vemulapalli
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John Dewitt
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Thomas F Imperiale
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mohammad Al-Haddad
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Jang JY, Park T, Lee S, Kang MJ, Lee SY, Lee KB, Chang YR, Kim SW. Validation of international consensus guidelines for the resection of branch duct-type intraductal papillary mucinous neoplasms. Br J Surg 2014; 101:686-92. [DOI: 10.1002/bjs.9491] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2014] [Indexed: 12/12/2022]
Abstract
Abstract
Background
Classifications of intraductal papillary mucinous neoplasm (IPMN) remain ambiguous, especially for the mixed type. Factors predicting malignancy remain unclear. The aim of this study was to evaluate the usefulness of factors predicting malignancy in the new international consensus guidelines for resection of branch duct-type (BD)-IPMN and to compare them with those in the previous version.
Methods
A prospectively collected database of patients with biopsy-proven BD-IPMN was analysed to compare factors between the first and second consensus guidelines, particularly as predictors of malignancy.
Results
Of 350 patients with BD-IPMN, sensitivity (0·724) and balanced accuracy (0·751) of the second guidelines were superior to those (0·639 and 0·730) in the first version at the expense of slightly reduced specificity (0·779 versus 0·822 for the first version) by random forest models. Multiple logistic regression analysis showed that main pancreatic duct dilatation greater than 5 mm (hazard ratio (HR) 4·54, 95 per cent confidence interval 2·45 to 8·41; P < 0·001), mural nodules (HR 6·27, 3·27 to 12·01; P < 0·001) and carbohydrate antigen 19–9 level above 37 units/ml (HR 4·03, 1·83 to 8·90; P = 0·001) were independent predictors of BD-IPMN malignancy.
Conclusion
The new consensus guidelines provide better sensitivity, performance of factors predicting malignancy, and balanced accuracy in the diagnosis of BD-IPMN malignancy. Size alone was limited in predicting malignancy. Variability in clinical significance of the individual factors associated with a risk of malignancy indicates the need for a tailored approach in the management of patients with BD-IPMN.
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Affiliation(s)
- J-Y Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - T Park
- Department of Statistics, Seoul National University College of Natural Sciences, Seoul, Korea
| | - S Lee
- Department of Statistics, Seoul National University College of Natural Sciences, Seoul, Korea
| | - M J Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - S Y Lee
- Department of Mathematics and Statistics, Sejong University College of Natural Sciences, Seoul, Korea
| | - K B Lee
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Y R Chang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - S-W Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Abstract
BACKGROUND There are few data on blood group (BG) types and types of pancreatic cancers. The aims of this study were to study BG types and BG-antigens in pancreatic intraductal papillary mucinous neoplasms (IPMNs). METHODS BG type and tumor BG-antigen (glycoprotein) expression (studied by immunohistochemistry on tissue microarrays) were analyzed with regard to characteristics of 101 surgically resected pancreatic IPMNs. RESULTS Non-O BG type predicted invasive carcinoma independently from high serum CA19-9 and male gender. BG type A was observed more frequently in women than in men. Chronic pancreatitis was more frequently seen in patients with BG type B or AB. Aberrant tumor expression (with regard to BG type) of loss of A antigen expression type occurred in 15.0% of IPMNs and of loss of B antigen expression type in 62.5% of IPMNs. Intraneoplasm BG-antigen expression was not related to dysplasia grade or invasion. CONCLUSION The results of the study suggest that in pancreatic IPMN, non-O BG type predicted invasive carcinoma, whereas for intratumor BG-antigen expression no specific patterns were detected with regard to the progression of glandular epithelial dysplasia or invasion.
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Del Chiaro M, Verbeke C, Salvia R, Klöppel G, Werner J, McKay C, Friess H, Manfredi R, Van Cutsem E, Löhr M, Segersvärd R, Adham M, Albin N, Andren-Sandberg Å, Arnelo U, Bruno M, Cahen D, Cappelli C, Costamagna G, Del Chiaro M, Delle Fave G, Esposito I, Falconi M, Friess H, Ghaneh P, Gladhaug IP, Haas S, Hauge T, Izbicki JR, Klöppel G, Lerch M, Lundell L, Lüttges J, Löhr M, Manfredi R, Mayerle J, McKay C, Oppong K, Pukitis A, Rangelova E, Rosch T, Salvia R, Schulick R, Segersvärd R, Sufferlein T, Van Cutsem E, Van der Merwe SW, Verbeke C, Werner J, Zamboni G. European experts consensus statement on cystic tumours of the pancreas. Dig Liver Dis 2013; 45:703-11. [PMID: 23415799 DOI: 10.1016/j.dld.2013.01.010] [Citation(s) in RCA: 315] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 01/08/2013] [Accepted: 01/09/2013] [Indexed: 12/11/2022]
Abstract
Cystic lesions of the pancreas are increasingly recognized. While some lesions show benign behaviour (serous cystic neoplasm), others have an unequivocal malignant potential (mucinous cystic neoplasm, branch- and main duct intraductal papillary mucinous neoplasm and solid pseudo-papillary neoplasm). European expert pancreatologists provide updated recommendations: diagnostic computerized tomography and/or magnetic resonance imaging are indicated in all patients with cystic lesion of the pancreas. Endoscopic ultrasound with cyst fluid analysis may be used but there is no evidence to suggest this as a routine diagnostic method. The role of pancreatoscopy remains to be established. Resection should be considered in all symptomatic lesions, in mucinous cystic neoplasm, main duct intraductal papillary mucinous neoplasm and solid pseudo-papillary neoplasm as well as in branch duct intraductal papillary mucinous neoplasm with mural nodules, dilated main pancreatic duct >6mm and possibly if rapidly increasing in size. An oncological partial resection should be performed in main duct intraductal papillary mucinous neoplasm and in lesions with a suspicion of malignancy, otherwise organ preserving procedures may be considered. Frozen section of the transection margin in intraductal papillary mucinous neoplasm is suggested. Follow up after resection is recommended for intraductal papillary mucinous neoplasm, solid pseudo-papillary neoplasm and invasive cancer.
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Affiliation(s)
- Marco Del Chiaro
- Division of Surgery, CLINTEC, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden.
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Management of pancreatic intraductal papillary mucinous neoplasm in an academic hospital (2005-2010): what follow-up for unoperated patients? Pancreas 2013; 42:696-700. [PMID: 23160482 DOI: 10.1097/mpa.0b013e318270b98b] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are diagnosed frequently in asymptomatic patients. It is still not clear what follow-up is indicated for patients not undergoing surgical resection. METHODS Review of all reports of magnetic resonance cholangiopancreatography (MRCP) from June 2005 to June 2010, identifying all patients diagnosed with IPMN; subsequent reconstruction of the initial therapeutic decision, indications for and adherence to scheduled follow-up, and IPMN evolution by morphology and by biology. RESULTS Overall, 4943 MRCP reports were analyzed, identifying 234 patients with IPMN. Although 143 (61.1%) of these were comprised in Sendai criteria for resection, surgical resection was considered in only 42 (17.9%) patients. Of the remainder, 52 were not subjected to any control, 58 to a single short time check, 77 to MRCP-based regular annual follow-up, and 5 were treated for associated ductal adenocarcinoma. With a median follow-up of 39.5 months (range, 12-72), 37.6% of 125 patients in follow-up had a morphological evolution, but only 2.4% has developed a malignant IPMN. No deaths were recorded, directly related to IPMN, in all 187 conservatively managed patients. CONCLUSIONS In the analyzed series, fewer patients than expected underwent surgical resection, and only 67.2% undergo regular follow-up, but no more than 2.4% developed malignancy.
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Jang JW, Kim MH, Jeong SU, Kim J, Park DH, Lee SS, Seo DW, Lee SK, Kim JH. Clinical characteristics of intraductal papillary mucinous neoplasm manifesting as acute pancreatitis or acute recurrent pancreatitis. J Gastroenterol Hepatol 2013; 28:731-8. [PMID: 23301513 DOI: 10.1111/jgh.12121] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/31/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIM Comparatively little is known about acute pancreatitis or acute recurrent pancreatitis (AP/ARP) with intraductal papillary mucinous neoplasm of the pancreas (IPMN) as the causative lesion although there have been many reports about the malignant potential of IPMN as a premalignant lesion. METHODS From 2000 to 2008, in a single tertiary referral center, out of 784 patients coded by the International Classification of Disease-10 with IPMN, 489 patients fulfilled our diagnostic criteria of IPMN. After careful exclusion of all known causes of AP/ARP, 34 patients with IPMN as the cause of AP/ARP were enrolled. RESULTS AP/ARP caused by IPMN occurred in 34 (7%) out of 488 patients with IPMN, and the prevalence rate of AP/ARP was higher in the main-duct/combined type than in the branch-duct type (14% [16/111] vs 5% [18/378], respectively, P = 0.002). The severity of pancreatitis was mild, based on the computed tomography severity index score (median 2, range 0-4). Histologic review of 24 patients with surgical resection revealed four adenomas (17%), 17 borderline malignancies (71%), two carcinomas in situ (8%), and one invasive carcinoma (4%). AP/ARP did not recur in any of the 24 surgically resected patients during the follow-up period (median 52 months, range 38-115 months). CONCLUSIONS AP/ARP caused by IPMN was of infrequent occurrence. AP/ARP caused by IPMN occurred more frequently in the main-duct/combined type than in the branch-duct type. Most cases were mild in severity and benign in histopathology. AP/ARP can be an initial manifestation of IPMN, though uncommon, which leads to diagnosis.
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Affiliation(s)
- Ji Woong Jang
- Department of Gastroenterology, Eulji University College of Medicine, Eulji University Hospital, Daejeon, Korea
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YONAIYAMA S, TOYOKI Y, MOROHASHI S, SAKURABA S, YOSHIZAWA T, SUZUKI T, WU Y, KIJIMA H, HAKAMADA K. Epithelial cell adhesion molecule (EpCAM) overexpression is correlated with malignant potentials of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. Biomed Res 2013; 34:87-95. [DOI: 10.2220/biomedres.34.87] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Baiocchi GL, Bertagna F, Gheza F, Grazioli L, Calanducci D, Giubbini R, Portolani N, Giulini SM. Searching for indicators of malignancy in pancreatic intraductal papillary mucinous neoplasms: the value of 18FDG-PET confirmed. Ann Surg Oncol 2012; 19:3574-80. [PMID: 22752369 DOI: 10.1245/s10434-012-2234-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Malignancy in intraductal papillary mucinous neoplasms (IPMN) of the pancreas may be predicted on the basis of a number of clinical and radiologic features, which have raised sensitivity but result in a specificity as low as 20-50%. We sought to confirm the additional value of (18)F-18-fluorodeoxyglucose-positron emission tomography ((18)FDG-PET) in diagnostic accuracy of imaging-based IPMN malignancy assessment. METHODS This prospective uncontrolled case series contained 44 patients with IPMN undergoing comprehensive diagnostic evaluation, including magnetic resonance cholangiopancreatography and (18)FDG-PET. Average follow-up time was 39.3 months (range 3-97 months). Diagnostic performance regarding the diagnosis of malignancy was evaluated for the classic preoperative assessment, including clinical signs, CA 19-9, imaging (computed tomography and magnetic resonance cholangiopancreatography), and International Consensus Guidelines criteria, as well as (18)FDG-PET scan. RESULTS Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 100, 22, 32, 100, and 43%, and 83, 100, 100, 94, and 96%, respectively, for comprehensive assessment without and with (18)FDG-PET [maximum standardized uptake value (SUV(max)) cutoff of 2.5 MBq]. Elevated CA 19-9 values and positive PET scan were the only independent prognostic factors for malignancy (odds ratio 2.11, 95% confidence interval 1.15-2.74 and 5.49, 95% confidence interval 3.98-21.44, respectively). CONCLUSIONS (18)FDG-PET is useful for detection of malignancy in IPMN, improving the differential diagnosis with benign cases by functional data. The choice of SUV(max) cutoff should maximize specificity.
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Affiliation(s)
- Gian Luca Baiocchi
- Department of Medical and Surgical Sciences, Surgical Clinic, University of Brescia, Brescia, Italy.
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Comparison of International Consensus Guidelines versus 18-FDG PET in detecting malignancy of intraductal papillary mucinous neoplasms of the pancreas. Ann Surg 2012; 254:971-6. [PMID: 22076067 DOI: 10.1097/sla.0b013e3182383137] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To assess the reliability of the International Consensus Guidelines (ICG) and 18-fluorodeoxyglucose positron emission tomography (PET) in distinguishing benign from malignant intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. BACKGROUND Since 2006 the ICG have been used to choose immediate surgery or surveillance for IPMN patients, but their low specificity increases the number of benign IPMNs that undergo resective surgery. PET has proved highly sensitive and specific in detecting malignancy in cystic neoplasms of the pancreas, including IPMNs. METHODS Patients suspected with IPMNs of the pancreas seen at our Department from January 1989 to July 2010 were identified and classified as cases of main duct, mixed type and branch type IPMN. The indication for resection or surveillance was verified a posteriori for all patients according to the ICG. PET was considered positive for a Standardized Uptake Value ≥2.5. Surveillance included clinical examination, laboratory tests, CA 19-9 serum levels, and computed tomography and/or magnetic resonance and magnetic resonance cholangiopancreatography every 6 months for 2 years and yearly thereafter. Endoscopic ultrasound was rarely performed. PET was repeated in clinically or radiologically suspect cases, or if tumor markers increased. RESULTS Sixty-one main duct or mixed type and 101-branch type IPMNs were included in the study. A histological diagnosis was available for 81 of 162 patients, missing for 1 locally advanced IPMN, whereas 62 patients are under surveillance and it proved impossible to contact 18. Conservative surgery was performed in 16 of 68 patients with benign IPMNs. The sensitivity, specificity, positive and negative predictive value, and accuracy of the ICG in detecting malignancy were 93.2, 22.2, 59.4, 72.7, and 61.2, whereas for PET they were 83.3, 100, 100, 84.6, and 91.3. CONCLUSIONS PET is more accurate than the ICG in distinguishing benign from malignant (invasive and noninvasive) IPMNs. Prophylactic IPMN resection in young patients fit for surgery should be guided by the ICG, whereas PET should be performed in older patients, cases at increased surgical risk, or when the feasibility of parenchyma-sparing surgery demands a reliable preoperative exclusion of malignancy.
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Cytology adds value to imaging studies for risk assessment of malignancy in pancreatic mucinous cysts. Ann Surg 2012. [PMID: 22041510 DOI: 10.1097/sla.0b013e318238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Evaluate the value of cytology relative to imaging features in risk assessment for malignancy as defined in the Sendai Guidelines. BACKGROUND The Sendai Guidelines list symptoms, cyst size >30 mm, dilated main pancreatic duct (MPD) >6 mm, mural nodule (MN) and "positive" cytology as high risk stigmata for malignancy warranting surgical triage. METHODS We reviewed clinical, radiological and cytological data of 112 patients with histologically confirmed mucinous cysts of the pancreas evaluated in a single tertiary medical center. Cytology slides were blindly re-reviewed and epithelial cells grouped as either benign or high-grade atypia (HGA) [≥high-grade dysplasia]. Histologically, neoplasms were grouped as benign (low-grade and moderate dysplasia) and malignant (in situ and invasive carcinoma). Performance characteristics of cytology relative to other risk factors were evaluated. RESULTS Dilated MPD, MN, and HGA were independent predictors of malignancy (p < 0.0001), but not symptoms (p = 0.29) or cyst size >30 mm (p = 0.51). HGA was the most sensitive predictor of malignancy in all cysts (72%) and in small (≤30 mm) branch-duct intraductal papillary mucinous neoplasm (BD IPMN; 67%), whereas also being specific (85 and 88%, respectively). MN and dilated MPD were highly specific (>90%), but insensitive (39%-44%). Cytology detected 30% more cancers in small cysts than dilated MPD or MN and half of the cancers without either of these high-risk imaging features. CONCLUSIONS Cytology adds value to the radiological assessment of predicting malignancy in mucinous cysts, particularly in small BD IPMN.
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