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Brandi N, Renzulli M. Towards a Simplified and Cost-Effective Diagnostic Algorithm for the Surveillance of Intraductal Papillary Mucinous Neoplasms (IPMNs): Can We Save Contrast for Later? Cancers (Basel) 2024; 16:905. [PMID: 38473267 DOI: 10.3390/cancers16050905] [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: 02/08/2024] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/14/2024] Open
Abstract
The increased detection of pancreatic cysts in recent years has triggered extensive diagnostic investigations to clarify their potential risk of malignancy, resulting in a large number of patients undergoing numerous imaging follow-up studies for many years. Therefore, there is a growing need for optimization of the current surveillance protocol to reduce both healthcare costs and waiting lists, while still maintaining appropriate sensibility and specificity. Imaging is an essential tool for evaluating patients with intraductal papillary mucinous neoplasms (IPMNs) since it can assess several predictors for malignancy and thus guide further management recommendations. Although contrast-enhanced magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) has been widely recommended by most international guidelines, recent results support the use of unenhanced abbreviated-MRI (A-MRI) protocols as a surveillance tool in patients with IPMN. In fact, A-MRI has shown high diagnostic performance in malignant detection, with high sensitivity and specificity as well as excellent interobserver agreement. The aim of this paper is, therefore, to discuss the current available evidence on whether the implementation of an abbreviated-MRI (A-MRI) protocol for cystic pancreatic lesion surveillance could improve healthcare economics and reduce waiting lists in clinical practice without significantly reducing diagnostic accuracy.
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Affiliation(s)
- Nicolò Brandi
- Department of Radiology, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Department of Radiology, AUSL Romagna, 48018 Faenza, Italy
| | - Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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Ohno E, Balduzzi A, Hijioka S, De Pastena M, Marchegiani G, Kato H, Takenaka M, Haba S, Salvia R. Association of high-risk stigmata and worrisome features with advanced neoplasia in intraductal papillary mucinous neoplasms (IPMN): A systematic review. Pancreatology 2024; 24:48-61. [PMID: 38161091 DOI: 10.1016/j.pan.2023.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/24/2023] [Accepted: 12/03/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND This systematic review aimed to assess the diagnostic accuracy of the International Consensus Fukuoka Guidelines (ICG2017) in identifying high-risk lesions of Intraductal Papillary Mucinous Neoplasms (IPMNs). METHODS The ICG2017 revision committee conducted a comprehensive literature review to establish evidence-based statements on IPMNs. The review focused on articles examining the diagnostic value of imaging features (e.g., cyst or main pancreatic duct diameter), clinical symptoms associated with IPMN, and serum biomarkers. Five clinical questions regarding high-risk stigmata (HRS) and worrisome features (WF) in the ICG2017 guidelines were addressed. RESULTS A total of 210 articles were reviewed. The findings revealed a significant association between the presence of mural nodules ≥5 mm in diameter or solid components with contrast enhancement and the diagnosis of high-grade dysplasia or invasive carcinoma. Contrast-enhanced diagnostic tools, such as CT, MRI, or EUS, demonstrated the highest prediction rate and were recommended. Positive cytology was identified as an HRS, while symptoms like acute pancreatitis and cyst diameter growth ≥2.5 mm per year were considered WFs. The use of nomograms and multiple diagnostic factors was recommended for optimal IPMN management. CONCLUSIONS This systematic review provides evidence supporting the improved diagnostic accuracy of ICG2017 in identifying high-risk lesions of IPMN. The multidisciplinary incorporation of HRS and WF based on imaging findings and clinical symptoms is crucial. These findings should inform the revision of ICG2017, enhancing the evaluation and management of IPMN patients. By implementing these recommendations, clinicians can make more informed decisions, leading to better diagnosis and treatment outcomes for high-risk IPMN cases.
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Affiliation(s)
- Eizaburo Ohno
- Fujita Health University, Department of Gastroenterology and Hepatology, Japan; Nagoya University Hospital, Department of Gastroenterology and Hepatology, Japan
| | - Alberto Balduzzi
- The Pancreas Institute Verona, Unit of General and Pancreatic Surgery Department of Surgery, Dentistry, Paediatrics and Gynaecology University of Verona, Italy
| | - Susumu Hijioka
- National Cancer Center Hospital, Department of Hepatobiliary and Pancreatic Oncology, Japan
| | - Matteo De Pastena
- The Pancreas Institute Verona, Unit of General and Pancreatic Surgery Department of Surgery, Dentistry, Paediatrics and Gynaecology University of Verona, Italy
| | - Giovanni Marchegiani
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences (DISCOG), University of Padua, Padua, Italy
| | - Hironari Kato
- Okayama University Hospital, Department of Gastroenterology and Hepatology, Japan
| | - Mamoru Takenaka
- Kindai University, Department of Gastroenterology and Hepatology, Japan
| | - Shin Haba
- Aichi Cancer Center Hospital, Department of Gastroenterology, Japan
| | - Roberto Salvia
- The Pancreas Institute Verona, Unit of General and Pancreatic Surgery Department of Surgery, Dentistry, Paediatrics and Gynaecology University of Verona, Italy.
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Lee DY, Shin J, Kim S, Baek SE, Lee S, Son NH, Park MS. Radiomics model versus 2017 revised international consensus guidelines for predicting malignant intraductal papillary mucinous neoplasms. Eur Radiol 2024; 34:1222-1231. [PMID: 37615762 DOI: 10.1007/s00330-023-10158-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/05/2023] [Accepted: 07/20/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVES To evaluate a CT-based radiomics model for identifying malignant pancreatic intraductal papillary mucinous neoplasms (IPMNs) and compare its performance with the 2017 international consensus guidelines (ICGs). MATERIALS AND METHODS We retrospectively included 194 consecutive patients who underwent surgical resection of pancreatic IPMNs between January 2008 and December 2020. Surgical histopathology was the reference standard for diagnosing malignancy. Using radiomics features from preoperative contrast-enhanced CT, a radiomics model was built with the least absolute shrinkage and selection operator by a five-fold cross-validation. CT and MR images were independently reviewed based on the 2017 ICGs by two abdominal radiologists, and the performances of the 2017 ICGs and radiomics model were compared. The areas under the curve (AUCs) were compared using the DeLong method. RESULTS A total of 194 patients with pancreatic IPMNs (benign, 83 [43%]; malignant, 111 [57%]) were chronologically divided into training (n = 141; age, 65 ± 8.6 years; 88 males) and validation sets (n = 53; age, 66 ± 9.7 years; 31 males). There was no statistically significant difference in the diagnostic performance of the 2017 ICGs between CT and MRI (AUC, 0.71 vs. 0.71; p = 0.93) with excellent intermodality agreement (k = 0.86). In the validation set, the CT radiomics model had higher AUC (0.85 vs. 0.71; p = 0.038), specificity (84.6% vs. 61.5%; p = 0.041), and positive predictive value (84.0% vs. 66.7%; p = 0.044) than the 2017 ICGs. CONCLUSION The CT radiomics model exhibited better diagnostic performance than the 2017 ICGs in classifying malignant IPMNs. CLINICAL RELEVANCE STATEMENT Compared with the radiologists' evaluation based on the 2017 international consensus guidelines, the CT radiomics model exhibited better diagnostic performance in classifying malignant intraductal papillary mucinous neoplasms. KEY POINTS • There is a paucity of comparisons between the 2017 international consensus guidelines (ICGs) and radiomics models for malignant intraductal papillary mucinous neoplasms (IPMNs). • The CT radiomics model developed in this study exhibited better diagnostic performance than the 2017 ICGs in classifying malignant IPMNs. • The radiomics model may serve as a valuable complementary tool to the 2017 ICGs, potentially allowing a more quantitative assessment of IPMNs.
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Affiliation(s)
- Doo Young Lee
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jaeseung Shin
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University College of Medicine, 81 Irwon-Ro, Kangnam-Gu, Seoul, 06351, Republic of Korea.
| | - Sungwon Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Song-Ee Baek
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Suji Lee
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Nak-Hoon Son
- Department of Statistics, Keimyung University, Daegu, Korea
| | - Mi-Suk Park
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Wood LD, Adsay NV, Basturk O, Brosens LAA, Fukushima N, Hong SM, Kim SJ, Lee JW, Luchini C, Noë M, Pitman MB, Scarpa A, Singhi AD, Tanaka M, Furukawa T. Systematic review of challenging issues in pathology of intraductal papillary mucinous neoplasms. Pancreatology 2023; 23:878-891. [PMID: 37604731 DOI: 10.1016/j.pan.2023.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMNs) are a cystic precursor to pancreatic cancer. IPMNs deemed clinically to be at high-risk for malignant progression are frequently treated with surgical resection, and pathological examination of the pancreatectomy specimen is a key component of the clinical care of IPMN patients. METHODS Systematic literature reviews were conducted around eight topics of clinical relevance in the examination of pathological specimens in patients undergoing resection of IPMN. RESULTS This review provides updated perspectives on morphological subtyping of IPMNs, classification of intraductal oncocytic papillary neoplasms, nomenclature for high-grade dysplasia, assessment of T stage, distinction of carcinoma associated or concomitant with IPMN, role of molecular assessment of IPMN tissue, role of intraoperative assessment by frozen section, and preoperative evaluation of cyst fluid cytology. CONCLUSIONS This analysis provides the foundation for data-driven approaches to several challenging issues in the pathology of IPMNs.
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Affiliation(s)
- Laura D Wood
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - N Volkan Adsay
- Department of Pathology, Koç University Hospital and Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey
| | - Olca Basturk
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Noriyoshi Fukushima
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Joo Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae W Lee
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134, Verona, Italy; ARC-Net Research Center, University of Verona, 37134, Verona, Italy
| | - Michaël Noë
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134, Verona, Italy; ARC-Net Research Center, University of Verona, 37134, Verona, Italy
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mariko Tanaka
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toru Furukawa
- Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
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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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Shockley KE, To B, Chen W, Lozanski G, Cruz-Monserrate Z, Krishna SG. The Role of Genetic, Metabolic, Inflammatory, and Immunologic Mediators in the Progression of Intraductal Papillary Mucinous Neoplasms to Pancreatic Adenocarcinoma. Cancers (Basel) 2023; 15:1722. [PMID: 36980608 PMCID: PMC10046238 DOI: 10.3390/cancers15061722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/21/2023] [Accepted: 03/08/2023] [Indexed: 03/16/2023] Open
Abstract
Intraductal papillary mucinous neoplasms (IPMN) have the potential to progress to pancreatic ductal adenocarcinoma (PDAC). As with any progression to malignancy, there are a variety of genetic and metabolic changes, as well as other disruptions to the cellular microenvironment including immune alterations and inflammation, that can contribute to tumorigenesis. Previous studies further characterized these alterations, revealing changes in lipid and glucose metabolism, and signaling pathways that mediate the progression of IPMN to PDAC. With the increased diagnosis of IPMNs and pancreatic cysts on imaging, the opportunity to attenuate risk with the removal of high-risk lesions is possible with the understanding of what factors accelerate malignant progression and how they can be clinically utilized to determine the level of dysplasia and stratify the risk of progression. Here, we reviewed the genetic, metabolic, inflammatory, and immunologic pathways regulating the progression of IPMN to PDAC.
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Affiliation(s)
- Kylie E. Shockley
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Briana To
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Wei Chen
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Gerard Lozanski
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Zobeida Cruz-Monserrate
- Division of Gastroenterology, Hepatology, and Nutrition, and The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Somashekar G. Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, and The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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Yoon JH, Bae JS, Jeon S, Chang W, Lee SM, Park JY, Lee JS, Lee ES, Cho IR, Lee SH, Lee JM. Accelerated Pancreatobiliary MRI for Pancreatic Cancer Surveillance in Patients With Pancreatic Cystic Neoplasms. J Magn Reson Imaging 2022; 56:1757-1768. [PMID: 35388939 DOI: 10.1002/jmri.28189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Pancreatobiliary MRI is often recommended for patients at risk of developing pancreas cancer. But the surveillance MRI protocol has not yet been widely accepted. PURPOSE To establish an accelerated MRI protocol targeting the table time of 15 minutes for pancreatic cancer surveillance and test its performance in lesion characterization. STUDY TYPE Prospective. POPULATION A total of 30 participants were enrolled, who were undergoing follow-up care for intraductal papillary mucinous neoplasms or newly diagnosed pancreatic cysts (≥10 mm) and were scheduled for or had recently undergone contrast-enhanced CT (CECT). FIELD STRENGTH/SEQUENCE A 3 T; heavily T2WI, 3D MRCP, DWI, dynamic T1WI, two-point Dixon. ASSESSMENT In-room time and table time were measured. Seven radiologists independently reviewed image quality of MRI and then the presence of high-risk stigmata and worrisome features in addition to diagnostic confidence for accelerated MRI, CECT, and the noncontrast part of accelerated MRI (NC-MRI). STATISTICAL ANALYSIS Fisher's exact test was used for categorical variables and either the Student's t-test or Mann-Whitney test was performed for continuous variables. The generalized estimated equation was used to compare the diagnostic performance of examinations on a per-patient basis. Interobserver agreement was evaluated via Fleiss kappa. A P value of <0.05 was considered to be statistically significant. RESULTS The in-room time was 18.5 ± 2.6 minutes (range: 13.7-24.9) and the table time was 13.9 ± 1.9 minutes (range: 10.7-17.5). There was no significant difference between the diagnostic performances of the three examinations (pooled sensitivity: 75% for accelerated MRI and CECT, 68% for NC-MRI, P = 0.95), with the highest significant diagnostic confidence for accelerated MRI (4.2 ± 0.1). With accelerated MRI, the interobserver agreement was fair to excellent for high-risk stigmata (κ = 0.34-0.98). DATA CONCLUSION Accelerated MRI protocol affords a table time of 15 minutes, making it potentially suitable for cancer surveillance in patients at risk of developing pancreatic cancer. EVIDENCE LEVEL 2 TECHNICAL EFFICACY STAGE: 2.
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Affiliation(s)
- Jeong Hee Yoon
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03087, Republic of Korea
| | - Jae Seok Bae
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03087, Republic of Korea
| | - Sunkyung Jeon
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03087, Republic of Korea
| | - Won Chang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si 13620, Republic of Korea
| | - Sang Min Lee
- Department of Radiology, Hallym University Sacred Heart Hospital, Anyang, 14068, Republic of Korea
| | - Jin Young Park
- Department of Radiology, Inje University Busan Paik Hospital, Bokji-ro 75, Busangjin-gu, Busan, 47392, Republic of Korea
| | - Jeong Sub Lee
- Department of Radiology, Jeju National University Hospital, Jeju-si, 63241, Republic of Korea
| | - Eun Sun Lee
- Department of Radiology, Chung-Ang University Hospital, 101 Heukseok-ro, Dongjak-gu, Seoul, 06973, Republic of Korea
| | - In Rae Cho
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Sang-Hyub Lee
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jeong Min Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03087, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul 03087, Republic of Korea
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Lee SW, Shim SR, Jeong SY, Kim SJ. Comparison of Preoperative Imaging Modalities for the Assessment of Malignant Potential of Pancreatic Cystic Lesions: A Network Meta-analysis. Clin Nucl Med 2022; 47:849-855. [PMID: 35713890 DOI: 10.1097/rlu.0000000000004323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aims of this study are to compare the performance of various preoperative imaging modalities for assessing the malignant potential of pancreatic cystic lesions (PCLs) through a network meta-analysis (NMA) and to clarify the role of 18 F-FDG PET in the management of patients with PCL. METHODS PubMed, EMBASE, and Cochrane Library were searched for the studies evaluating the performance of preoperative imaging modalities for identifying malignant PCLs. The NMA was performed for 4 representative categories of various imaging modalities in terms of diagnostic performance for differentiating malignant from benign PCL and intraductal papillary mucinous neoplasms only as a subgroup analysis. To calculate the probability of each imaging modality being the most effective diagnostic method, the surface under the cumulative ranking curve values were obtained. RESULTS A total of 1018 patients from 17 direct comparison studies using 2 or more preoperative imaging modalities were included for differentiating malignant from benign PCL. The positive predictive value (PPV) and accuracy of 18 F-FDG PET were significantly higher than that of CT (PPV: odds ratio [OR], 2.66; 95% credible interval [CrI], 1.21-6.17; accuracy: OR, 2.63; 95% CrI, 1.41-5.38) or MRI (PPV: OR, 2.50; 95% CrI, 1.09-6.26; accuracy: OR, 2.50; 95% CrI, 1.28-5.47) in all PCLs, as well as in the subgroup analysis for intraductal papillary mucinous neoplasm only. 18 F-FDG PET showed the highest surface under the cumulative ranking curve values in all diagnostic performance areas of sensitivity, specificity, PPV, negative predictive value, and accuracy, followed by MRI or CT. CONCLUSIONS The results from this NMA suggest that 18 F-FDG PET is the best preoperative imaging modality for differentiating malignant from benign PCLs and that it can be used for the preoperative evaluation of PCLs.
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Affiliation(s)
- Sang-Woo Lee
- From the Department of Nuclear Medicine, School of Medicine and Chilgok Hospital, Kyungpook National University, Daegu
| | - Sung Ryul Shim
- Department of Health and Medical Informatics, Kyungnam University College of Health Sciences, Changwon
| | - Shin Young Jeong
- From the Department of Nuclear Medicine, School of Medicine and Chilgok Hospital, Kyungpook National University, Daegu
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Hong SB, Lee NK, Kim S, Seo HI, Park YM, Noh BG, Kim DU, Han SY, Kim TU. Diagnostic performance of magnetic resonance image for malignant intraductal papillary mucinous neoplasms: the importance of size of enhancing mural nodule within cyst. Jpn J Radiol 2022; 40:1282-1289. [PMID: 35781178 DOI: 10.1007/s11604-022-01312-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/19/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate the clinical significance of enhancing mural nodules ≥ 5 mm by comparing the diagnostic performance of high-risk stigmata for diagnosing the malignant IPMN between the international consensus guideline (ICG) 2012 and 2017 in pancreatic magnetic resonance image (MRI). MATERIALS AND METHODS In this retrospective study, we reviewed preoperative pancreatic MRI with surgically confirmed IPMNs between May 2009 and April 2021. High-risk stigmata, defined by ICG 2012 and ICG 2017, associated with malignant IPMN were evaluated using logistic regression analysis. We calculated and compared the sensitivity and specificity of ICG 2012 and ICG 2017 for diagnosing malignant IPMNs. Receiver-operating characteristic (ROC) curves were used to compare ICG 2012 to ICG 2017. RESULTS A total of 73 patients (43 men and 30 women; mean age, 69 years; standard deviation, 8 years) with 34 malignant IPMNs and 39 benign IPMNs were included. Among high-risk stigmata, enhancing mural nodule ≥ 5 mm, and MPD diameter ≥ 10 mm were the significant predictor of malignant IPMN, in multivariate logistic regression (P < 0.001 for all). For the diagnosis of malignant IPMN, the specificity of ICG 2017 for enhancing mural nodules ≥ 5 mm as the high-risk stigmata was significantly higher than that of ICG 2012 (87.2% vs. 64.1%, P = 0.008). However, there was no significant difference in sensitivity between the two guidelines (94.1% vs. 97.1%, P = 1.0). The comparison of the ROC curves showed that the diagnostic performance of ICG 2017 for malignant IPMNs (AUC, 0.91) significantly improved when compared to that of ICG 2012 (AUC, 0.81) (P = 0.01). CONCLUSION When applying enhancing mural nodule ≥ 5 mm as a high-risk stigmata, ICG 2017 provided a significantly higher specificity than ICG 2012 without a reduction in sensitivity.
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Affiliation(s)
- Seung Baek Hong
- Department of Radiology and Biomedical Research Institute of Radiology, Pusan National University Hospital, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan, 49241, Korea
| | - Nam Kyung Lee
- Department of Radiology and Biomedical Research Institute of Radiology, Pusan National University Hospital, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan, 49241, Korea.
| | - Suk Kim
- Department of Radiology and Biomedical Research Institute of Radiology, Pusan National University Hospital, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan, 49241, Korea
| | - Hyung-Il Seo
- Department of Surgery, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Young Mok Park
- Department of Surgery, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Byeong Gwan Noh
- Department of Surgery, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Dong Uk Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Sung Yong Han
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Tae Un Kim
- Department of Radiology, Biomedical Research Institute, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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Kubo N, Yazawa S, Yokobori T, Sano R, Eguchi H, Kobayashi S, Akita H, Mitsufuji S, Yamashita YI, Nakao Y, Fujii T, Okumura T, Shibuya K, Hoshino Y, Yamada S, Hayashi M, Shimokawa M, Shirabe K. The malignant potential of pancreatic intraductal papillary mucinous neoplasm is reflected in expression levels of fucosylated glycans in α 1 -acid glycoprotein. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 30:503-513. [PMID: 35776060 DOI: 10.1002/jhbp.1208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/07/2022] [Accepted: 06/03/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pancreatic intraductal papillary mucinous neoplasm (IPMN) involves multiple histopathological stages from benign to malignant lesions. Further, a biomarker to diagnose the malignant IPMN (IPMC) is clinically relevant. Recently, we found that serum fucosylated α1 -acid glycoprotein (fAGP) level markedly elevated along with disease progression in large cohorts of patients with various cancers. METHODS The fAGP level was retrospectively analyzed in preoperative sera from 109 patients with IPMN, and the clinical relevance of fAGP was compared with currently available predictors as standard. RESULTS The fAGP level in IPMC was found to be significantly higher than in benign IPMN (P=0.0012). At a cutoff value of 27.04 U/μg, its sensitivity, specificity, and accuracy for IPMC were determined to be 83.61, 65.96 and 75.93%, respectively. Multivariate analyses revealed that the fAGP level was the only independent risk factor for predicting IPMC. Additionally, a combination of the fAGP level and 18 F-fluorodeoxyglucose uptake on the PET/CT imaging in the lesions seemed to offer the best diagnosis of IPMN. Accordingly, 27 of the 28 patients who were positive in both tests had IPMC, while patients who are negative had benign IPMN. CONCLUSIONS The fAGP level appeared to be a relevant biomarker for malignant potential of IPMN.
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Affiliation(s)
- Norio Kubo
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Shin Yazawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Takehiko Yokobori
- Department of Innovative Cancer Immunotherapy, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Rie Sano
- Department of Legal Medicine, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Hirofumi Akita
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Suguru Mitsufuji
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Yo-Ichi Yamashita
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yosuke Nakao
- Department of Gastroenterological Surgery, Graduate School of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Tomoyuki Okumura
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Kazuto Shibuya
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Yui Hoshino
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Suguru Yamada
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masamichi Hayashi
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mototsugu Shimokawa
- Department of Biostatistics, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Ken Shirabe
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, Maebashi, Japan
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11
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Lin T, Chen X, Liu J, Cao Y, Cui W, Wang Z, Wang C, Chen X. MRI-Based Pancreatic Atrophy Is Associated With Malignancy or Invasive Carcinoma in Intraductal Papillary Mucinous Neoplasm. Front Oncol 2022; 12:894023. [PMID: 35719938 PMCID: PMC9204001 DOI: 10.3389/fonc.2022.894023] [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: 03/11/2022] [Accepted: 05/06/2022] [Indexed: 11/19/2022] Open
Abstract
Background Abrupt change in the caliber of the main pancreatic duct (MPD) with distal pancreatic atrophy (PA) was considered as one of worrisome features in the International Association of Pancreatology guideline and American College of Gastroenterology guideline for the management of intraductal papillary mucinous neoplasms (IPMNs). However, this feature was not included in other guidelines. Moreover, the association between PA alone and malignancy in IPMNs has not been fully evaluated. In the present study, we investigated the role of image-based PA in identifying malignant IPMNs or invasive carcinoma. Methods A total of 186 patients with IPMNs were included for analysis. The tumor size, location, MPD diameter, presence of a mural nodule (MN), and PA were evaluated using magnetic resonance imaging. Demographic information and serum carbohydrate antigen 19-9 and carcinoembryonic antigen (CEA) levels were also collected. IPMNs with high-grade dysplasia and associated invasive carcinoma were regarded as malignant IPMNs. Results PA was observed in 34 cases (18.3%). The occurrence of malignant IPMNs or invasive carcinoma in patients with PA were significantly higher than in those without PA (52.9% vs. 22.3%; 44.1% vs. 8.9%, all P < 0.01). Multivariate logistic regression analysis showed that PA was an independently associated factor for malignant IPMNs [odds ratio (OR) = 2.69, 95% confidence interval (CI): 1.07-6.78] or invasive carcinoma (OR = 7.78, 95%CI: 2.62-23.10) after modified with confounders. Subgroup analysis in MPD-involved IPMNs also indicated that PA was an independently associated factor for invasive carcinoma (OR = 9.72, 95%CI: 2.43-38.88). PA had a similar performance with MPD plus MN [the area under the curve (AUC) was both 0.71] in identifying malignancy. PA had a higher performance in identifying invasive carcinoma in MPD-involved IPMNs than MN (AUC = 0.71 vs. 0.65, P = 0.02). Conclusion Our data showed that imaging-based PA was associated with malignancy or invasive carcinoma regardless of abrupt change in the caliber of MPD in IPMNs. PA had an acceptable performance in identifying malignant IPMNs.
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Affiliation(s)
- Tingting Lin
- Department of Radiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Xin Chen
- Department of Radiology, Shanghai Sixth People's Hospital, Shanghai, China
| | - Jingjing Liu
- Department of Radiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Yingying Cao
- Department of Radiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Wenjing Cui
- Department of Radiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Zhongqiu Wang
- Department of Radiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Cheng Wang
- Department of Radiology, Nanjing Drum Tower Hospital, Nanjing, China
| | - Xiao Chen
- Department of Radiology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China.,Institute of Radiation Medicine, Fudan University, Shanghai, China
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12
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Ohno E, Ishikawa T, Mizutani Y, Iida T, Uetsuki K, Yashika J, Yamada K, Gibo N, Aoki T, Kawashima H. Factors associated with misdiagnosis of preoperative endoscopic ultrasound in patients with pancreatic cystic neoplasms undergoing surgical resection. J Med Ultrason (2001) 2022; 49:433-441. [PMID: 35411413 DOI: 10.1007/s10396-022-01205-7] [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: 12/27/2021] [Accepted: 02/24/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Pancreatic cystic lesions (PCLs) include various types of cysts. Accurate preoperative diagnosis is essential to avoid unnecessary surgery on benign cysts. In this study, we aimed to identify the factors associated with misdiagnosis in preoperative endoscopic ultrasound (EUS) imaging and clinicopathological findings for PCLs. METHODS This study included 302 surgically resected patients with PCLs who underwent preoperative EUS. The preoperative EUS findings were re-evaluated and compared with the pathological diagnosis. Additionally, the factors associated with misdiagnosis of PCLs were investigated by multivariate analysis. RESULTS The preoperative diagnoses of PCLs were intraductal papillary mucinous neoplasm (IPMN) in 213 patients (70.5%), mucinous cystic neoplasm (MCN) in 33 patients (10.9%), serous neoplasm (SN) in 7 patients (2.3%), cystic degeneration cyst of solid tumor in 46 patients (15.2%), and pancreatic cancer with cystic degeneration in three patients (1.0%). A discrepancy between preoperative and postoperative diagnosis was found in 47 patients (15.6%). Based on the pathological diagnosis, the sensitivity of preoperative EUS imaging was IPMN 97.6% (206/211), MCN 90.0% (18/19), cystic degeneration 87.1% (27/31), and SN 15.4% (2/13). Multivariate analysis revealed that main pancreatic duct (MPD) communication ( - ) (odds ratio (OR), 4.54; 95% confidence interval (CI) 1.29-15.9), honeycomb-like structure ( +) (OR, 14.7; 95% CI 2.61-83.3), and MPD size ≦ 2 mm (OR, 16.3; 95% CI 3.93-67.6) were independently associated with misdiagnosis. CONCLUSION For cases in which MCN and cystic degeneration of solid tumor are presumed based on preoperative EUS imaging and cases with PCLs with a honeycomb-like structure, diagnosis with multimodalities or fluid analysis with EUS-guided fine-needle aspiration should be considered.
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Affiliation(s)
- Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Tadashi Iida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Kota Uetsuki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Jun Yashika
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Kenta Yamada
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Noriaki Gibo
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Toshinori Aoki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hiroki Kawashima
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Aichi, Japan
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13
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Jabłońska B, Szmigiel P, Mrowiec S. Pancreatic intraductal papillary mucinous neoplasms: Current diagnosis and management. World J Gastrointest Oncol 2021; 13:1880-1895. [PMID: 35070031 PMCID: PMC8713311 DOI: 10.4251/wjgo.v13.i12.1880] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/17/2021] [Accepted: 10/18/2021] [Indexed: 02/06/2023] Open
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) represent approximately 1% of all pancreatic neoplasms and 25% of cystic neoplasms. They are divided into three types: main duct-IPMN (MD-IPPMN), branch duct-IPMN (BD-IPMN), and mixed type-IPMN. In this review, diagnostics, including clinical presentation and radiological investigations, were described. Magnetic resonance imaging is the most useful for most IPMNs. Management depends on the type and radiological features of IPMNs. Surgery is recommended for MD-IPMN. For BD-IPMN, management involves surgery or surveillance depending on the tumor size, cyst growth rate, solid components, main duct dilatation, high-grade dysplasia in cytology, the presence of symptoms (jaundice, new-onset diabetes, pancreatitis), and CA 19.9 serum level. The patient’s age and comorbidities should also be taken into consideration. Currently, there are different guidelines regarding the diagnosis and management of IPMNs. In this review, the following guidelines were presented: Sendai International Association of Pancreatology guidelines (2006), American Gastroenterological Association guidelines, revised international consensus Fukuoka guidelines (2012), revised international consensus Fukuoka guidelines (2017), and European evidence-based guidelines according to the European Study Group on Cystic Tumours of the Pancreas (2018). The Verona Evidence-Based Meeting 2020 was also presented and discussed.
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Affiliation(s)
- Beata Jabłońska
- Department of Digestive Tract Surgery, Medical University of Silesia, Katowice 40-752, Poland
| | - Paweł Szmigiel
- Department of Digestive Tract Surgery, Medical University of Silesia, Katowice 40-752, Poland
| | - Sławomir Mrowiec
- Department of Digestive Tract Surgery, Medical University of Silesia, Katowice 40-752, Poland
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