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Cheung TT, Lee YT, Tang RSY, She WH, Cheng KC, Cheung CC, Chiu KWH, Chok KSH, Chow WS, Lai TW, Seto WK, Yau T. The Hong Kong consensus recommendations on the diagnosis and management of pancreatic cystic lesions. Hepatobiliary Surg Nutr 2023; 12:715-735. [PMID: 37886207 PMCID: PMC10598309 DOI: 10.21037/hbsn-22-471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/10/2023] [Indexed: 10/28/2023]
Abstract
Background The finding of pancreatic cystic lesions (PCL) on incidental imaging is becoming increasingly common. International studies report a prevalence of 2.2-44.7% depending on the population, imaging modality and indication for imaging, and the prevalence increases with age. Patients with PCL are at risk of developing pancreatic cancer, a disease with a poor prognosis. This publication summarizes recommendations for the diagnosis and management of PCL and post-operative pancreatic exocrine insufficiency (PEI) from a group of local specialists. Methods Clinical evidence was consolidated from narrative reviews and consensus statements formulated during two online meetings in March 2022. The expert panel included gastroenterologists, hepatobiliary surgeons, oncologists, radiologists, and endocrinologists. Results Patients with PCL require careful investigation and follow-up due to the risk of malignant transformation of these lesions. They should undergo clinical investigation and pancreas-specific imaging to classify lesions and understand the risk profile of the patient. Where indicated, patients should undergo pancreatectomy to excise PCL. Following pancreatectomy, patients are at risk of PEI, leading to gastrointestinal dysfunction and malnutrition. Therefore, such patients should be monitored for symptoms of PEI, and promptly treated with pancreatic enzyme replacement therapy (PERT). Patients with poor response to PERT may require increases in dose, addition of a proton pump inhibitor, and/or further investigation, including tests for pancreatic function. Patients are also at risk of new-onset diabetes mellitus after pancreatectomy; they should be screened and treated with insulin if indicated. Conclusions These statements are an accurate summary of our approach to the diagnosis and management of patients with PCL and will be of assistance to clinicians treating these patients in a similar clinical landscape.
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Affiliation(s)
- Tan-To Cheung
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Yuk Tong Lee
- Gastroenterologist in private practice, Hong Kong, China
| | - Raymond Shing-Yan Tang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Wong Hoi She
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Kai Chi Cheng
- Department of Surgery, Kwong Wah Hospital, Hong Kong, China
| | | | - Keith Wan Hang Chiu
- Department of Radiology & Imaging, Queen Elizabeth Hospital, Hong Kong, China
| | - Kenneth Siu Ho Chok
- Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Wing Sun Chow
- Department of Medicine, The University of Hong Kong, Hong Kong, China
| | - Tak Wing Lai
- Department of Surgery, Princess Margaret Hospital, Hong Kong, China
| | - Wai-Kay Seto
- Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong, China
- State Key Laboratory of Liver Research, The University of Hong Kong, Hong Kong, China
| | - Thomas Yau
- Department of Medicine, The University of Hong Kong, Hong Kong, China
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2
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Cattelani A, Perri G, Marchegiani G, Salvia R, Crinò SF. Risk Models for Pancreatic Cyst Diagnosis. Gastrointest Endosc Clin N Am 2023; 33:641-654. [PMID: 37245940 DOI: 10.1016/j.giec.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The overall prevalence of pancreatic cysts (PCs) is high in the general population. In clinical practice PCs are often incidentally discovered and are classified into benign, premalignant, and malignant lesions according to the World Health Organization. For this reason, in the absence of reliable biomarkers, to date clinical decision-making relies mostly on risk models based on morphological features. The aim of this narrative review is to present the current knowledge regarding PC's morphologic features with related estimated risk of malignancy and discuss available diagnostic tools to minimize clinically relevant diagnostic errors.
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Affiliation(s)
- Alice Cattelani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, G.B. Rossi University Hospital, Verona, Italy.
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3
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Balaban DV, Coman L, Balaban M, Zoican A, Pușcașu DA, Ayatollahi S, Mihălțeanu E, Costache RS, Ioniță-Radu F, Jinga M. Glycemic Abnormalities in Pancreatic Cystic Lesions—A Single-Center Retrospective Analysis. GASTROENTEROLOGY INSIGHTS 2023; 14:191-203. [DOI: doi.org/10.3390/gastroent14020015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
Abstract
Background and Objectives: Glucose metabolism alterations are very common in solid pancreatic lesions, particularly in pancreatic cancer. Similarly, diabetes and especially new-onset diabetes (NOD) have been associated with the malignant transformation of pancreatic cysts. We aimed to assess the prevalence and relevant associations of glycemic abnormalities in pancreatic cystic lesions (PCLs) in a retrospective analysis. Materials and Methods: We retrospectively recruited all patients who underwent endoscopic ultrasound for a PCL over a period of 36 months (January 2018 to December 2021). Final diagnosis was set by means of tissue acquisition, surgery, follow-up, or board decision. Demographic and clinical data, laboratory workup, and imaging features were extracted from the patients’ charts according to a predefined protocol. We considered fasting blood glucose (FBG) and HbA1c values and stratified the patients as nondiabetic (FBG ≤ 99 mg/dL, HbA1c ≤ 5.6%, no history of glycemic abnormalities), prediabetic (FBG 100–125 mg/dL, HbA1c 5.7–6.4%), or diabetic (long-lasting diabetes or NOD). Results: Altogether, 81 patients were included, with a median age of 66 years, and 54.3% of them were male. The overall prevalence of fasting hyperglycemia was 54.3%, comprising 34.6% prediabetes and 22.2% diabetes, of which 16.7% had NOD. The mean FBG and HbA1c levels were higher in malignant and premalignant PCLs (intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), cystadenocarcinoma, and cystic neuroendocrine tumor) compared to the benign lesions (pseudocysts, walled-off necrosis, and serous cystadenoma): 117.0 mg/dL vs. 108.3 mg/dL and 6.1% vs. 5.5%, respectively. Conclusions: Hyperglycemia and diabetes are common in PCLs, with a high prevalence in premalignant and malignant cysts. Screening and follow-up for glycemic abnormalities should be routinely conducted for PCLs, as they can contribute to a tailored risk assessment of cysts.
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Affiliation(s)
- Daniel Vasile Balaban
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Laura Coman
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Marina Balaban
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Andreea Zoican
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Danusia Adriana Pușcașu
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Simin Ayatollahi
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Emanuela Mihălțeanu
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Raluca Simona Costache
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Florentina Ioniță-Radu
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Mariana Jinga
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
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4
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Flammia F, Innocenti T, Galluzzo A, Danti G, Chiti G, Grazzini G, Bettarini S, Tortoli P, Busoni S, Dragoni G, Gottin M, Galli A, Miele V. Branch duct-intraductal papillary mucinous neoplasms (BD-IPMNs): an MRI-based radiomic model to determine the malignant degeneration potential. LA RADIOLOGIA MEDICA 2023; 128:383-392. [PMID: 36826452 DOI: 10.1007/s11547-023-01609-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 02/05/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Branch duct-intraductal papillary mucinous neoplasms (BD-IPMNs) are the most common pancreatic cystic tumors and have a low risk of malignant transformation. Features able to early identify high-risk BD-IPMNs are lacking, and guidelines currently rely on the occurrence of worrisome features (WF) and high-risk stigmata (HRS). AIM In our study, we aimed to use a magnetic resonance imaging (MRI) radiomic model to identify features linked to a higher risk of malignant degeneration, and whether these appear before the occurrence of WF and HRS. METHODS We retrospectively evaluated adult patients with a known BD-IPMN who had had at least two contrast-enhanced MRI studies at our center and a 24-month minimum follow-up time. MRI acquisition protocol for the two examinations included pre- and post-contrast phases and diffusion-weighted imaging (DWI)/apparent diffusion coefficient (ADC) map. Patients were divided into two groups according to the development of WF or HRS at the end of the follow-up (Group 0 = no WF or HRS; Group 1 = WF or HRS). We segmented the MRI images and quantitative features were extracted and compared between the two groups. Features that showed significant differences (SF) were then included in a LASSO regression method to build a radiomic-based predictive model. RESULTS We included 50 patients: 31 in Group 0 and 19 in Group 1. No patients in this cohort developed HRS. At baseline, 47, 67, 38, and 68 SF were identified for pre-contrast T1-weighted (T1-W) sequence, post-contrast T1-W sequence, T2-weighted (T2- W) sequence, and ADC map, respectively. At the end of follow-up, we found 69, 78, 53, and 91 SF, respectively. The radiomic-based predictive model identified 16 SF: more particularly, 5 SF for pre-contrast T1-W sequence, 6 for post-contrast T1-W sequence, 3 for T2-W sequence, and 2 for ADC. CONCLUSION We identified radiomic features that correlate significantly with WF in patients with BD-IPMNs undergoing contrast-enhanced MRI. Our MRI-based radiomic model can predict the occurrence of WF.
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Affiliation(s)
- Federica Flammia
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Tommaso Innocenti
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale G.B. Morgagni 50, 50134, Florence, Italy.,Clinical Gastroenterology Unit, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Antonio Galluzzo
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Ginevra Danti
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy.
| | - Giuditta Chiti
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Giulia Grazzini
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Silvia Bettarini
- Department of Health Physics, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Paolo Tortoli
- Department of Health Physics, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Simone Busoni
- Department of Health Physics, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Gabriele Dragoni
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale G.B. Morgagni 50, 50134, Florence, Italy.,Clinical Gastroenterology Unit, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Matteo Gottin
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale G.B. Morgagni 50, 50134, Florence, Italy.,Clinical Gastroenterology Unit, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Andrea Galli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale G.B. Morgagni 50, 50134, Florence, Italy.,Clinical Gastroenterology Unit, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
| | - Vittorio Miele
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
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5
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Lang M, Spektor AM, Hielscher T, Hoppner J, Glatting FM, Bicu F, Hackert T, Heger U, Pausch T, Gutjahr E, Rathke H, Giesel FL, Kratochwil C, Tjaden C, Haberkorn U, Röhrich M. Static and Dynamic 68Ga-FAPI PET/CT for the Detection of Malignant Transformation of Intraductal Papillary Mucinous Neoplasia of the Pancreas. J Nucl Med 2023; 64:244-251. [PMID: 35906094 PMCID: PMC9902850 DOI: 10.2967/jnumed.122.264361] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/16/2022] [Accepted: 07/16/2022] [Indexed: 02/04/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) may arise from intraductal papillary mucinous neoplasms (IPMN) with malignant transformation, but a significant portion of IPMN remains to show benign behavior. Therefore, it is important to differentiate between benign IPMN and IPMN lesions undergoing malignant transformation. However, nonoperative differentiation by ultrasound, CT, MRI, and carbohydrate antigen 19-9 (CA19-9) is still unsatisfactory. Here, we assessed the clinical feasibility of additional assessment of malignancy by PET using 68Ga-labeled fibroblast activation protein inhibitors (68Ga-FAPI PET) in 25 patients with MRI- or CT-proven cystic pancreatic lesions. Methods: Twenty-five patients with cystic pancreatic lesions who were followed up in the European Pancreas Center of Heidelberg University hospital and who were led to surgical resection or fine-needle aspiration due to suspicious clinical, laboratory chemistry, or radiologic findings were examined by static (all patients) and dynamic (20 patients) 68Ga-FAPI PET. Cystic pancreatic lesions were delineated and SUVmax and SUVmean were determined. Time-activity curves and dynamic parameters (time to peak, K 1, k 2, K3, k 4) were extracted from dynamic PET data. Receiver-operating curves of static and dynamic PET parameters were calculated. Results: Eleven of the patients had menacing IPMN (high-grade IPMN with [6 cases] or without [5 cases] progression into PDAC) and 11 low-grade IPMN; 3 patients had other benign entities. Menacing IMPN showed significantly elevated 68Ga-FAPI uptake compared with low-grade IPMN and other benign cystic lesions. In dynamic imaging, menacing IPMN showed increasing time-activity curves followed by slow decrease afterward; time-activity curves of low-grade IPMN showed an immediate peak followed by rapid decrease for about 10 min and slower decrease for the rest of the time. Receiver-operating curves showed high sensitivity and specificity (area under the curve greater than 80%) of static and dynamic PET parameters for the differentiation of IPMN subtypes. Conclusion: 68Ga-FAPI PET is a helpful new tool for the differentiation of menacing and low-grade IPMN and shows the potential to avoid unnecessary surgery for nonmalignant pancreatic IPMN.
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Affiliation(s)
- Matthias Lang
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Anna-Maria Spektor
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Hielscher
- Department of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - Jorge Hoppner
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Frederik M. Glatting
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany;,Clinical Cooperation Unit Molecular and Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany;,Department of Radiation Oncology, University Hospital Heidelberg, Heidelberg, Germany
| | - Felix Bicu
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ulrike Heger
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Pausch
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ewgenija Gutjahr
- Department of Pathology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hendrik Rathke
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany;,Department of Nuclear Medicine, The Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Frederik L. Giesel
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany;,Department of Nuclear Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Clemens Kratochwil
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Christine Tjaden
- Department of General, Visceral, and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Uwe Haberkorn
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany;,Translational Lung Research Center Heidelberg (TLRC), Member of the German Center for Lung Research DZL, Heidelberg, Germany; and,Clinical Cooperation Unit Nuclear Medicine, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Manuel Röhrich
- Department of Nuclear Medicine, University Hospital Heidelberg, Heidelberg, Germany;
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6
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Peisl S, Burckhardt O, Egger B. Limitations and prospects in the management of IPMN: a retrospective, single-center observational study. BMC Surg 2023; 23:3. [PMID: 36611137 PMCID: PMC9824987 DOI: 10.1186/s12893-023-01902-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND With increasing use and enhanced accuracy of cross-sectional imaging, the diagnosis of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas has increased over the last few decades. The extent to which malignant transformation occurs remains unclear, making the management of IPMNs controversial. The aim of this study was to evaluate the progression rate and outcome of follow-up in patients with IPMNs. METHODS A database of all patients diagnosed with IPMN at the Cantonal Hospital HFR Fribourg, Switzerland, between January 2006 and December 2019 with a follow-up of at least 6 months was analyzed retrospectively. Descriptive statistics were performed on patient demographics, IPMN characteristics, and follow-up data. RESULTS A total of 56 patients were included in this study. Ten patients underwent primary surgery, 46 were enrolled in a surveillance program.21.7% (n = 5) of patients under surveillance presented with worrisome features of IPMN; progression rates were significantly higher in these patients (p = 0.043). Most progression occurred in the early follow-up period. Five patients underwent surgery due to progression, of which 2 presented high-grade dysplasia and 2 malignancy on postoperative histology. CONCLUSIONS The limited predictive value of current guidelines may lead to surgical overtreatment, and the decision to proceed with surgical resection should be made with caution. Further prospective analyses and the development of novel biomarkers are needed to better understand the natural history of IPMN and improve diagnostic precision.
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Affiliation(s)
- Sarah Peisl
- grid.413366.50000 0004 0511 7283Department of Surgery, HFR Fribourg-Cantonal Hospital, Chemin des Pensionnats 2-6, 1708 Fribourg, Switzerland
| | - Oliver Burckhardt
- grid.413366.50000 0004 0511 7283Department of Surgery, HFR Fribourg-Cantonal Hospital, Chemin des Pensionnats 2-6, 1708 Fribourg, Switzerland
| | - Bernhard Egger
- grid.413366.50000 0004 0511 7283Department of Surgery, HFR Fribourg-Cantonal Hospital, Chemin des Pensionnats 2-6, 1708 Fribourg, Switzerland
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7
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Nakhaei M, Bligh M, Chernyak V, Bezuidenhout AF, Brook A, Brook OR. Incidence of pancreatic cancer during long-term follow-up in patients with incidental pancreatic cysts smaller than 2 cm. Eur Radiol 2022; 32:3369-3376. [PMID: 35013764 DOI: 10.1007/s00330-021-08428-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/07/2021] [Accepted: 10/21/2021] [Indexed: 11/04/2022]
Abstract
PURPOSE To assess the long-term malignancy risk of incidental small pancreatic cysts. MATERIALS AND METHODS In this HIPAA-compliant, IRB-approved, retrospective, multi-institutional study, the long-term incidence of pancreatic cancer was compared between patients with and without small pancreatic cysts. Patients with incidental pancreatic cysts ≥ 0.5 and < 2.0 cm in maximal diameter, detected on MRI performed between 1999 and 2011, represented the "small pancreatic cyst" group. Patients that underwent MRI between 2005 and 2011 and had no reported pancreatic cysts represented the comparison "no cyst" group. RESULTS The "small pancreatic cyst" group included 267 patients, ages 63.4 ± 11.8 years, 166/267 (62%) women with a mean follow-up of 8.6 ± 4.3 years, median 9.2 years; the "no cyst" group included 1,459 patients, ages 64.6 ± 12 years, 794/1,459 (54%) women with a mean follow-up of 7.0 ± 4.2 years, median 7.8 (p values 0.12, 0.02, < 0.001, respectively). Two/267 (0.7%) patients developed pancreatic cancer at a separate location from the known cyst in the "small pancreatic cyst" group, with a cancer rate of 0.9 (95% CI 0.1-3.1) cases per 1,000 patient-years. In the "no cyst" cohort, 18/1,459 (1.2%) patients developed pancreatic cancer, with a cancer rate of 1.8 (95% CI 1.2-3.1) cases per 1,000 patient-years (p = 0.6). The all-cause mortality was similar in both groups: 57/267 (21%) vs. 384/1,459 (26%) (p = 0.09). CONCLUSION The long-term risk of pancreatic malignancy in asymptomatic patients with incidental pancreatic cysts less than 2 cm is 0.9 cases per 1,000 patient-years of follow-up, similar to those without pancreatic cysts. These very few pancreatic cancers developed at a separate location from the known cyst. KEY POINTS • After a median of 9.2 years of follow-up, the risk of pancreatic malignancy in patients with an asymptomatic small pancreatic cyst was 0.9 cases per 1,000 patient-years of follow-up, similar to those without pancreatic cysts. • Very few pancreatic cancer cases developed in the location separate from the known pancreatic cyst.
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Affiliation(s)
- Masoud Nakhaei
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Mathew Bligh
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Victoria Chernyak
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
- Department of Radiology, Montefiore, Bronx, NY, USA
| | | | - Alexander Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
| | - Olga R Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA.
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8
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Yoon SJ, Kim H, Lee O, Jung JH, Lim CS, Shin YC, Kwon W, Jang JY, Shin SH, Heo JS, Han IW. Development and external validation of a nomogram with inflammatory markers for predicting invasiveness of intraductal papillary mucinous neoplasm of pancreas. Medicine (Baltimore) 2022; 101:e29036. [PMID: 35356913 PMCID: PMC10684245 DOI: 10.1097/md.0000000000029036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 02/19/2022] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Recent studies have reported that inflammatory markers, such as neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and advanced lung cancer inflammation index, are associated with invasiveness of intraductal papillary mucinous neoplasm (IPMN). This study aimed to develop and validate a new nomogram that includes inflammatory markers for predicting the invasiveness of IPMN.The data of 365 patients who underwent surgical resection for IPMN at 4 centers between 1995 and 2016 were retrospectively reviewed to develop a new nomogram. For external validation, a separate patient cohort was used. The predictive ability of the nomogram was evaluated using the area under the receiver operating characteristic curve.The new nomogram was developed using the following variables which were identified as risk factors for invasive IPMN: body mass index, preoperative serum bilirubin level, carbohydrate antigen 19-9, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, advanced lung cancer inflammation index, main duct type, presence of solid portion, and tumor size. After external validation, the area under the curve value was 0.649 (95% CI: 0.578-0.720, P < .001).To the best of our knowledge, this study is the first to predict and externally validate the invasiveness in IPMN using inflammatory markers. Further research is necessary to improve predictability of the model for selecting patients for surgical resection.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - In Woong Han
- Correspondence: In Woong Han, Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School ofMedicine, 81, Irwon-ro, Gangnam-gu, Seoul 06351, South Korea (e-mail: ).
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9
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Zhao W, Liu S, Cong L, Zhao Y. Imaging Features for Predicting High-Grade Dysplasia or Malignancy in Branch Duct Type Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Systematic Review and Meta-Analysis. Ann Surg Oncol 2021; 29:1297-1312. [PMID: 34554343 DOI: 10.1245/s10434-021-10662-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 08/05/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The consensus guidelines for branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) of the pancreas are mostly based on imaging features. This study aimed to determine imaging features and their diagnostic accuracy for predicting high-grade dysplasia (HGD)/malignancy in BD-IPMN, including mixed type. METHODS The PubMed, Embase, and Cochrane databases were searched, and data were extracted from relevant studies. As the main diagnostic accuracy index, diagnostic odds ratios (DORs) of imaging features for diagnosing HGD/malignancy in BD-IPMNs were pooled using the random-effects model. A bivariate random-effects approach was used to construct summary receiver operating characteristic curves for sensitivity and specificity estimation. RESULTS The pooled DOR was the highest for the enhanced solid component/mural nodule (MN) (DOR, 12.21; 95 % confidence interval [CI], 6.14-24.27), followed by a main pancreatic duct (MPD) diameter of 10 mm or greater (DOR, 7.93; 95 % CI, 3.02-20.83), solid component (DOR, 4.85; 95 % CI, 2.49-9.42), lymphadenopathy (DOR, 4.84; 95 % CI, 1.11-21.06), MN (DOR, 4.48; 95 % CI, 3.15-6.39), an MPD diameter of 5 mm or greater (DOR, 3.69; 95 % CI, 2.62-5.19), abrupt change in MPD caliber with distal pancreatic atrophy (DOR, 2.65; 95 % CI, 1.66-4.24), thickened/enhancing walls (DOR, 2.38; 95 % CI, 1.57-3.60), and cyst size of 3 cm or larger (DOR, 1.98; 95 % CI, 1.48-2.64). The largest area under the curve (0.89 and 0.95, respectively) and high specificity (0.95 and 0.98, respectively) also were found for enhanced solid component/MN and an MPD diameter of 10 mm or greater, albeit with low sensitivity (0.38 and 0.14, respectively). CONCLUSIONS The aforementioned imaging features could aid in predicting HGD/malignancy of BD-IPMN. Furthermore, enhanced solid component/MN and an MPD diameter of 10 mm or greater were the most important predictors of HGD/malignancy in BD-IPMN and should be considered as indications for surgery.
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Affiliation(s)
- Wenjing Zhao
- Central Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, China
| | - Shanglong Liu
- Department of General Surgery, Affiliated Hospital of Qingdao University, Shandong, China
| | - Lin Cong
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
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10
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Clinical Utility and Limitation of Diagnostic Ability for Different Degrees of Dysplasia of Intraductal Papillary Mucinous Neoplasms of the Pancreas Using 18F-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography. Cancers (Basel) 2021; 13:cancers13184633. [PMID: 34572860 PMCID: PMC8465733 DOI: 10.3390/cancers13184633] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/31/2021] [Accepted: 09/14/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Elucidating risk factors for different degrees of dysplasia of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas is important in determining strategies for management. In this study, we searched for risk factors for different degrees of dysplasia of IPMNs. Our study indicated that there were no useful factors that significantly differentiated low-grade dysplasia and high-grade dysplasia; however, 18F-fluorodeoxyglucose–positron emission tomography/computed tomography is useful for differentiating between non-invasive and invasive IPMNs. Our results offer critical information that may determine surgical treatment strategies. Abstract The diagnostic value of 18F-fluorodeoxyglucose (FDG) uptake in the management of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas remains unclear. This study aimed to assess the role of FDG uptake in the diagnosis of different degrees of dysplasia of IPMNs. We retrospectively analyzed the following three points in 84 patients with IPMNs: (1) risk factors to predict high-grade dysplasia (HGD) and invasive carcinoma (INV); (2) the relationship between FDG uptake and glucose transporter 1 (GLUT-1) expression; and (3) the relationship between FDG uptake and the presence of mural nodules. The histopathological diagnosis was low-grade dysplasia (LGD) in 43 patients, HGD in 16, and INV in 25. The maximum standardized uptake value (SUV-max) was significantly higher in INV than in LGD/HGD (p < 0.0001, p = 0.0136). The sensitivity and specificity to discriminate INV from LGD/HGD were 80.0% and 86.2%, respectively, using the receiver operator characteristic curve, when the optimal cutoff score of SUV-max was set at 4.03. Those values were not different between HGD and LGD. More than half of HGD patients had low GLUT-1 expression. Taken together, FDG-PET/CT is useful in distinguishing between non-invasive and invasive IPMN. Our results offer critical information that may determine surgical treatment strategies.
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11
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Pan S, Brand RE, Lai LA, Dawson DW, Donahue TR, Kim S, Khalaf NI, Othman MO, Fisher WE, Bronner MP, Simeone DM, Brentnall TA, Chen R. Proteome heterogeneity and malignancy detection in pancreatic cyst fluids. Clin Transl Med 2021; 11:e506. [PMID: 34459141 PMCID: PMC8382978 DOI: 10.1002/ctm2.506] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/08/2021] [Accepted: 07/12/2021] [Indexed: 01/12/2023] Open
Affiliation(s)
- Sheng Pan
- The Brown Foundation Institute of Molecular MedicineUniversity of Texas Health Science Center at HoustonHoustonTexasUSA,Department of Integrative Biology and PharmacologyMcGovern Medical SchoolUniversity of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Randall E. Brand
- Department of MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Lisa A. Lai
- Division of GastroenterologyDepartment of Medicinethe University of WashingtonSeattleWashingtonUSA
| | - David W. Dawson
- Department of Pathology and Laboratory MedicineDavid Geffen School of Medicine, UCLALos AngelesCaliforniaUSA,Jonsson Comprehensive Cancer CenterDavid Geffen School of Medicine, UCLALos AngelesCaliforniaUSA
| | - Timothy R. Donahue
- Jonsson Comprehensive Cancer CenterDavid Geffen School of Medicine, UCLALos AngelesCaliforniaUSA,Department of SurgeryDavid Geffen School of Medicine, UCLALos AngelesCaliforniaUSA
| | - Stephen Kim
- Division of Digestive DiseasesDavid Geffen School of Medicine, UCLALos AngelesCaliforniaUSA
| | - Natalia I. Khalaf
- Section of Gastroenterology and HepatologyDepartment of MedicineBaylor College of MedicineHoustonTexasUSA
| | - Mohamed O. Othman
- Section of Gastroenterology and HepatologyDepartment of MedicineBaylor College of MedicineHoustonTexasUSA
| | | | - Mary P. Bronner
- Department of PathologyUniversity of UtahSalt Lake CityUtahUSA
| | - Diane M. Simeone
- Department of SurgeryNew York UniversityNew YorkNew YorkUSA,Perlmutter Cancer CenterNew York UniversityNew YorkNew YorkUSA
| | - Teresa A. Brentnall
- Division of GastroenterologyDepartment of Medicinethe University of WashingtonSeattleWashingtonUSA
| | - Ru Chen
- Section of Gastroenterology and HepatologyDepartment of MedicineBaylor College of MedicineHoustonTexasUSA
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12
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Djordjevic V, Grubor N, Kovac JD, Micev M, Milic N, Knezevic D, Gregoric P, Lausevic Z, Kerkez M, Knezevic S, Radenkovic D. Comparison of Preoperative Evaluation with the Pathological Report in Intraductal Papillary Mucinous Neoplasms: A Single-Center Experience. J Clin Med 2021; 10:678. [PMID: 33578680 PMCID: PMC7916322 DOI: 10.3390/jcm10040678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/05/2021] [Accepted: 02/07/2021] [Indexed: 12/17/2022] Open
Abstract
The key to the successful management of pancreatic cystic neoplasm (PCN), among which intraductal papillary mucinous neoplasm (IPMN) is the one with the highest risk of advanced neoplasia in resected patients, is a careful combination of clinical, radiological, and histopathological findings. This study aims to perform the comparison of a preoperative evaluation with pathological reports in IPMN and further, to evaluate and compare the diagnostic performance of European evidence-based guidelines on pancreatic cystic neoplasms (EEBGPCN) and Fukuoka Consensus guidelines (FCG). We analyzed 106 consecutive patients diagnosed with different types of PCN, among whom 68 had IPMN diagnosis, at the Clinical Center of Serbia. All the patients diagnosed with IPMNs were stratified concerning the presence of the absolute and relative indications according to EEBGPCN and high-risk stigmata and worrisome features according to FCG. Final histopathology revealed that IPMNs patients were further divided into malignant (50 patients) and benign (18 patients) groups, according to the pathological findings. The preoperative prediction of malignancy according to EEBGPCN criteria was higher than 70% with high sensitivity of at least one absolute or relative indication for resection. The diagnostic performance of FCG was shown as comparable to EEBGPCN. Nevertheless, the value of false-positive rate for surgical resection showed that in some cases, overtreating patients or treating them too early cannot be prevented. A multidisciplinary approach is essential to adequately select patients for the resection considering at the same time both the risks of surgery and malignancy.
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Affiliation(s)
- Vladimir Djordjevic
- Clinic for Digestive Surgery, First Surgical Clinic, Clinical Centre of Serbia, 11000 Belgrade, Serbia; (N.G.); (D.K.); (M.K.); (S.K.); (D.R.)
| | - Nikica Grubor
- Clinic for Digestive Surgery, First Surgical Clinic, Clinical Centre of Serbia, 11000 Belgrade, Serbia; (N.G.); (D.K.); (M.K.); (S.K.); (D.R.)
- Department for Surgery, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (P.G.); (Z.L.)
| | - Jelena Djokic Kovac
- Centre for Radiology and Magnetic Resonance Imaging, Clinical Centre of Serbia, 11000 Belgrade, Serbia;
- Department for Radiology, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Marjan Micev
- Department of Histopathology, Clinical Centre of Serbia, 11000 Belgrade, Serbia;
| | - Natasa Milic
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; or
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, NY 55905, USA
| | - Djordje Knezevic
- Clinic for Digestive Surgery, First Surgical Clinic, Clinical Centre of Serbia, 11000 Belgrade, Serbia; (N.G.); (D.K.); (M.K.); (S.K.); (D.R.)
- Department for Surgery, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (P.G.); (Z.L.)
| | - Pavle Gregoric
- Department for Surgery, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (P.G.); (Z.L.)
- Centre for Emergency Surgery, Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Zeljko Lausevic
- Department for Surgery, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (P.G.); (Z.L.)
- Centre for Emergency Surgery, Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Mirko Kerkez
- Clinic for Digestive Surgery, First Surgical Clinic, Clinical Centre of Serbia, 11000 Belgrade, Serbia; (N.G.); (D.K.); (M.K.); (S.K.); (D.R.)
- Department for Surgery, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (P.G.); (Z.L.)
| | - Srbislav Knezevic
- Clinic for Digestive Surgery, First Surgical Clinic, Clinical Centre of Serbia, 11000 Belgrade, Serbia; (N.G.); (D.K.); (M.K.); (S.K.); (D.R.)
- Department for Surgery, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (P.G.); (Z.L.)
| | - Dejan Radenkovic
- Clinic for Digestive Surgery, First Surgical Clinic, Clinical Centre of Serbia, 11000 Belgrade, Serbia; (N.G.); (D.K.); (M.K.); (S.K.); (D.R.)
- Department for Surgery, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (P.G.); (Z.L.)
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13
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Giuffrida P, Biagiola D, Ardiles V, Uad P, Palavecino M, de Santibañes M, Clariá RS, Pekolj J, de Santibañes E, Mazza O. Long-term follow-up of Branch-Duct Intraductal Papillary Mucinous Neoplasms with negative Sendai Criteria: the therapeutic challenge of patients who convert to positive Sendai Criteria. HPB (Oxford) 2021; 23:290-300. [PMID: 32709558 DOI: 10.1016/j.hpb.2020.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 04/15/2020] [Accepted: 06/19/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The management of Branch-Duct Intraductal Papillary Mucinous Neoplasm (BD-IPMN) is still controversial. Our objective was to assess the long-term follow-up (FU) of patients with "low-risk" BD-IPMN according to the Sendai-International Consensus Guidelines (ICG-I). METHODS We retrospectively analyzed a cohort of patients with BD-IPMN and Negative Sendai-Criteria (NSC) from January 2004 to October 2019. A univariate analysis was performed to determine factors associated with conversion to Positive Sendai-Criteria (PSC) and malignancy. Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of the IGC-I were assessed for the development of malignancy. RESULTS A total of 219 patients were selected and underwent a median 58-month FU. Thirty-seven (17%) patients developed PSC during FU including 12 (5.5%) with malignant lesions. Conversely, 182 patients (83%) did not develop malignancy. The NPV and PPV of ICG-I for malignancy were 100% and 32.4%, respectively. Among patients who developed PSC, those with cancer were >65years (OR = 3.57;p = 0.015) and had significantly higher serum CA-19-9 levels (OR = 5.27;p = 0.007). CONCLUSION The ICG-I is a safe strategy for FU of patients with BD-IPMN. The absence of PSC exclude malignancy. Among patients who develops PSC, the risk of cancer remains low and surgery should be decided according to their surgical risk and life expectancy.
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Affiliation(s)
- Pablo Giuffrida
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - David Biagiola
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Victoria Ardiles
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Pedro Uad
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Martin Palavecino
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Martín de Santibañes
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Rodrigo S Clariá
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Juan Pekolj
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Oscar Mazza
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina.
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14
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Sharib J, Esserman L, Koay EJ, Maitra A, Shen Y, Kirkwood KS, Ozanne EM. Cost-effectiveness of consensus guideline based management of pancreatic cysts: The sensitivity and specificity required for guidelines to be cost-effective. Surgery 2020; 168:601-609. [PMID: 32739138 PMCID: PMC8754171 DOI: 10.1016/j.surg.2020.04.052] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/25/2020] [Accepted: 04/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Detection of cystic lesions of the pancreas has outpaced our ability to stratify low-grade cystic lesions from those at greater risk for pancreatic cancer, raising a concern for overtreatment. METHODS We developed a Markov decision model to determine the cost-effectiveness of guideline-based management for asymptomatic pancreatic cysts. Incremental costs per quality-adjusted life year gained and survival were calculated for current management guidelines. A sensitivity analysis estimated the effect on cost-effectiveness and mortality if overtreatment of low-grade cysts is avoided, and the sensitivity and specificity thresholds required of methods of cyst stratification to improve costs expended. RESULTS "Surveillance" using current management guidelines had an incremental cost-effectiveness ratio of $171,143/quality adjusted life year compared with no surveillance or operative treatment ("do nothing"). An incremental cost-effectiveness ratio for surveillance decreases to $80,707/quality adjusted life year if the operative overtreatment of low-grade cysts was avoided. Assuming a societal willingness-to-pay of $100,000/quality adjusted life year, the diagnostic specificity for high-risk cysts must be >67% for surveillance to be preferred over surgery and "do nothing." Changes in sensitivity alone cannot make surveillance cost-effective. Most importantly, survival in surveillance is worse than "do nothing" for 3 years after cyst diagnosis, although long-term survival is improved. The disadvantage is eliminated when overtreatment of low-grade cysts is avoided. CONCLUSION Current management of pancreatic cystic lesions is not cost-effective and may increase mortality owing to overtreatment of low-grade cysts. The specificity for risk stratification for high-risk cysts must be greater than 67% to make surveillance cost-effective.
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Affiliation(s)
- Jeremy Sharib
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA
| | - Laura Esserman
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA
| | - Eugene J Koay
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anirban Maitra
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yu Shen
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kimberly S Kirkwood
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA.
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
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15
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Predictive Features of Malignancy in Branch Duct Type Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Meta-Analysis. Cancers (Basel) 2020; 12:cancers12092618. [PMID: 32937809 PMCID: PMC7563991 DOI: 10.3390/cancers12092618] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/07/2020] [Accepted: 09/11/2020] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Currently, there are several guidelines that are widely used to establish the treatment strategy for branch duct type intraductal papillary mucinous neoplasms. Although there are some common grounds, there are discrepancies on which features they adopt, how much each feature is weighted, and how the features are combined. Furthermore, some of the features are based on lower level evidences or expert opinions. The aim of this meta-analysis was to investigate important clinical, radiological, and biochemical risk factors for malignancy and their impact as predictors. This study found symptom, size, cyst wall thickening, presence of mural nodule, change in main pancreatic duct caliber, lymphadenopathy, CA 19-9, and CEA as risk factors. Lymphadenopathy (odd ratio [OR]: 8.55), abrupt caliber change (OR: 7.41), and mural nodule (OR: 4.10) had the highest odd ratios. We expect the higher level evidences of this study to help shape better guidelines and reduce discrepancies among future guidelines. Abstract The current guidelines on branch duct type intraductal papillary mucinous neoplasm (BD-IPMN) recommend various predictive features of malignancy as well as different treatment strategies. This study aimed to identify the risk factors for malignancy with higher level of evidence. A meta-analysis was performed on 40 literatures published between 2000 and 2019. These literatures included 6301 patients with pathologically proven IPMN. Malignancy was defined as high-grade dysplasia and invasive carcinoma. It was significantly associated with symptoms (odds ratio [OR] 1.35, confidence interval [CI] 1.01–1.79), size ≥ 3 cm (OR 1.90, CI 1.51–2.40), cystic wall thickening (OR 2.53, CI 1.50–4.27), mural nodule (OR 4.10, CI 3.38–4.97), main pancreatic duct dilatation (OR 2.98, CI 2.11–4.21), abrupt caliber change of the pancreatic duct (OR 7.41, CI 2.49–22.06), lymphadenopathy (OR 8.55, CI 3.25–22.51), elevated carbohydrate antigen 19-9 (OR 4.01, CI 2.55–6.28), and elevated carcinoembryonic antigen (OR 2.04, CI 1.60–2.61). Multilocular cysts and multiple cysts did not show a significant association with malignancy. This study examined the clinical, radiological, and biochemical features of BD-IPMN, often used as malignancy predictors according to the widely used guidelines. The results confirmed that all the features currently being used are valid.
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16
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Diabetes mellitus in intraductal papillary mucinous neoplasms: A systematic review and meta-analysis. Surgery 2020; 169:411-418. [PMID: 32838986 DOI: 10.1016/j.surg.2020.07.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/07/2020] [Accepted: 07/03/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Our current knowledge of diabetes mellitus in intraductal papillary mucinous neoplasm is very limited and its prevalence and predictive value for malignant transformation are not clear. This study sought to systematically review the literature to define the prevalence of diabetes mellitus in intraductal papillary mucinous neoplasm and to evaluate the association of diabetes mellitus with the progression to high-grade dysplasia or invasive cancer. METHODS A PubMed/Medline systematic search was performed to identify studies reporting data on preoperative diabetes mellitus in intraductal papillary mucinous neoplasm. Articles meeting the predefined inclusion criteria were analyzed and a meta-analysis was performed. The study was preregistered (PROSPERO ID: CRD42020153581). RESULTS From the initially detected 827 studies, 27 studies including resected patients with histologically confirmed intraductal papillary mucinous neoplasm were included. The global prevalence of preoperative diabetes mellitus was 25% (1,112 of 4,412); whereas new-onset/worsening diabetes mellitus was reported in 6% of patients (68 of 1,202). The meta-analysis revealed that patients with pre-existing diabetes mellitus had an increased risk of harboring a main pancreatic duct involvement (risk ratio 1.43, 95% confidence interval: 1.21-1.69, P < .001), high-grade dysplasia (risk ratio 1.27, 95% confidence interval: 1.01-1.59, P = .04), and invasive cancer (risk ratio 1.61, 95% confidence interval: 1.33-1.95, P < .001). CONCLUSION The prevalence of diabetes mellitus in intraductal papillary mucinous neoplasm is high, and diabetic patients demonstrate an increased risk of a more aggressive disease. Therefore, diabetes mellitus should be increasingly considered in the stratification of patients with intraductal papillary mucinous neoplasm. Further investigations to determine the mechanisms behind the association with progression should be carried out.
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Abstract
OBJECTIVE To create a simple, objective model to predict the presence of malignancy in patients with intraductal papillary mucinous neoplasm (IPMN), which can be easily applied in daily practice and, importantly, adopted for any lesion types. BACKGROUND No predictive model for malignant IPMN has been widely applied in clinical practice. METHODS The clinical details of 466 patients with IPMN who underwent pancreatic resection at 3 hospitals were retrospectively analyzed for model development. Then, the model was validated in 664 surgically resected patients at 8 hospitals in Japan.In the preoperative examination, endoscopic ultrasonography (EUS) was considered to be essential to observe mural nodules in both the model development and external validation sets. Malignant IPMNs were defined as those with high-grade dysplasia and associated invasive carcinoma. RESULTS Of the 466 patients, 258 (55%) had malignant IPMNs (158 high-grade dysplasia, 100 invasive carcinoma), and 208 (45%) had benign IPMNs. Logistic regression analysis resulted in 3 variables (mural nodule size, main pancreatic duct diameter, and cyst size) being selected to construct the model. The area under the receiver operating characteristic curve (AUC) for the model was 0.763. In external validation sets, the pathological diagnosis was malignant and benign IPMN in 351 (53%) and 313 (47%) cases, respectively. For the external validation, the malignancy prediction ability of the model corresponded to an AUC of 0.725. CONCLUSION This predictive model provides important information for physicians and patients in assessing an individual's risk for malignancy and may help to identify patients who need surgery.
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Izumo W, Higuchi R, Furukawa T, Yazawa T, Uemura S, Shiihara M, Yamamoto M. Importance of each high-risk stigmata and worrisome features as a predictor of high-grade dysplasia in intraductal papillary mucinous neoplasms of the pancreas. Pancreatology 2020; 20:895-901. [PMID: 32624417 DOI: 10.1016/j.pan.2020.06.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/15/2020] [Accepted: 06/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND High-risk stigmata (HRS) and 'worrisome features' (WFs) are defined as predictive factors for malignancies of intraductal papillary mucinous neoplasms (IPMNs). We performed this study to determine the importance and odds ratio (OR) of each HRS and WFs as predictors for high-grade dysplasia (HGD). METHODS We analyzed 295 patients who underwent pancreatectomy for branch duct and mixed-type IPMN, and evaluated the association between HRS and WFs (as defined by the '2017 Fukuoka Consensus Guidelines') and HGD. RESULTS The proportions of patients with low-grade dysplasia (LGD), HGD, and invasive carcinoma were 47%, 28%, and 25%, respectively. Multivariate analysis comparing patients with LGD and HGD using all HRS and WFs revealed that an enhancing mural nodule ≥5 mm (OR: 4.1), pancreatitis (OR: 2.2), and thickened/enhancing cyst walls (OR: 2.2) were independent predictive factors for HGD. Based on the OR (the former factor is two points and the latter two factors are each one point), the incidence of HGD in patients with none (n = 43), one (n = 82), two (n = 25), three (n = 52), and four (n = 19) of these predictive factors were 9%, 26%, 52%, 62%, and 63%, respectively. Assuming a score of one or higher as a surgical indication, the sensitivity, specificity, positive predict value, and negative predict value of HGD were 95, 38, 44, and 91%. CONCLUSIONS Our derived scoring system using more important factors in HRS and WFs may be useful for predicting HGD and determining surgical indications of IPMN.
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Affiliation(s)
- Wataru Izumo
- Department of Surgery, Institute of Gastroenterology, Tokyo Woman's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Woman's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Toru Furukawa
- Department of Investigative Pathology, Tohoku University Graduate School of Medicine, 2-1 Seiryomachi, Aoba-ku, Sendai, 980-8575, Japan
| | - Takehisa Yazawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Woman's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shuichiro Uemura
- Department of Surgery, Institute of Gastroenterology, Tokyo Woman's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Masahiro Shiihara
- Department of Surgery, Institute of Gastroenterology, Tokyo Woman's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Woman's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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Brunner M, Belyaev O, Bösch F, Müller-Debus CF, Radulova-Mauersberger O, Wellner UF, Keck T, Uhl W, Werner J, Witzigmann H, Grützmann R. [Indications for the Surgical Management of Pancreatic Cystic Lesions]. Zentralbl Chir 2020; 145:344-353. [PMID: 32498095 DOI: 10.1055/a-1158-9536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
A steady improvement in modern imaging as well as increasing age in society have led to an increasing number of cystic pancreatic tumours being detected. Pancreatic cysts are a clinically challenging entity because they span a broad biological spectrum and their differentiation is often difficult, especially in small tumours. Therefore, they require a differentiated indication for indication of surgery. To determine recommendations for the surgical indication in cystic tumours of the pancreas, a quality committee for pancreatic diseases of the German Society for General and Visceral Surgery performed a systematic literature search and created this review. Based on the current evidence, signs of malignancy and high-risk criteria (icterus due to cystic pancreatic duct obstruction in the bile duct, enhancing mural nodules ≥ 5 mm or solid components in the cyst or pancreatic duct ≥ 10 mm), as well as symptoms, are a surgical indication, independently of the cyst entity (except pseudocysts). If the entity of the pancreatic cyst is detectable by diagnostic imaging, all main duct IPMN and IPMN of the mixed type, all MCN > 4 cm and all SPN should be resected. SCN and branch-duct IPMN without worrisome features do not constitute an indication for surgery. The indication of operation in branch-duct IPMN with relative risk criteria and MCN < 4 cm is the subject of current discussions and should be individualised. By defining indication recommendations, the present work aims to improve the indication quality in cystic pancreatic tumours. However, the surgical indication should always be individualised, taking into account age, comorbidities and the patient's wishes.
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Affiliation(s)
- Maximilian Brunner
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Deutschland
| | - Orlin Belyaev
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum St. Josef-Hospital Bochum, Deutschland
| | - Florian Bösch
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, LMU, Klinikum der Universität München, Deutschland
| | | | | | | | - Tobias Keck
- Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Deutschland
| | - Waldemar Uhl
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum St. Josef-Hospital Bochum, Deutschland
| | - Jens Werner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, LMU, Klinikum der Universität München, Deutschland
| | - Helmut Witzigmann
- Klinik für Allgemein- und Viszeralchirurgie, Städtisches Klinikum Dresden-Friedrichstadt, Deutschland
| | - Robert Grützmann
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Deutschland
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20
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Hwang JA, Choi SY, Lee JE, Kim SS, Lee S, Moon JY, Heo NH. Pre-operative nomogram predicting malignant potential in the patients with intraductal papillary mucinous neoplasm of the pancreas: focused on imaging features based on revised international guideline. Eur Radiol 2020; 30:3711-3722. [DOI: 10.1007/s00330-020-06736-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 02/04/2020] [Accepted: 02/10/2020] [Indexed: 12/14/2022]
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21
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Hirono S, Yamaue H. Surgical strategy for intraductal papillary mucinous neoplasms of the pancreas. Surg Today 2020; 50:50-55. [PMID: 31807871 PMCID: PMC6923258 DOI: 10.1007/s00595-019-01931-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 10/08/2019] [Indexed: 12/17/2022]
Abstract
The current treatment strategy for intraductal papillary mucinous neoplasms (IPMNs), based on the international consensus guideline, has been accepted widely. However, reported outcomes after surgical resection for IPMN show that once the tumor progresses to invasive intraductal papillary mucinous carcinoma (IPMC), recurrence is not uncommon. The surgical treatment for IPMN is invasive and sometimes followed by complications. Therefore, the best timing for resection might be at the point when high-grade dysplasia (HGD) is evident. According to previous reports, main duct type IPMN has a high malignant potential and its surgical resection is universally accepted, whereas, the incidence of HGD/invasive IPMC in branch duct and mixed type IPMNs is thought to be lower. In addition to mural nodules and a dilated main pancreatic duct, cytology and measurement of the carcinoembryonic antigen level in the pancreatic juice might be useful to differentiate HGD/invasive IPMC from low-grade dysplasia. The nomogram proposed recently to predict the risk of HGD/invasive IPMC in IPMN patients might help surgeons decide on the best treatment strategy, depending on the patient's age and general condition. Second resection for high-risk lesions in the remnant pancreas might improve the survival of IPMN patients.
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Affiliation(s)
- Seiko Hirono
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan.
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
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22
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Lara LF, Luthra A, Conwell DL, Krishna SG. Pancreatic Cysts in the Elderly. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:457-469. [PMID: 31707690 DOI: 10.1007/s11938-019-00260-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Incidental pancreatic cysts are common, and management strategies continue to evolve. This review summarizes diagnostic and management recommendations in older patients with these lesions based on guidelines and best clinical evidence. RECENT FINDINGS Diagnosis of cyst type has been enhanced with improved imaging and cyst fluid analysis and visualization. Recent outcome studies indicate that certain cyst types should be followed independent of patient age as long as certain criteria which are reviewed are met. Differentiation of pancreatic cyst type is important as this dictates the need for long-term follow-up. Because most cyst-related neoplasia occurs in older patients, surveillance should continue within certain guidelines.
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Affiliation(s)
- Luis F Lara
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA.
| | - Anjuli Luthra
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA
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23
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Wu J, Wang Y, Li Z, Miao H. Accuracy of Fukuoka and American Gastroenterological Association Guidelines for Predicting Advanced Neoplasia in Pancreatic Cyst Neoplasm: A Meta-Analysis. Ann Surg Oncol 2019; 26:4522-4536. [PMID: 31617119 DOI: 10.1245/s10434-019-07921-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND A differential diagnosis of advanced pancreatic cystic neoplasms (PCNs) is critical to determine optimal treatment. The Fukuoka and American Gastroenterological Association (AGA) guidelines are the most widely accepted criteria for the management of PCNs. OBJECTIVE This study aimed to evaluate the diagnostic value of these guidelines in predicting advanced neoplasia (AN). METHODS A comprehensive electronic search of the PubMed, EMBASE, Web of Science, Cochrane Library, and Scopus databases was conducted to identify all relevant studies evaluating the Fukuoka and AGA guidelines in surgically resected and histologically confirmed PCNs. Pooled sensitivity, specificity, and diagnostic odds ratios (DORs) were calculated as compound measures of diagnostic accuracy using the random-effects model. Summary of receiver operating characteristic (SROC) curves and the area under the curve (AUC) were also performed. RESULTS A total of 21 studies with 3723 patients were included in this meta-analysis. Of these studies, 15, 4, and 2 evaluated the Fukuoka guidelines, the AGA guidelines, and both guidelines, respectively. For AN prediction, the Fukuoka guidelines had a pooled sensitivity of 0.67 (95% confidence interval [CI] 0.64-0.70), pooled specificity of 0.64 (95% CI 0.62-0.66), and pooled DOR of 6.28 (95% CI 4.38-9.01), with an AUC of the SROC of 0.78. AGA guidelines showed a pooled sensitivity of 0.59 (95% CI 0.52-0.65), pooled specificity of 0.77 (95% CI 0.74-0.80), and pooled DOR of 5.84 (95% CI 2.60-13.15), with an AUC of 0.79 (95% CI 0.70-0.88). CONCLUSION When used alone, the Fukuoka and AGA guidelines showed similar but unsatisfactory diagnostic accuracy in the risk stratification of malignant potential of PCN. Thus, we recommend that they be applied only as a broad framework in clinical practice.
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Affiliation(s)
- Jiayuan Wu
- Department of Clinical Research, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, People's Republic of China.
| | - Yufeng Wang
- School of Public Health, Guangdong Medical University, Zhanjiang, People's Republic of China
| | - Zitao Li
- Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang, People's Republic of China
| | - Huilai Miao
- Department of Clinical Research, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, People's Republic of China. .,Department of Hepatobiliary Surgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang, People's Republic of China.
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24
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Sun L, Wang Y, Jiang F, Qian W, Shao C, Jin Z. Prevalence of pancreatic cystic lesions detected by magnetic resonance imaging in the Chinese population. J Gastroenterol Hepatol 2019; 34:1656-1662. [PMID: 30883900 DOI: 10.1111/jgh.14658] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/08/2019] [Accepted: 03/10/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM Incidental pancreatic cystic lesions (PCLs) are being diagnosed more frequently. However, little is known about the prevalence of PCLs in the Chinese population. The aim of the study was to assess the crude prevalence of PCLs in individuals who underwent magnetic resonance imaging (MRI). METHODS Data from consecutive patients who underwent MRI without pancreatic indications were included. MRI images were reviewed for the presence of pancreatic cysts. The prevalence of PCLs and high-risk PCLs in different gender and age groups was calculated. To assess the crude prevalence, the prevalence and demographic data were standardized on the basis of Chinese national population data in 2017. RESULTS A total of 10 987 individuals were included (7344 men). Incidental PCLs were identified in 212 individual (128 men). The prevalence of PCLs was 1.93%, and PCLs were more often discovered in women (1.74% vs 2.31%, P = 0.043). Prevalence increased with age (r = 0.804, P < 0.001). The prevalence of high-risk PCLs was 0.12% (n = 13). Gender predominance and age distribution showed no difference between high-risk PCLs and low-risk PCLs (P = 0.234 and P = 0.855), but cysts located in the pancreatic head were more likely to develop into high-risk PCLs (P = 0.001). After data standardization, the crude prevalence of PCLs was 1.31%, and PCLs were more often discovered in women (1.11% vs 1.5%, P < 0.001). The crude prevalence of high-risk PCLs was 0.07%. CONCLUSION Pancreatic cystic lesions in the Chinese population are not rare. The prevalence of PCLs increased with age and is higher in the female population. The prevalence of high-risk PCLs should not be ignored.
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Affiliation(s)
- Liqi Sun
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yang Wang
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Fei Jiang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Wei Qian
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Chengwei Shao
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhendong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
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Abstract
Intraductal papillary mucinous neoplasm (IPMN) is the most common pancreatic cystic neoplasm (PCN). The increased attention to IPMN is due to its unique features of malignant progression, being different between main duct IPMN and branch duct IPMN, and increased de novo development of conventional pancreatic ductal adenocarcinoma elsewhere in the pancreas. The increased interest in IPMN led to publication of many guidelines on its clinical management. This chapter aims to summarize and compare characteristics of nine guidelines on the clinical management of IPMN and other PCNs published in the English literature and further to show a current strategy for surgical decision making in the management of IPMN.
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Affiliation(s)
- Masao Tanaka
- Shimonoseki City Hospital, Kyushu University, Shimonoseki, Yamaguchi, Japan.
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26
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Cortegoso Valdivia P, Chialà C, Venezia L, Gaiani F, Leandro G, Di Mario F, De' Angelis GL. Diagnosis and management of intraductal papillary mucinous neoplasms of the pancreas. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:147-152. [PMID: 30561408 PMCID: PMC6502192 DOI: 10.23750/abm.v89i9-s.7958] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Indexed: 12/16/2022]
Abstract
Background and aim of the work: Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are cystic lesions with malignant potential. Given their increasing incidence in the latest years, a precise characterization and management of these lesions have become more and more crucial: even though the majority of IPMN has a benign and indolent course, it is fundamental to early recognize and stratify patients in order to accurately plan a tailored follow-up and to individuate those that would benefit of surgical treatment. The aim of this paper is to highlight the most recent evidence on IPMN available in the current literature. Methods: We performed a review of the recent literature and of the recent guidelines about pancreatic cystic lesions, especially IPMN. Results: The incidence of IPMN is now on the rise: an increasing number of patients, possibly because of the increasing diagnostic yield of imaging techniques, is being diagnosed with pancreatic cystic lesions, a great part of which are IPMN. The possibility of malignant transformation requires a careful approach to these patients, in the need of tailoring the follow-up and the therapy. Conclusion: A detailed diagnosis, the determination of risk factors for malignant transformation and a multisciplinary approach are of foremost importance for an effective management of IPMN. (www.actabiomedica.it)
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27
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Sharib JM, Fonseca AL, Swords DS, Jaradeh K, Bracci PM, Firpo MA, Hatcher S, Scaife CL, Wang H, Kim GE, Mulvihill SJ, Maitra A, Koay EJ, Kirkwood KS. Surgical overtreatment of pancreatic intraductal papillary mucinous neoplasms: Do the 2017 International Consensus Guidelines improve clinical decision making? Surgery 2018; 164:1178-1184. [DOI: 10.1016/j.surg.2018.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/24/2018] [Accepted: 07/10/2018] [Indexed: 12/17/2022]
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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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29
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Watanabe Y, Niina Y, Nishihara K, Okayama T, Tamiya S, Nakano T. Neutrophil-to-lymphocyte ratio and mural nodule height as predictive factors for malignant intraductal papillary mucinous neoplasms. Acta Chir Belg 2018; 118:239-245. [PMID: 29334845 DOI: 10.1080/00015458.2018.1427329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Accurate preoperative prediction for malignant IPMN is still challenging. The aim of this study was to investigate the validity of neutrophil-to-lymphocyte ratio (NLR) and mural nodule height (MNH) for predicting malignant intraductal papillary mucinous neoplasm (IPMN). METHODS The medical records of 60 patients who underwent pancreatectomy for IPMN were retrospectively reviewed. RESULTS NLR tended to be higher in malignant IPMN (median: 2.23) than in benign IPMN (median: 2.04; p = .14). MNH was significantly greater in malignant IPMN (median: 16 mm) than in benign IPMN (median: 8 mm; p < .01). The optimal cutoff values for the NLR and MNH were 3.60 and 11 mm, respectively. The sensitivity and specificity of NLR ≥3.60 for predicting malignant IPMN were 40% and 93%, and those of MNH ≥11 mm were 73% and 77%, respectively. Univariate analysis revealed that NLR ≥3.60 (p < .01) and MNH ≥11 mm (p < .01) were significant predictive factors. On multivariate analysis, enhanced solid component was identified as an independent factor, but NLR ≥3.60 and MNH ≥11 mm were not. CONCLUSIONS NLR and MNH are suboptimal tests in predicting malignant IPMN; however, they can be useful to assist in clinical decision-making.
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Affiliation(s)
- Yusuke Watanabe
- Departments of Surgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Yusuke Niina
- Department of Gastroenterology, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Kazuyoshi Nishihara
- Departments of Surgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Takafumi Okayama
- Departments of Surgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Sadafumi Tamiya
- Department of Pathology, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Toru Nakano
- Departments of Surgery, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
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30
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Takakura K, Torisu Y, Kinoshita Y, Tomita Y, Nakano M, Oikawa T, Tsukinaga S, Sumiyama K, Eibl G, Saruta M. An Appraisal of Current Guidelines for Managing Malignancy in Pancreatic Intraductal Papillary Mucinous Neoplasm. JOP : JOURNAL OF THE PANCREAS 2018; 19:178-182. [PMID: 30636939 PMCID: PMC6327957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Pancreatic intraductal papillary mucinous neoplasm was originally regarded as a benign mucinous cystic tumor but certainly has a marked malignant potential. With the array of high-resolution imaging modalities that are now available, more frequent incidental asymptomatic intraductal papillary mucinous neoplasm patients can be diagnosed. Until now, our clinicians have been managing intraductal papillary mucinous neoplasm patients by referring to the international consensus guidelines which have been revised twice or American Gastroenterological Association guidelines. The aim of this review is to reassess the current guidelines for the management of malignancy in intraductal papillary mucinous neoplasm. Furthermore, we specifically discuss the problems to be solved for establishing more refined guideline for the early detection, risk stratification and better management of pancreatic cancer in intraductal papillary mucinous neoplasm patients.
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Affiliation(s)
- Kazuki Takakura
- Division of Gastroenterology and Hepatology, Department of Internal Medicine
| | - Yuichi Torisu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine
| | - Yuji Kinoshita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine
| | - Yoichi Tomita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine
| | - Masanori Nakano
- Division of Gastroenterology and Hepatology, Department of Internal Medicine
| | - Tsunekazu Oikawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine
| | - Shintaro Tsukinaga
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Kazuki Sumiyama
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
| | - Guido Eibl
- Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, USA
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine
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31
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Srinivasan N, Teo JY, Chin YK, Hennedige T, Tan DM, Low AS, Thng CH, Goh BKP. Systematic review of the clinical utility and validity of the Sendai and Fukuoka Consensus Guidelines for the management of intraductal papillary mucinous neoplasms of the pancreas. HPB (Oxford) 2018; 20:497-504. [PMID: 29486917 DOI: 10.1016/j.hpb.2018.01.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 12/16/2017] [Accepted: 01/03/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND This systematic review was performed to assess the clinical utility of the Sendai Consensus Guidelines (SCG) and Fukuoka Consensus Guidelines (FCG) for intraductal papillary mucinous neoplasm (IPMN). METHODS A computerized search of PubMed was performed to identify all the studies which evaluated the SCG and FCG in surgically resected, histologically confirmed IPMNs. RESULTS Ten studies evaluating the FCG, 8 evaluating the SCG and 4 evaluating both guidelines were included. In 14 studies evaluating the FCG, out of a total of 2498 neoplasms, 849 were malignant and 1649 were benign neoplasms. Pooled analysis showed that 751 of 1801 (42%) FCG+ve neoplasms were malignant and 599 neoplasms of 697 (86%) FCG-ve neoplasms were benign. PPV of the high risk and worrisome risk groups were 465/986 (47%) and 239/520 (46%) respectively. In 12 studies evaluating the SCG, 1234 neoplasms were analyzed of which 388 (31%) were malignant and 846 (69%) were benign. Pooled analysis demonstrated that 265 of 802 (33%) SCG+ve neoplasms were malignant and 238 of 266 SCG-ve (90%) neoplasms were benign. CONCLUSION The FCG had a higher positive predictive value (PPV) compared to the SCG. However, the negative predictive value (NPV) of the FCG was slightly lower than that of the SCG. Malignant and even invasive IPMN may be missed according to both guidelines.
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Affiliation(s)
- Nandhini Srinivasan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jin-Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Yung-Ka Chin
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Tiffany Hennedige
- Department of Oncologic Imaging, National Cancer Center Singapore, Singapore; Duke-NUS Medical School Singapore, Singapore
| | - Damien M Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Albert S Low
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | - Choon Hua Thng
- Department of Oncologic Imaging, National Cancer Center Singapore, Singapore; Duke-NUS Medical School Singapore, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke-NUS Medical School Singapore, Singapore.
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32
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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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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: 369] [Impact Index Per Article: 61.5] [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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Hoshi H, Zaheer A, El Abiad RG, Maxwell JE, Chu LC, Gerke H, Chan CH. Management of pancreatic intraductal papillary mucinous neoplasm. Curr Probl Surg 2018; 55:126-152. [DOI: 10.1067/j.cpsurg.2018.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/11/2018] [Indexed: 12/16/2022]
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Marchegiani G, Andrianello S, Borin A, Dal Borgo C, Perri G, Pollini T, Romanò G, D'Onofrio M, Gabbrielli A, Scarpa A, Malleo G, Bassi C, Salvia R. Systematic review, meta-analysis, and a high-volume center experience supporting the new role of mural nodules proposed by the updated 2017 international guidelines on IPMN of the pancreas. Surgery 2018; 163:1272-1279. [PMID: 29454468 DOI: 10.1016/j.surg.2018.01.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 12/19/2017] [Accepted: 01/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Mural nodules (MNs) have a predominant role in the 2016 revision of the international guidelines on intraductal papillary mucinous neoplasms (IPMN) of the pancreas. The aim of this study was to evaluate MNs as predictors of invasive cancer (iCa) or high-grade dysplasia (HGD) in IPMNs and to investigate the role of MN size in risk prediction. METHODS A PRISMA-compliant systematic review of the literature and meta-analysis on selected studies were conducted. The random effect model was adopted, and the pooled SMD (standardized mean difference) obtained. The surgical series of IPMNs at a single high-volume institution was reviewed. RESULTS This review included 70 studies and 2297 resected IPMNs. MNs have a positive predictive value for malignancy of 62.2%. The meta-analysis suggested that MN size has a considerable effect on predicting IPMNs with both iCa or HGD with a mean SMD of 0.79. All studies included in the meta-analysis used contrast-enhanced endosonography (CE-EUS) to assess MNs. Due to the heterogeneity of the proposed thresholds, no reliable MN size cut-off was identified. Of 317 IPMNs resected at our institution, 102 (32.1%) had a preoperative diagnosis of MN. Multivariate analysis showed that MN is the only independent predictor of iCa and HGD for all types of IPMNs. CONCLUSION MNs are reliable predictors of iCa and HGD in IPMNs as proposed by the 2016 IAP guidelines. CE-EUS seems to be the best tool for characterizing size and has the best accuracy for predicting malignancy. Further studies should determine potential MN dimensional cut-offs.
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Affiliation(s)
- Giovanni Marchegiani
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefano Andrianello
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alex Borin
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Chiara Dal Borgo
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giampaolo Perri
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Tommaso Pollini
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giorgia Romanò
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Mirko D'Onofrio
- Radiology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Armando Gabbrielli
- Gastroenterology and Digestive Endoscopy, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Aldo Scarpa
- Pathology, ARCNet Research Center, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
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Neutrophil-to-lymphocyte Ratio is a Predictive Marker for Invasive Malignancy in Intraductal Papillary Mucinous Neoplasms of the Pancreas. Ann Surg 2017; 266:339-345. [PMID: 27631774 DOI: 10.1097/sla.0000000000001988] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the correlation between neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) values, and the presence of invasive carcinoma in patients with intraductal papillary mucinous neoplasm (IPMN). BACKGROUND NLR and (PLR) are inflammatory markers that have been associated with overall survival in patients with invasive malignancies, including pancreatic cancer. METHODS We retrospectively reviewed 272 patients who underwent surgical resection for histologically confirmed IPMN from January 1997 to July 2015. NLR and PLR were calculated and coevaluated with additional demographic, clinical, and imaging data for possible correlation with IPMN-associated carcinoma in the form of a predictive nomogram. RESULTS NLR and PLR were significantly elevated in patients with IPMN-associated invasive carcinoma (P < 0.001). In the multivariate analysis, NLR value higher than 4 (P < 0.001), IPMN cyst of size more than 3 cm (P < 0.001), presence of enhanced solid component (P = 0.014), main pancreatic duct dilatation of more than 5 mm (P < 0.001), and jaundice (P < 0.001) were statistically significant variables. The developed statistical model has a c-index of 0.895. Implementation of the statistically significant variables in a predictive nomogram provided a reliable point system for estimating the presence of IPMN-associated invasive carcinoma. CONCLUSIONS NLR is an independent predictive marker for the presence of IPMN-associated invasive carcinoma. Further prospective studies are needed to assess the predictive ability of NLR and how it can be applied in the clinical setting.
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Tanaka M, Fernández-Del Castillo C, Kamisawa T, Jang JY, Levy P, Ohtsuka T, Salvia R, Shimizu Y, Tada M, Wolfgang CL. Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology 2017; 17:738-753. [PMID: 28735806 DOI: 10.1016/j.pan.2017.07.007] [Citation(s) in RCA: 1022] [Impact Index Per Article: 146.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 07/12/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023]
Abstract
The management of intraductal papillary mucinous neoplasm (IPMN) continues to evolve. In particular, the indications for resection of branch duct IPMN have changed from early resection to more deliberate observation as proposed by the international consensus guidelines of 2006 and 2012. Another guideline proposed by the American Gastroenterological Association in 2015 restricted indications for surgery more stringently and recommended physicians to stop surveillance if no significant change had occurred in a pancreatic cyst after five years of surveillance, or if a patient underwent resection and a non-malignant IPMN was found. Whether or not it is safe to do so, as well as the method and interval of surveillance, has generated substantial debate. Based on a consensus symposium held during the meeting of the International Association of Pancreatology in Sendai, Japan, in 2016, the working group has revised the guidelines regarding prediction of invasive carcinoma and high-grade dysplasia, surveillance, and postoperative follow-up of IPMN. As the working group did not recognize the need for major revisions of the guidelines, we made only minor revisions and added most recent articles where appropriate. The present guidelines include updated information and recommendations based on our current understanding, and highlight issues that remain controversial or where further research is required.
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Affiliation(s)
- Masao Tanaka
- Department of Surgery, Shimonoseki City Hospital, Shimonoseki, Japan.
| | | | - Terumi Kamisawa
- Department of Gastroenterology, Komagome Metropolitan Hospital, Tokyo, Japan
| | - Jin Young Jang
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Philippe Levy
- Pôle des Maladies de l'Appareil Digestif, Service de Gastroentérologie-Pancréatologie, Hopital Beaujon, Clichy Cedex, France
| | - Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Yasuhiro Shimizu
- Dept. of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Christopher L Wolfgang
- Cameron Division of Surgical Oncology and The Sol Goldman Pancreatic Cancer Research Center, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
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Abstract
Pancreatic cysts, especially incidental asymptomatic ones seen on noninvasive imaging such as CT or MR imaging, remain a clinical challenge. The etiology of such cysts may range from benign cysts without any malignant potential such as pancreatic pseudocysts and serous cystadenomas to premalignant or frankly malignant cysts such as mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, cystic degeneration associated with solid tumors such as pancreatic ductal adenocarcinoma or pancreatic endocrine neoplasms, and solid pseudopapillary neoplasms. The clinical challenge in 2017 is to accurately preoperatively diagnose them and their malignant potential before deciding about surgery, surveillance or doing nothing. This review will focus on the currently available clinical guidelines for doing so.
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Affiliation(s)
- James J Farrell
- Yale Center for Pancreatic Diseases, Interventional Endoscopy, Yale School of Medicine, New Haven, CT, USA. .,Section of Digestive Diseases, Yale University School of Medicine, LMP 1080, 15 York Street, New Haven, CT, 06510-3221, USA.
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Crippa S, Bassi C, Salvia R, Malleo G, Marchegiani G, Rebours V, Levy P, Partelli S, Suleiman SL, Banks PA, Ahmed N, Chari ST, Fernández-Del Castillo C, Falconi M. Low progression of intraductal papillary mucinous neoplasms with worrisome features and high-risk stigmata undergoing non-operative management: a mid-term follow-up analysis. Gut 2017; 66:495-506. [PMID: 26743012 DOI: 10.1136/gutjnl-2015-310162] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 11/15/2015] [Accepted: 11/16/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate mid-term outcomes and predictors of survival in non-operated patients with pancreatic intraductal papillary mucinous neoplasms (IPMNs) with worrisome features or high-risk stigmata as defined by International Consensus Guidelines for IPMN. Reasons for non-surgical options were physicians' recommendation, patient personal choice or comorbidities precluding surgery. METHODS In this retrospective, multicentre analysis, IPMNs were classified as branch duct (BD) and main duct (MD), the latter including mixed IPMNs. Univariate and multivariate analysis for overall survival (OS) and disease-specific survival (DSS) were obtained. RESULTS Of 281 patients identified, 159 (57%) had BD-IPMNs and 122 (43%) had MD-IPMNs; 50 (18%) had high-risk stigmata and 231 (82%) had worrisome features. Median follow-up was 51 months. The 5-year OS and DSS for the entire cohort were 81% and 89.9%. An invasive pancreatic malignancy developed in 34 patients (12%); 31 had invasive IPMNs (11%) and 3 had IPMN-distinct pancreatic ductal adenocarcinoma (1%). Independent predictors of poor DSS in the entire cohort were age >70 years, atypical/malignant cyst fluid cytology, jaundice and MD >15 mm. Compared with MD-IPMNs, BD-IPMNs had significantly better 5-year OS (86% vs 74.1%, p=0.002) and DSS (97% vs 81.2%, p<0.0001). Patients with worrisome features had better 5-year DSS compared with those with high-risk stigmata (96.2% vs 60.2%, p<0.0001). CONCLUSIONS In elderly patients with IPMNs that have worrisome features, the 5-year DSS is 96%, suggesting that conservative management is appropriate. By contrast, presence of high-risk stigmata is associated with a 40% risk of IPMN-related death, reinforcing that surgical resection should be offered to fit patients.
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Affiliation(s)
- Stefano Crippa
- Division of Pancreatic Surgery, Università Politecnica delle Marche, Ancona, Italy.,Division of Pancreatic Surgery, Università Vita-Salute, San Raffaele Scientific Institute, Milan, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.,Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vinciane Rebours
- Service de Gastroenterologie-Pancreatologie, Hopital Beaujon, APHP, Université Paris Diderot, DHU UNITY, Clichy, France
| | - Philippe Levy
- Service de Gastroenterologie-Pancreatologie, Hopital Beaujon, APHP, Université Paris Diderot, DHU UNITY, Clichy, France
| | - Stefano Partelli
- Division of Pancreatic Surgery, Università Politecnica delle Marche, Ancona, Italy.,Division of Pancreatic Surgery, Università Vita-Salute, San Raffaele Scientific Institute, Milan, Italy
| | - Shadeah L Suleiman
- Center for Pancreatic Disease, Brigham and Woman's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter A Banks
- Center for Pancreatic Disease, Brigham and Woman's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nazir Ahmed
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Massimo Falconi
- Division of Pancreatic Surgery, Università Politecnica delle Marche, Ancona, Italy.,Division of Pancreatic Surgery, Università Vita-Salute, San Raffaele Scientific Institute, Milan, Italy
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Evaluation of the 2015 AGA guidelines on pancreatic cystic neoplasms in a large surgically confirmed multicenter cohort. Endosc Int Open 2017; 5:E201-E208. [PMID: 28317015 PMCID: PMC5352566 DOI: 10.1055/s-0042-122010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and study aims The American Gastroenterological Association (AGA) recently published guidelines for the management of asymptomatic pancreatic cystic neoplasms (PCNs). We aimed to evaluate the diagnostic characteristics of the AGA guidelines in appropriately recommending surgery for malignant PCNs. Patients and methods A retrospective multicenter study was performed of patients who underwent endoscopic ultrasound (EUS) for evaluation of PCNs who ultimately underwent surgical resection from 2004 - 2014. Demographics, EUS characteristics, fine-needle aspiration (FNA) results, type of resection, and final pathologic diagnosis were recorded. Patients were categorized into 2 groups (surgery or surveillance) based on what the AGA guidelines would have recommended. Performance characteristics for the diagnosis of cancer or high-grade dysplasia (HGD) on surgical pathology were calculated. Results Three hundred patients underwent surgical resection for PCNs, of whom the AGA guidelines would have recommended surgery in 121 (40.3 %) and surveillance in 179 (59.7 %) patients. Among patients recommended for surgery, 45 (37.2 %) had cancer, whereas 76 (62.8 %) had no cancer/HGD. Among patients recommended for surveillance, 170 (95.0 %) had no cancer/HGD; however, 9 (5.0 %) patients had cancer that would have been missed. For the finding of cancer/HGD on surgical pathology, the AGA guidelines had 83.3 % sensitivity (95 % CI 70.7 - 92.1), 69.1 % specificity (95 % CI 62.9 - 74.8), 37.2 % positive predictive value (95 % CI 28.6 - 46.4), 95.0 % negative predictive value (95 % CI 90.7 - 97.7), and 71.7 % accuracy (95 % CI 67.4 - 74.6). Conclusions The 2015 AGA guidelines would have resulted in 60 % fewer patients being referred for surgical resection, and accurately recommended surveillance in 95 % of patients with asymptomatic PCNs. Future prospective studies are required to validate these guidelines. Meeting presentations: Presented in part at Digestive Diseases Week 2016.
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A Different Viewpoint on the Size Criterion for Surgical Resection of Branch-Duct Intraductal Papillary Mucinous Neoplasm. Pancreas 2017; 46:e1-e2. [PMID: 27977629 DOI: 10.1097/mpa.0000000000000746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Sharib J, Kirkwood K. Early and accurate diagnosis of pancreatic cancer? Oncotarget 2016; 7:85676-85677. [PMID: 27829239 PMCID: PMC5349864 DOI: 10.18632/oncotarget.13142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 11/03/2016] [Indexed: 11/29/2022] Open
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Risk Factors for Malignancy of Branch-Duct Intraductal Papillary Mucinous Neoplasms: A Critical Evaluation of the Fukuoka Guidelines With a Systematic Review and Meta-analysis. Pancreas 2016; 45:1243-1254. [PMID: 27776043 DOI: 10.1097/mpa.0000000000000642] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES This study aimed to evaluate the accuracy of the risk factors proposed by Fukuoka guidelines in detecting malignancy of branch-duct intraductal papillary mucinous neoplasms. METHOD Diagnostic meta-analysis of cohort studies. A systematic literature search was conducted using MEDLINE, the Cochrane Library, Scopus, and the ISI-Web of Science databases to identify all studies published up to 2014. RESULTS Twenty-five studies (2025 patients) were suitable for the meta-analysis. The "high risk stigmata" showed the highest pooled diagnostic odds ratio (jaundice, 6.3; positive citology, 5.5; mural nodules, 4.8) together with 2 "worrisome features" (thickened/enhancing walls, 4.2; duct dilatation, 4.0) and 1 "other parameters" (carbohydrate antigen 19-9 serum levels, 4.6). CONCLUSIONS An "ideal risk factor" capable of recognizing all malignant branch-duct intraductal papillary mucinous neoplasms was not identified and some "dismal areas" remain. However, "high risk stigmata" were strongly related to malignancy, mainly enhancing mural nodules. Among the "worrisome features," duct dilatation and thickened/enhancing walls were underestimated, and their diagnostic performance was similar to those of "high risk stigmata." The carbohydrate antigen 19-9 serum level should be added to the Fukuoka algorithm because this value could help in carrying out correct management.
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Hsiao CY, Yang CY, Wu JM, Kuo TC, Tien YW. Utility of the 2006 Sendai and 2012 Fukuoka guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas: A single-center experience with 138 surgically treated patients. Medicine (Baltimore) 2016; 95:e4922. [PMID: 27661043 PMCID: PMC5044913 DOI: 10.1097/md.0000000000004922] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This study aimed to evaluate the utility of the 2006 Sendai and 2012 Fukuoka guidelines for differentiating malignant intraductal papillary mucinous neoplasm (IPMN) of the pancreas from benign IPMN.Between January 2000 and March 2015, a total of 138 patients underwent surgery and had a pathologically confirmed pancreatic IPMN. Clinicopathological parameters were reviewed, and all patients were classified according to both the 2006 Sendai and 2012 Fukuoka guidelines. Univariate and multivariate analyses were used for identifying significant factors associated with malignancy in IPMN.There were 9 high-grade dysplasia (HGD) and 37 invasive cancers (ICs) in the 138 patients. The positive predictive value (PPV) and negative predictive value (NPV) of the Sendai and Fukuoka guidelines for HGD/IC was 35.1%, 43.3%, 100%, and 85.4%, respectively. Of the 36 patients with worrisome features using the Fukuoka guideline, 7 patients had HGD/IC in their IPMNs. According to the multivariate analysis, jaundice, tumors of ≥3 cm, presence of mural nodule on imaging, and aged <65 years were associated with HGD/IC in patients with IPMN.The Sendai guideline had a better NPV, but the Fukuoka guideline had a better PPV. We suggest that patients with worrisome features based on the Fukuoka guideline be aggressively managed.
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Affiliation(s)
| | | | | | | | - Yu-Wen Tien
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan, ROC
- Correspondence: Yu-Wen Tien, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Rd, Taipei 10002, Taiwan, ROC (e-mail: )
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45
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Ridtitid W, DeWitt JM, Schmidt CM, Roch A, Stuart JS, Sherman S, Al-Haddad MA. Management of branch-duct intraductal papillary mucinous neoplasms: a large single-center study to assess predictors of malignancy and long-term outcomes. Gastrointest Endosc 2016; 84:436-45. [PMID: 26905937 DOI: 10.1016/j.gie.2016.02.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 02/02/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Management of branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) remains challenging. We determined factors associated with malignancy in BD-IPMNs and long-term outcomes. METHODS This retrospective cohort study included all patients with established BD-IPMNs by the International Consensus Guidelines (ICG) 2012 and/or pathologically confirmed BD-IPMNs in a tertiary care referral center between 2001 and 2013. Main outcome measures were the association between high-risk stigmata (HRS)/worrisome features (WFs) of the ICG 2012 and malignant BD-IPMNs, performance characteristics of EUS-FNA for the diagnosis of malignant BD-IPMNs, and recurrence and long-term outcomes of BD-IPMN patients undergoing surgery or imaging surveillance. RESULTS Of 364 BD-IPMN patients, 229 underwent imaging surveillance and 135 underwent surgery. Among the 135 resected BD-IPMNs, HRS/WFs on CT/magnetic resonance imaging (MRI) were similar between the benign and malignant groups, but main pancreatic duct (MPD) dilation (5-9 mm) was more frequently identified in malignant lesions. On EUS-FNA, mural nodules, MPD features suspicious for involvement, and suspicious/positive malignant cytology were more frequently detected in the malignant group with a sensitivity, specificity, and accuracy of 33%, 94%, and 86%; 42%, 91%, and 83%; and 33% 91%, and 82%, respectively. Mural nodules identified by EUS were missed by CT/MRI in 28% in the malignant group. Patients with malignant lesions had a higher risk of any IPMN recurrence during a mean follow-up period of 131 months (P = .01). CONCLUSIONS Among HRS and WFs of the ICG 2012, an MPD size of 5 to 9 mm on CT/MRI was associated with malignant BD-IPMNs. EUS features including mural nodules, MPD features suspicious for involvement, and suspicious/malignant cytology were accurate and highly specific for malignant BD-IPMNs. Our study highlights the incremental value of EUS-FNA over imaging in identifying malignant BD-IPMNs, particularly in patients without WFs and those with smaller cysts. Benign IPMN recurrence was observed in some patients up to 8 years after resection.
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Affiliation(s)
- Wiriyaporn Ridtitid
- Indiana University School of Medicine, Indianapolis, Indiana, USA; Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - John M DeWitt
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - C Max Schmidt
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alexandra Roch
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Stuart Sherman
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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A Cutoff of 2 cm Instead of 3 cm Would Detect More Malignant BD-IPMNs: Is There a Reason to Be Wary of the International Consensus Guidelines? Pancreas 2016; 45:5-7. [PMID: 26658036 DOI: 10.1097/mpa.0000000000000468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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47
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Leal JN, Kingham TP, D’Angelica MI, DeMatteo RP, Jarnagin WR, Kalin MF, Allen PJ. Intraductal Papillary Mucinous Neoplasms and the Risk of Diabetes Mellitus in Patients Undergoing Resection Versus Observation. J Gastrointest Surg 2015; 19:1974-81. [PMID: 26160323 PMCID: PMC4809678 DOI: 10.1007/s11605-015-2885-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 06/23/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of this study is to determine the prevalence of diabetes mellitus (DM) in patients with intraductal papillary mucinous neoplasm of the pancreas (IPMN) and compare rates of new/progressive DM between IPMN patients undergoing pancreatectomy versus observation. METHODS Patients diagnosed with IPMN were identified from institutional databases, divided into two groups based on treatment type, pancreatectomy versus clinical observation, and subsequently evaluated. Standard demographic and clinicopathologic variables, fasting glucose, diabetic status, and pancreatic volume data, were obtained and compared between groups. RESULTS One hundred thirty-four IPMN patients were identified; 103 (77 %) underwent pancreatectomy and 31 (23 %) were observed. Baseline DM rate was 18 % (24/134). This was not different between groups [17 % (17/103) resected vs. 23 % (7/31) observed, p = 0.51]. Median follow-up was 53 months and new/progressive DM occurred in 37 (28 %) patients with no difference between groups [29 (28 %) resected vs. 8 (26 %) observed, p = 0.74]. Among resected patients, degree of dysplasia was associated with increase risk of new/progressive DM [moderate dysplasia OR 5.76 (1.24-26.79) and severe dysplasia OR 9.43 (1.54-57.74), p = 0.04], while procedure type and remnant volume were not. CONCLUSIONS The incidence and prevalence of DM among patients with IPMN was high and did not differ between resected and observed groups. Degree of dysplasia, not the amount of resected pancreas, was associated with increased risk of DM, suggesting that the presence or development of DM may be a marker of malignant progression. Confirmatory studies are required.
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Affiliation(s)
- Julie N. Leal
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - T. Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Michael I. D’Angelica
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Ronald P. DeMatteo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - William R. Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Marcia F. Kalin
- Department of Endocrinology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Peter J. Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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48
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Comparison of the international consensus guidelines for predicting malignancy in intraductal papillary mucinous neoplasms. Surgery 2015; 159:878-84. [PMID: 26506564 DOI: 10.1016/j.surg.2015.08.042] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 07/28/2015] [Accepted: 08/12/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND This study sought to evaluate the predictors of malignancy in the 2012 international consensus guidelines for intraductal papillary mucinous neoplasms (IPMNs) and validate their diagnostic value relative to the 2006 guidelines. METHODS Between 2002 and 2014, 177 consecutive patients who underwent curative resection of IPMN were reviewed. Based on the 2012 guidelines, high-risk stigmata (mural nodule with enhancement, main pancreatic duct [MPD] ≥ 10 mm, and obstructive jaundice) and worrisome features (cyst size ≥ 30 mm, thickened cyst wall, mural nodule without enhancement, MPD 5-9 mm, an abrupt change in MPD diameter, and lymphadenopathy) were assessed, and predictive and diagnostic values were analyzed statistically. RESULTS Multivariate analysis identified obstructive jaundice (odds ratio [OR], 23.9; P < .0001), abrupt change in MPD diameter (OR, 3.01; P = .017) and lymphadenopathy (OR, 5.84; P = .027) as independent predictive factors, with an accuracy of 69.8, 67.4, and 66.3%, respectively. Operative intervention was indicated in 156 patients (94.0%) using the 2006 guidelines, and in 130 (78.3%) using the 2012 guidelines. The accuracy of the 2006 guidelines was 35.5% compared with 44.8% for the 2012 guidelines. The area under the curve (AUC) for the 2006 and 2012 guidelines was 0.65 and 0.67, respectively; ΔAUC was 0.02, which was not statistically significant. When the worrisome features were combined with high-risk stigmata, the AUC increased to 0.79. CONCLUSION Obstructive jaundice, abrupt change in MPD diameter, and lymphadenopathy were independent predictive factors in the 2012 guidelines with high accuracy. Using the new guidelines, the number of patients with IPMN managed with observation and the predictive accuracy increased.
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49
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Goh BKP, Tan DMY, Chan CY, Lee SY, Lee VTW, Thng CH, Low ASC, Tai DWM, Cheow PC, Chow PKH, Ooi LLPJ, Chung AYF. Are preoperative blood neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios useful in predicting malignancy in surgically-treated mucin-producing pancreatic cystic neoplasms? J Surg Oncol 2015; 112:366-71. [PMID: 26280242 DOI: 10.1002/jso.23997] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/12/2015] [Indexed: 12/22/2022]
Abstract
INTRODUCTION The aim of this study was to determine if neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were predictive of malignancy in mucin-producing pancreatic cystic neoplasms (MpPCN). METHODS One hundred and twenty patients with MpPCN were retrospectively reviewed. Malignant neoplasms were defined as neoplasms harbouring invasive carcinoma or high grade dysplasia. A high NLR and PLR were defined as ≥2.551 and ≥208.1, respectively. RESULTS High NLR was significantly associated with symptomatic tumors, larger tumors, solid component, main-duct IPMN, and Sendai high risk category. High PLR was significantly associated with jaundice and Sendai high risk category. On univariate analyses, symptomatic tumors, jaundice, solid component, dilated pancreatic duct, and both a high NLR and PLR were significant predictors of malignant and invasive MpPCN. On multivariate analyses, solid component and dilated pancreatic duct were independent predictors of malignant and invasive MpPCN. PLR was an independent predictor for invasive MpPCN. When MpPCN were stratified by the Fukuoka and Sendai Guidelines, both a high NLR and PLR were significantly associated with malignant neoplasms within the high risk categories. CONCLUSIONS PLR is an independent predictor of invasive carcinoma. The addition of PLR as a criterion to the FCG and SCG significantly improved the predictive value of these guidelines in detecting invasive neoplasms.
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Affiliation(s)
- Brian K P Goh
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore.,Duke-NUS Graduate Medical School, Singapore
| | - Damien M Y Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Chung-Yip Chan
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore
| | - Ser-Yee Lee
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore
| | - Victor T W Lee
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore
| | - Choon-Hua Thng
- Department of Oncologic Imaging, National Cancer Centre, Singapore
| | - Albert S C Low
- Department of Radiology, Singapore General Hospital, Singapore
| | - David W M Tai
- Division of Medical Oncology, National Cancer Centre, Singapore
| | - Peng-Chung Cheow
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore
| | - Pierce K H Chow
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore.,Duke-NUS Graduate Medical School, Singapore
| | - London L P J Ooi
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore.,Duke-NUS Graduate Medical School, Singapore
| | - Alexander Y F Chung
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore
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50
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Goh BKP, Lin Z, Tan DMY, Thng CH, Khor CJL, Lim TKH, Ooi LLPJ, Chung AYF. Evaluation of the Fukuoka Consensus Guidelines for intraductal papillary mucinous neoplasms of the pancreas: Results from a systematic review of 1,382 surgically resected patients. Surgery 2015; 158:1192-202. [PMID: 26032832 DOI: 10.1016/j.surg.2015.03.021] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 02/26/2015] [Accepted: 03/20/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND International consensus guidelines to guide management of intraductal papillary mucinous neoplasms (IPMN) were revised in Fukuoka and published in 2012. However, despite widespread acceptance of the Fukuoka Consensus Guidelines (FCG), the utility of these guidelines have not been well-validated. This systematic review was performed to evaluate the clinical utility of the FCG. DESIGN A computerized search of the PubMed and Scopus databases was performed to identify all studies evaluating the utility of the FCG in surgically resected IPMN. IPMN were stratified according to the FCG as high risk (HR), worrisome risk (WR), and low risk (LR). HR and WR IPMN were termed FCG+ve and LR IPMN were termed FCG-ve. RESULTS Seven studies analyzing 1,382 patients were included. There were 402 malignant neoplasms (29%), including 242 invasive IPMNs. There were 1,000 IPMN classified as FCG+ve. The FCG+ve group had a positive predictive value (PPV) ranging from 27 to 62% and the FCG-ve group had negative predictive value ranging from 82 to 100%. Pooled analysis demonstrated that there was 362 of 1,000 (36%) malignant FCG+ve IPMN and 342 of 382 (90%) benign FCG-ve IPMN. PPV of the HR group and the WR groups alone were 104 of 158 (66%) and 75 of 261 (29%), respectively. Forty of 382 (11%), including 22 (6%) invasive FCG-ve IPMN, were malignant. Twenty-six malignant including 18 invasive FCG-ve IPMN were reported from a single study. When the results from this study were excluded, there were only 14 of 241 malignant neoplasms (6%), including 4 of 241 (2%) invasive FCG-ve IPMN in the remaining 6 studies. CONCLUSION The FCG+ve criteria had a similarly low PPV compared with the 2006 consensus criteria. Stratification of IPMN into HR and WR groups resulted in a higher PPV in the HR group. Some malignant and even invasive IPMN may be missed by the FCG criteria.
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Affiliation(s)
- Brian K P Goh
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore; Duke-National University of Singapore Graduate Medical School, Singapore.
| | - Zhimin Lin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Damien M Y Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Choon-Hua Thng
- Department of Oncologic Imaging, National Cancer Center Singapore, Singapore
| | - Christopher J L Khor
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Tony K H Lim
- Department of Pathology, Singapore General Hospital, Singapore
| | - London L P J Ooi
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore; Duke-National University of Singapore Graduate Medical School, Singapore
| | - Alexander Y F Chung
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore
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