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Yip-Schneider MT, Muraru R, Rao N, Kim RC, Rempala-Kurucz J, Baril JA, Roch AM, Schmidt CM. Potential Health Disparities in the Early Detection and Prevention of Pancreatic Cancer. Cureus 2024; 16:e60240. [PMID: 38872680 PMCID: PMC11169996 DOI: 10.7759/cureus.60240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION Pancreatic cancer remains one of the deadliest cancers in the United States. Some types of pancreatic cysts, which are being detected more frequently and often incidentally on imaging, have the potential to develop into pancreatic cancer and thus provide a valuable window of opportunity for cancer interception. Although racial disparity in pancreatic cancer has been described, little is known regarding health disparities in pancreatic cancer prevention. In the present study, we investigate potential health disparities along the continuum of care for pancreatic cancer. METHODS The racial and ethnic composition of pancreatic patients at high-volume centers in Indiana were evaluated, representing patients undergoing surgery for pancreatic cancer (n=390), participating in biobanking (972 pancreatic cancer patients and 1984 patients with pancreatic disease), or being monitored for pancreatic cysts at an early detection center (n=1514). To assess racial disparities and potential differences in decision-making related to pancreatic cancer prevention and early detection, an exploratory online survey was administered through a volunteer registry (n=708). Results: We show that despite comprising close to 10% or 30% of the Indiana or Indianapolis population, respectively, African Americans make up only about 4-5% of our study cohorts consisting of patients undergoing pancreatic surgery or participating in biobanking and early detection. Analysis of online survey results revealed that given the hypothetical situation of being diagnosed with a pancreatic cyst or pancreatic cancer, the vast majority of respondents (>90%) would agree to undergo surveillance or surgery, respectively, regardless of race. Only a minority (3-12%) acknowledged any significant transportation, financial, or emotional barriers that would impact a decision to undergo surveillance or surgery. This suggests that the observed racial disparities may be due in part to the existence of other barriers that lie upstream of this decision point. CONCLUSION Racial disparities exist not only for pancreatic cancer but also at earlier points along the continuum of care such as prevention and early detection. To our knowledge, this is the first study to document racial disparity in the management of patients with pancreatic cysts who are at risk of developing pancreatic cancer. Our results suggest that improving access to information and care for such at-risk individuals may lead to more equitable outcomes.
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Affiliation(s)
- Michele T Yip-Schneider
- Surgery, Indiana University School of Medicine, Indianapolis, USA
- Pancreatic Cyst and Cancer Early Detection Center, Indiana University Health, Indianapolis, USA
| | - Rodica Muraru
- Center for Outcomes Research in Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Nikita Rao
- Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Rachel C Kim
- Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Jennifer Rempala-Kurucz
- Pancreatic Cyst and Cancer Early Detection Center, Indiana University Health, Indianapolis, USA
| | - Jackson A Baril
- Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Alexandra M Roch
- Surgery, Indiana University School of Medicine, Indianapolis, USA
- Pancreatic Cyst and Cancer Early Detection Center, Indiana University Health, Indianapolis, USA
| | - C Max Schmidt
- Surgery, Biochemistry/Molecular Biology, Indiana University School of Medicine, Indianapolis, USA
- Simon Comprehensive Cancer Center, Indiana University, Indianapolis, USA
- Pancreatic Cyst and Cancer Early Detection Center, Indiana University Health, Indianapolis, USA
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Miao J, Zhang Z, Zhang X, Huang X, Zhang S, Zhan Z, Chen J, Chen L, Li L. Label-free assessment of pathological changes in pancreatic intraepithelial neoplasia by biomedical multiphoton microscopy. JOURNAL OF BIOPHOTONICS 2024; 17:e202300417. [PMID: 38221649 DOI: 10.1002/jbio.202300417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/26/2023] [Accepted: 12/21/2023] [Indexed: 01/16/2024]
Abstract
Pancreatic intraepithelial neoplasia (PanIN) is the most common precursor lesion that has the potential to progress to invasive pancreatic cancer, and early and rapid detection may offer patients a chance for treatment before the development of invasive carcinoma. Therefore, the identification of PanIN holds significant clinical importance. In this study, we first used multiphoton microscopy (MPM) combining two-photon excitation fluorescence and second-harmonic generation imaging to label-free detect PanIN and attempted to differentiate between normal pancreatic ducts and different grades of PanIN. Then, we also developed an automatic image processing strategy to extract eight morphological features of collagen fibers from MPM images to quantify the changes in collagen fibers surrounding the ducts. Experimental results demonstrate that the combination of MPM and quantitative information can accurately identify normal pancreatic ducts and different grades of PanIN. This study may contribute to the rapid diagnosis of pancreatic diseases and may lay the foundation for further clinical application of MPM.
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Affiliation(s)
- Jikui Miao
- Key Laboratory of OptoElectronic Science and Technology for Medicine of Ministry of Education, Fujian Provincial Key Laboratory of Photonics Technology, College of Photonic and Electronic Engineering, Fujian Normal University, Fuzhou, China
| | - Zheng Zhang
- Key Laboratory of OptoElectronic Science and Technology for Medicine of Ministry of Education, Fujian Provincial Key Laboratory of Photonics Technology, College of Photonic and Electronic Engineering, Fujian Normal University, Fuzhou, China
| | - Xiong Zhang
- Key Laboratory of OptoElectronic Science and Technology for Medicine of Ministry of Education, Fujian Provincial Key Laboratory of Photonics Technology, College of Photonic and Electronic Engineering, Fujian Normal University, Fuzhou, China
| | - Xingxin Huang
- Key Laboratory of OptoElectronic Science and Technology for Medicine of Ministry of Education, Fujian Provincial Key Laboratory of Photonics Technology, College of Photonic and Electronic Engineering, Fujian Normal University, Fuzhou, China
| | - Shichao Zhang
- Key Laboratory of OptoElectronic Science and Technology for Medicine of Ministry of Education, Fujian Provincial Key Laboratory of Photonics Technology, College of Photonic and Electronic Engineering, Fujian Normal University, Fuzhou, China
| | - Zhenlin Zhan
- Key Laboratory of OptoElectronic Science and Technology for Medicine of Ministry of Education, Fujian Provincial Key Laboratory of Photonics Technology, College of Photonic and Electronic Engineering, Fujian Normal University, Fuzhou, China
| | - Jianxin Chen
- Key Laboratory of OptoElectronic Science and Technology for Medicine of Ministry of Education, Fujian Provincial Key Laboratory of Photonics Technology, College of Photonic and Electronic Engineering, Fujian Normal University, Fuzhou, China
| | - Linying Chen
- Department of Pathology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Lianhuang Li
- Key Laboratory of OptoElectronic Science and Technology for Medicine of Ministry of Education, Fujian Provincial Key Laboratory of Photonics Technology, College of Photonic and Electronic Engineering, Fujian Normal University, Fuzhou, China
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3
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Waltz J, Mercer MK, Dani G, Rieter WJ. Incidental Serous Cystadenoma Presenting as a Photopenic Pancreatic Defect on 18F-Fluciclovine PET/CT. Clin Nucl Med 2021; 46:e600-e602. [PMID: 34735415 DOI: 10.1097/rlu.0000000000003670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT 18F-fluciclovine (Axumin) PET/CT has been widely used for the evaluation of biochemically recurrent prostate cancer following prior treatment. While lymph node and visceral organ metastases typically show increased radiotracer uptake, altered patterns of normal physiologic activity may also provide insight into other disease processes. We present a case of an incidental pancreatic head mass presenting as a photopenic defect on a staging 18F-fluciclovine PET/CT, which was subsequently confirmed to be a benign serous cystadenoma using multisequence MRI.
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Affiliation(s)
- Jeffrey Waltz
- From the Department of Radiology, Medical University of South Carolina
| | - Megan K Mercer
- From the Department of Radiology, Medical University of South Carolina
| | - Genta Dani
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC
| | - William J Rieter
- From the Department of Radiology, Medical University of South Carolina
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Yip-Schneider MT, Wu H, Allison HR, Easler JJ, Sherman S, Al-Haddad MA, Dewitt JM, Schmidt CM. Biomarker Risk Score Algorithm and Preoperative Stratification of Patients with Pancreatic Cystic Lesions. J Am Coll Surg 2021; 233:426-434.e4. [PMID: 34166836 DOI: 10.1016/j.jamcollsurg.2021.05.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Pancreatic cysts are incidentally detected in up to 13% of patients undergoing radiographic imaging. Of the most frequently encountered types, mucin-producing (mucinous) pancreatic cystic lesions may develop into pancreatic cancer, while nonmucinous ones have little or no malignant potential. Accurate preoperative diagnosis is critical for optimal management, but has been difficult to achieve, resulting in unnecessary major surgery. Here, we aim to develop an algorithm based on biomarker risk scores to improve risk stratification. STUDY DESIGN Patients undergoing surgery and/or surveillance for a pancreatic cystic lesion, with diagnostic imaging and banked pancreatic cyst fluid, were enrolled in the study after informed consent (n = 163 surgical, 67 surveillance). Cyst fluid biomarkers with high specificity for distinguishing nonmucinous from mucinous pancreatic cysts (vascular endothelial growth factor [VEGF], glucose, carcinoembryonic antigen [CEA], amylase, cytology, and DNA mutation) were selected. Biomarker risk scores were used to design an algorithm to predict preoperative diagnosis. Performance was tested using surgical (retrospective) and surveillance (prospective) cohorts. RESULTS In the surgical cohort, the biomarker algorithm outperformed the preoperative clinical diagnosis in correctly predicting the final pathologic diagnosis (91% vs 73%; p < 0.000001). Specifically, nonmucinous serous cystic neoplasms (SCN) and mucinous cystic neoplasms (MCN) were correctly classified more frequently by the algorithm than clinical diagnosis (96% vs 30%; p < 0.000008 and 92% vs 69%; p = 0.04, respectively). In the surveillance cohort, the algorithm predicted a preoperative diagnosis with high confidence based on a high biomarker score and/or consistency with imaging from ≥1 follow-up visits. CONCLUSIONS A biomarker risk score-based algorithm was able to correctly classify pancreatic cysts preoperatively. Importantly, this tool may improve initial and dynamic risk stratification, reducing overdiagnosis and underdiagnosis.
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Affiliation(s)
- Michele T Yip-Schneider
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Walther Oncology Center, Indianapolis, IN; Indiana University Simon Cancer Center, Indianapolis, IN; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN
| | - Huangbing Wu
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN
| | | | - Jeffrey J Easler
- Department of Medicine, Division of Gastroenterology, Indianapolis, IN
| | - Stuart Sherman
- Department of Medicine, Division of Gastroenterology, Indianapolis, IN
| | - Mohammad A Al-Haddad
- Department of Medicine, Division of Gastroenterology, Indianapolis, IN; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN
| | - John M Dewitt
- Department of Medicine, Division of Gastroenterology, Indianapolis, IN
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; Biochemistry/Molecular Biology, Indianapolis, IN; Walther Oncology Center, Indianapolis, IN; Indiana University Simon Cancer Center, Indianapolis, IN; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN.
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5
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Hsieh MJ, Weng CC, Lin YC, Wu CC, Chen LT, Cheng KH. Inhibition of β-Catenin Activity Abolishes LKB1 Loss-Driven Pancreatic Cystadenoma in Mice. Int J Mol Sci 2021; 22:ijms22094649. [PMID: 33924999 PMCID: PMC8125161 DOI: 10.3390/ijms22094649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 04/16/2021] [Accepted: 04/16/2021] [Indexed: 01/02/2023] Open
Abstract
Pancreatic cancer (PC) is the seventh leading cause of cancer death worldwide, and remains one of our most recalcitrant and dismal diseases. In contrast to many other malignancies, there has not been a significant improvement in patient survival over the past decade. Despite advances in our understanding of the genetic alterations associated with this disease, an incomplete understanding of the underlying biology and lack of suitable animal models have hampered efforts to develop more effective therapies. LKB1 is a tumor suppressor that functions as a primary upstream kinase of adenine monophosphate-activated protein kinase (AMPK), which is an important mediator in the regulation of cell growth and epithelial polarity pathways. LKB1 is mutated in a significant number of Peutz–Jeghers syndrome (PJS) patients and in a small proportion of sporadic cancers, including PC; however, little is known about how LKB1 loss contributes to PC development. Here, we report that a reduction in Wnt/β-catenin activity is associated with LKB1 tumor-suppressive properties in PC. Remarkably, in vivo functional analyses of β-catenin in the Pdx-1-Cre LKB1L/L β-cateninL/L mouse model compared to LKB1 loss-driven cystadenoma demonstrate that the loss of β-catenin impairs cystadenoma development in the pancreas of Pdx-1Cre LKB1L/L mice and dramatically restores the normal development and functions of the pancreas. This study further determined the in vivo and in vitro therapeutic efficacy of the β-catenin inhibitor FH535 in suppressing LKB1 loss-driven cystadenoma and reducing PC progression that delineates the potential roles of Wnt/β-catenin signaling in PC harboring LKB1 deficiency.
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MESH Headings
- AMP-Activated Protein Kinase Kinases
- AMP-Activated Protein Kinases/metabolism
- Animals
- Cell Line, Tumor
- Cystadenoma, Mucinous/etiology
- Cystadenoma, Mucinous/metabolism
- Cystadenoma, Mucinous/prevention & control
- Female
- Humans
- Male
- Mice
- Mice, 129 Strain
- Mice, Inbred C57BL
- Mice, Knockout
- Mice, Transgenic
- Mutation
- Neoplasms, Experimental/genetics
- Neoplasms, Experimental/metabolism
- Pancreas/drug effects
- Pancreas/metabolism
- Pancreas/pathology
- Pancreatic Neoplasms/etiology
- Pancreatic Neoplasms/metabolism
- Pancreatic Neoplasms/prevention & control
- Peutz-Jeghers Syndrome/genetics
- Peutz-Jeghers Syndrome/metabolism
- Protein Serine-Threonine Kinases/deficiency
- Protein Serine-Threonine Kinases/genetics
- Sulfonamides/pharmacology
- Wnt Signaling Pathway/drug effects
- beta Catenin/antagonists & inhibitors
- beta Catenin/genetics
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Affiliation(s)
- Mei-Jen Hsieh
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan; (M.-J.H.); (C.-C.W.); (Y.-C.L.); (C.-C.W.)
- Division of Neurology, Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung 802, Taiwan
| | - Ching-Chieh Weng
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan; (M.-J.H.); (C.-C.W.); (Y.-C.L.); (C.-C.W.)
| | - Yu-Chun Lin
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan; (M.-J.H.); (C.-C.W.); (Y.-C.L.); (C.-C.W.)
| | - Chia-Chen Wu
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan; (M.-J.H.); (C.-C.W.); (Y.-C.L.); (C.-C.W.)
| | - Li-Tzong Chen
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan; (M.-J.H.); (C.-C.W.); (Y.-C.L.); (C.-C.W.)
- National Institute of Cancer Research, National Health Research Institutes, Tainan 704, Taiwan
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Oncology, National Cheng Kung University Hospital, National Cheng Kung University, Tainan 704, Taiwan
- Correspondence: (L.-T.C.); (K.-H.C.)
| | - Kuang-Hung Cheng
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan; (M.-J.H.); (C.-C.W.); (Y.-C.L.); (C.-C.W.)
- National Institute of Cancer Research, National Health Research Institutes, Tainan 704, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Medical Laboratory Science and Biotechnology, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Correspondence: (L.-T.C.); (K.-H.C.)
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6
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Aleksandric G, Matic S, Todorovic J, Terzic-Supic Z, Aleksic V. Misdiagnosis of cystic pancreatic tumors during a 30-year study period. Eur Surg 2020. [DOI: 10.1007/s10353-020-00628-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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7
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Lin SD, Soucisse ML, Lansom J, Morris DL. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a patient with peritoneal carcinomatosis from a pancreatic cystadenocarcinoma: A case report. Int J Surg Case Rep 2019; 63:48-52. [PMID: 31563663 PMCID: PMC6796650 DOI: 10.1016/j.ijscr.2019.08.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/10/2019] [Accepted: 08/17/2019] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a well-established procedure commonly employed in the management of peritoneal carcinomatosis (PC) from tumors of various specific origins. However, it is not traditionally used in the management of PC of pancreatic origin due to various reasons, including the aggressive nature of pancreatic tumors. CASE PRESENTATION A 67-year-old female presented with a large amount of intractable malignant ascites. Computed tomography (CT) imaging showed a nodule in the right paracolic gutter. A diagnostic laparoscopy and omental biopsy showed a well-differentiated adenocarcinoma of pancreatic origin. She was initially not considered suitable for CRS and HIPEC due to apparent liver metastases on CT imaging and was arranged to undergo palliative chemotherapy; however, due to her large amount of refractory ascites and a suspected ruptured right krukenberg tumor, surgical intervention was offered. We performed CRS, bilateral salpingo-oophorectomy, and an omentectomy with a CC (completeness of cytoreduction) score of 1. HIPEC with mitomycin C was also administered. Notably, our patient remains clinically well at 48-months post CRS and HIPEC, with no signs or symptoms suggestive of tumor recurrence. CONCLUSION Despite the current lack of evidence supporting the use of CRS and HIPEC in the curation of PC of pancreatic origin, this case report highlights the importance of patient selection in determining suitability for CRS. In the presence of positive prognostic factors and favorable tumor histology, CRS and HIPEC is a potential curative procedure that could be offered to highly selected patients presenting with PC from a primary pancreatic malignancy.
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Affiliation(s)
- Sophia D Lin
- Department of Surgery, University of New South Wales, St George Hospital, Sydney, Australia.
| | - Mikael L Soucisse
- Department of Surgery, University of New South Wales, St George Hospital, Sydney, Australia; Department of Surgery, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montreal, Canada
| | - Joshua Lansom
- Department of Surgery, University of New South Wales, St George Hospital, Sydney, Australia
| | - David L Morris
- Department of Surgery, University of New South Wales, St George Hospital, Sydney, Australia
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Keegan MJ, Paranandi B. Diagnosis and management of pancreatic cystic neoplasms. Frontline Gastroenterol 2019; 10:300-308. [PMID: 31288258 PMCID: PMC6583589 DOI: 10.1136/flgastro-2018-101122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/18/2019] [Accepted: 01/19/2019] [Indexed: 02/04/2023] Open
Abstract
This review outlines the current classification of pancreatic cystic lesions, with a particular emphasis on pancreatic cystic neoplasms (PCNs). It will describe the diagnostic approach to PCNs, with reference to clinicopathological features, cross-sectional radiology and endoscopic ultrasound. This review will conclude with an evidence-based discussion of the management of PCNs focused on recent clinical guidelines.
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Affiliation(s)
- Mathew James Keegan
- Gastroenterology, Northern Beaches Hospital, Sydney, New South Wales, Australia,Department of Gastroenterology, Peninsula Gastroenterology, Sydney, New South Wales, Australia
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9
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Salom F, Prat F. Current indications and yield of endoscopic ultrasound and ancillary techniques in pancreatic cystic neoplasms. Clin J Gastroenterol 2018; 12:93-101. [PMID: 30565189 DOI: 10.1007/s12328-018-00930-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 12/12/2018] [Indexed: 12/11/2022]
Abstract
An increase in the diagnosis of pancreatic cystic neoplasm has been described lately. Surgical treatment or surveillance is advised depending on the type of lesion diagnosed. The most accurate diagnostic approach is needed to make the best therapeutic decision. Endoscopic ultrasound is a very valuable tool in the evaluation of pancreatic cystic neoplasm. It generates high-quality images and allows the possibility of sampling the cystic fluid for cytology, microbiological and molecular evaluation. Even with this evaluation, the sensitivity of this approach is not always adequate. New technological resources have been developed to try to improve the diagnostic accuracy of pancreatic cystic neoplasms. The two most promising techniques are needle-based confocal laser endomicroscopy and contrast-enhanced harmonic endoscopic ultrasound. Needle-based confocal laser endomicroscopy allows a microscopic evaluation of mucosal glands and vascular pattern, to differentiate mucinous from non-mucinous lesions. Contrast-enhanced harmonic endoscopic ultrasound is used for the vascular evaluation of the microcirculation of the cyst wall and mural nodule, mainly to make the difference between malignant nodules and mucus plugs. A combination of these different diagnostic techniques can improve the diagnostic accuracy of pancreatic cystic neoplasms to offer the adequate therapeutic decision.
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Affiliation(s)
- Federico Salom
- Departamento de Gastroenterología, Hospital México, San José, 1641-2050, Costa Rica.
| | - Frédéric Prat
- Service de Gastroenterologie, d'endoscopie et de Cancerologie Digestive, APHP-Hopital Cochin, 75014, Paris, France
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Abstract
OBJECTIVES Two issues were put forth by clinicians in the management of the advanced stages of rare variants of pancreatic ductal adenocarcinoma and other exocrine histotypes with peculiar clinical and pathological features: Do chemotherapy regimens recommended in pancreatic ductal adenocarcinoma patients have a clinical activity in rare pancreatic tumors? Or should other chemotherapy combinations be considered in this subset of patients? METHODS We conducted a multicenter retrospective study that collected data from 2005 to 2016 at 14 Italian cancer centers with the aim to evaluate tumor response and time to progression for first- and second-line and overall survival. RESULTS Of approximately 4300 exocrine pancreatic cancer patients, 79 advanced cases affected by rare histological types were identified, with pancreatic acinar cell cancer (n = 23), pancreatic adenosquamous cancer (n = 16), and mucinous cystic neoplasm with an associated invasive mucinous cystadenocarcinoma (n = 15) most represented. Survival analyses for each subgroup in relation with the different chemotherapy regimens showed the lack of statistical significance correlations. CONCLUSIONS Because of the lack of clinical trials in patients affected by these rare pancreatic histotypes, only their molecular classification would help clinicians in future therapeutic choice.
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11
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El Gammal AT, Izbicki JR. Incidental Intraductal Papillary Mucinous Neoplasm, Cystic or Premalignant Lesions of the Pancreas. Surg Clin North Am 2018; 98:141-155. [DOI: 10.1016/j.suc.2017.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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12
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Ridtitid W, Al-Haddad MA. Endoscopic Ultrasound Imaging for Diagnosing and Treating Pancreatic Cysts. Gastrointest Endosc Clin N Am 2017; 27:615-642. [PMID: 28918802 DOI: 10.1016/j.giec.2017.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Cystic pancreatic lesions are increasingly diagnosed owing to the abundant use of cross-sectional imaging. Given their malignant potential, true pancreatic cysts should be considered for resection or periodic follow-up. Cystic lesions of the pancreas (CLPs) require further evaluation and management. Therefore, it is important to establish a solid diagnosis at the time of detection. Endoscopic ultrasound examination is the imaging modality of choice. Fine needle aspiration provides fluid for cytologic, biochemical, and molecular assays to classify lesions and predict biological behavior. This review provides an overview of the diagnosis and management of various types of commonly encountered true CLPs.
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Affiliation(s)
- Wiriyaporn Ridtitid
- Division of Gastroenterology and Hepatology, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100, Indianapolis, IN 46202, USA.
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13
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Tumor Markers in Pancreatic Cystic Fluids for Diagnosis of Malignant Cysts. Int J Biol Markers 2017; 32:e291-e296. [DOI: 10.5301/jbm.5000257] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2017] [Indexed: 12/18/2022]
Abstract
Background and aim Early diagnosis of premalignant or malignant pancreatic cysts is essential to improve prognosis. Sampling of pancreatic cyst fluid by fine-needle aspiration during endoscopic ultrasonography (EUS) enables cytopathological examination combined with biochemical analysis. This study aimed to provide an aid based on biological markers for the preoperative management of patients with pancreatic cysts. Methods Pancreatic fluids obtained by EUS-guided fine-needle aspiration from 115 patients with cystic lesions were assayed for amylase, lipase, carcinoembryonic antigen (CEA), CA 19-9 and CA 72-4. In addition, chromogranin A (CgA) and neuron-specific enolase (NSE) were measured in 28 fluid samples. Results ROC curve analysis of the different markers for diagnosis of mucinous cysts showed that CEA had the highest area under the curve (0.93, 95% CI 0.87-0.97), with a sensitivity and specificity of 89% and 93%, respectively, at the cutoff value of 317 μg/L. The CgA and NSE concentrations in 5 NET cysts (median values of 210 [63-492] and 68.5 [9-496] μg/L, respectively) were higher than in 23 other cysts (median values of 8 [7-828] and 2.7 [0.5-35.8] μg/L, respectively) (p = 0.0015 and p = 0.0045, respectively). Conclusions CEA is the best marker for identifying a cyst as mucinous. In case of low levels of CEA, our results suggest that CgA and NSE measurements may be helpful in the diagnosis of a neuroendocrine tumor and therefore deserve further investigation.
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14
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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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Rodríguez Torres C, Larrosa López R. Descripción radiológica de las neoplasias quísticas pancreáticas. RADIOLOGIA 2016; 58:404-14. [DOI: 10.1016/j.rx.2016.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 06/07/2016] [Accepted: 06/09/2016] [Indexed: 11/28/2022]
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16
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Kuo TL, Weng CC, Kuo KK, Chen CY, Wu DC, Hung WC, Cheng KH. APC haploinsufficiency coupled with p53 loss sufficiently induces mucinous cystic neoplasms and invasive pancreatic carcinoma in mice. Oncogene 2016; 35:2223-34. [PMID: 26411367 DOI: 10.1038/onc.2015.284] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 06/03/2015] [Accepted: 06/22/2015] [Indexed: 12/23/2022]
Abstract
Adenomatous polyposis coli (APC), a tumor-suppressor gene critically involved in familial adenomatous polyposis, is integral in Wnt/β-catenin signaling and is implicated in the development of sporadic tumors of the distal gastrointestinal tract including pancreatic cancer (PC). Here we report for the first time that functional APC is required for the growth and maintenance of pancreatic islets and maturation. Subsequently, a non-Kras mutation-induced premalignancy mouse model was developed; in this model, APC haploinsufficiency coupled with p53 deletion resulted in the development of a distinct type of pancreatic premalignant precursors, mucinous cystic neoplasms (MCNs), exhibiting pathomechanisms identical to those observed in human MCNs, including accumulation of cystic fluid secreted by neoplastic and ovarian-like stromal cells, with 100% penetrance and the presence of hepatic and gastric metastases in >30% of the mice. The major clinical implications of this study suggest targeting the Wnt signaling pathway as a novel strategy for managing MCN.
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Affiliation(s)
- T-L Kuo
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - C-C Weng
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - K-K Kuo
- Division of Hepatobiliopancreatic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - C-Y Chen
- Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - D-C Wu
- Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan
- Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Division of Internal Medicine, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - W-C Hung
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan
| | - K-H Cheng
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Center for Stem Cell Research, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Medical Laboratory Science and Biotechnology, Kaohsiung Medical University, Kaohsiung, Taiwan
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Abstract
Different types of benign or malignant cystic lesions can be observed in the pancreas. Pancreatic cystic lesions are classified under pathology terms into simple retention cysts, pseudocysts and cystic neoplasms. Mucinous cystic neoplasm is a frequent type of cystic neoplasm and has a malignant potential. Serous cystadenoma follows in frequency and is usually benign. Intraductal papillary mucinous neoplasms are the most commonly resected cystic pancreatic neoplasms characterized by dilated segments of the main pancreatic duct and/or side branches, the wall of which is covered by mucus secreting cells. These neoplasms can occupy the pancreatic head or any part of the organ. Solid pseudopapillary tumor is rare, has a low tendency for malignancy, and is usually located in the pancreatic body or tail. Endoscopic ultrasound with the use of fine-needle aspiration and cytology permits discrimination of those lesions. In this review, the main characteristics of those lesions are presented, as well as recommendations regarding their follow up and management according to recent guidelines.
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Affiliation(s)
- Ioannis Karoumpalis
- Division of Gastroenterology, General Hospital of Athens "G. Gennimatas", Athens (Ioannis Karoumpalis), Ioannina, Greece
| | - Dimitrios K Christodoulou
- Division of Gastroenterology, University Hospital of Ioannina, Ioannina (Dimitrios K. Christodoulou), Greece
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Predictors for Surgical Referral in Patients With Pancreatic Cystic Lesions Undergoing Endoscopic Ultrasound: Results From a Large Multicenter Cohort Study. Pancreas 2016; 45:51-7. [PMID: 26262589 DOI: 10.1097/mpa.0000000000000386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Endoscopic ultrasound (EUS) plays an integral role in the evaluation of pancreatic cysts lesions (PCLs). The aim of the study was to determine predictors of surgical referral in patients with PCLs undergoing EUS. METHODS We performed a multicenter retrospective study of patients undergoing EUS for evaluation of PCLs. Demographics, EUS characteristics, and fine-needle aspiration results were recorded. Patients were categorized into surgery or surveillance groups on the basis of post-EUS recommendations. Univariate and multivariate analyses were performed to identify predictors of surgical referral. RESULTS 1804 patients were included. 1301 patients were recommended to undergo surveillance and 503 patients were referred for surgical evaluation, of which 360 patients underwent surgery. Multivariate analysis revealed the following 5 independent predictors of surgical referral: symptoms of weight loss on presentation (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.44-5.03), EUS findings of associated solid mass (OR, 7.34; 95% CI, 3.81-14.16), main duct communication (OR, 4.13; 95% CI, 1.71-9.98), multilocular macrocystic morphology (OR, 2.79; 95% CI, 1.78-4.38), and fine-needle aspiration findings of mucin on cytology (OR, 3.06; 95% CI, 1.94-4.82). CONCLUSIONS This study identifies factors associated with surgical referral in patients with PCLs undergoing EUS. Future studies should focus on creation of risk stratification models to determine the need for surgery or enrollment in surveillance programs.
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Martin AK, Zhou Z. Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of pancreatic cysts by combined cytopathology and cystic content analysis. World J Gastrointest Endosc 2015; 7:1157-1169. [PMID: 26504505 PMCID: PMC4613805 DOI: 10.4253/wjge.v7.i15.1157] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 08/03/2015] [Accepted: 09/08/2015] [Indexed: 02/05/2023] Open
Abstract
Recent advances in imaging technology have resulted in an increase in incidental discoveries of pancreatic cystic lesions. Pancreatic cysts comprise a wide variety of lesions and include non-neoplastic cysts and neoplastic cysts. Because some pancreatic cysts have more of a malignant potential than others, it is absolutely essential that an accurate diagnosis is rendered so that effective care can be given to each patient. In many centers, endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) has emerged as the modality of choice that enables one to distinguish between mucinous and non-mucinous lesion, diagnose malignancy and collect cyst fluid for further diagnostic studies, such as pancreatic enzyme levels, molecular analysis and other tumor biomarkers. The current review will focus on EUS-guided FNA and the cytological diagnosis for pancreatic cysts.
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Zhang RC, Zhou YC, Mou YP, Huang CJ, Jin WW, Yan JF, Wang YX, Liao Y. Laparoscopic versus open enucleation for pancreatic neoplasms: clinical outcomes and pancreatic function analysis. Surg Endosc 2015; 30:2657-65. [PMID: 26487211 DOI: 10.1007/s00464-015-4538-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 09/01/2015] [Indexed: 01/18/2023]
Abstract
BACKGROUND The studies comparing laparoscopic enucleation (LE) with open enucleation (OE) are limited. This study aimed to compare perioperative outcomes of patients undergoing LE and OE and to assess the pancreatic function after LE. METHODS Between February 2001 and July 2014, patients who underwent enucleation were reviewed. Patients were divided into two groups as LE and OE. Data considered for comparison analysis were patient demographics, intraoperative variables, morbidity, postoperative hospital stay, mortality, pathologic findings, and long-term follow-up (including pancreatic function). RESULTS Thirty-seven patients (15 LE and 22 OE) were included in the final analysis. Baseline characteristics were similar in the two groups. LE group showed significantly shorter operating time (118.2 ± 33.1 vs. 155.2 ± 44.3 min, p = 0.009), lower estimated blood loss (80.0 ± 71.2 vs. 195.5 ± 103.4 ml, p = 0.001), shorter first flatus time (1.8 ± 1.0 vs. 3.4 ± 1.8 days, p = 0.004), shorter diet start time (2.4 ± 1.0 vs. 4.4 ± 2.0 days, p = 0.001), shorter postoperative hospital stay (7.9 ± 3.4 vs. 11.2 ± 5.7 days, p = 0.046). Postoperative outcomes, including morbidity (40.0 vs. 45.5 %, p = 1.000), grade B/C pancreatic fistula rates (20.0 vs. 13.6 %, p = 0.874), and mortality, were similar in the two groups. The median follow-up period was 47 months (range 7-163 months). No local recurrence or distant metastasis was detected in either group. Only one patient (4.8 %) underwent OE developed new-onset diabetes, in comparison with none in the LE group. One patient (7.1 %) had weight loss and received pancreatic enzyme supplementation in the LE group, in comparison with two patients (9.5 %) in the OE group. CONCLUSIONS LE is a safe and feasible technique for the benign or low malignant-potential pancreatic neoplasms. Compared to OE, LE had shorter operating time, lower estimated blood loss, and faster recovery. LE could preserve the pancreatic function as the OE.
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Affiliation(s)
- Ren-Chao Zhang
- Department of General Surgery, Zhejiang Provincial People's Hospital, Wenzhou Medical University, 158 Shangtang Road, Hangzhou, 310014, Zhejiang Province, China
| | - Yu-Cheng Zhou
- Department of General Surgery, Zhejiang Provincial People's Hospital, Wenzhou Medical University, 158 Shangtang Road, Hangzhou, 310014, Zhejiang Province, China
| | - Yi-Ping Mou
- Department of General Surgery, Zhejiang Provincial People's Hospital, Wenzhou Medical University, 158 Shangtang Road, Hangzhou, 310014, Zhejiang Province, China.
| | - Chao-Jie Huang
- Department of General Surgery, Zhejiang Provincial People's Hospital, Wenzhou Medical University, 158 Shangtang Road, Hangzhou, 310014, Zhejiang Province, China
| | - Wei-Wei Jin
- School of Medicine, Zhejiang University, Hangzhou, 310029, Zhejiang Province, China
| | - Jia-Fei Yan
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310016, Zhejiang Province, China
| | - Yong-Xiang Wang
- Department of General Surgery, Zhejiang Provincial People's Hospital, Wenzhou Medical University, 158 Shangtang Road, Hangzhou, 310014, Zhejiang Province, China
| | - Yi Liao
- Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
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Prospective Cross-Sectional Study of the Prevalence of Incidental Pancreatic Cysts During Routine Outpatient Endoscopic Ultrasound. Pancreas 2015; 44:1130-3. [PMID: 26335009 DOI: 10.1097/mpa.0000000000000408] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Incidental pancreatic cysts are often detected during abdominal imaging and require follow-up since some have malignant potential. Endoscopic ultrasound (EUS) is highly sensitive for pancreatic diseases, yet the prevalence of incidental pancreatic cysts discovered with EUS is unknown. The objective of the study was to determine its prevalence by EUS. METHODS A prospective cross-sectional study was conducted. Patients undergoing EUS for nonpancreatic indications and without known pancreatic abnormality were recruited to assess the prevalence of pancreatic cysts and its characteristics. Risk factors were determined by logistic regression. RESULTS We enrolled 341 patients (mean age, 59 years; 187 females) and found 46 incidental pancreatic cysts (median [range], 5 [2-80] mm) in 32 patients (9.4%). Branch duct intraductal papillary mucinous neoplasm was the most common finding. Seven cysts were larger than 1 cm and 1 adenocarcinoma was discovered. Multivariate logistic regression showed an association between pancreatic cysts and older age (odds ratio, 1.04 per year; 95% confidence interval, 1.01-1.08) and female sex (odds ratio, 3.08; 95% confidence interval, 1.25-7.45). CONCLUSIONS In our population, the prevalence of incidental pancreatic cyst discovered on EUS was 9.4% and the majority were less than 1 cm. Increasing age and female sex were associated with the development of pancreatic cysts.
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22
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Cystic pancreatic neuroendocrine tumors: To date a diagnostic challenge. Int J Surg 2015; 21 Suppl 1:S44-9. [DOI: 10.1016/j.ijsu.2015.04.087] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 03/23/2015] [Accepted: 04/10/2015] [Indexed: 12/16/2022]
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23
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Oppong KW, Dawwas MF, Charnley RM, Wadehra V, Elamin K, White S, Nayar M. EUS and EUS-FNA diagnosis of suspected pancreatic cystic neoplasms: Is the sum of the parts greater than the CEA? Pancreatology 2015; 15:531-537. [PMID: 26375415 DOI: 10.1016/j.pan.2015.08.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 08/04/2015] [Accepted: 08/05/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Carcinoembryonic antigen (CEA) is suggested as the single most useful EUS/EUS-FNA derived test for the diagnosis of mucinous pancreatic cysts. STUDY AIMS To investigate the yield and diagnostic performance of EUS/EUS-FNA on an intention to diagnose basis and to determine the utility of the recommended CEA and amylase cut-off values. PATIENTS AND METHODS A retrospective study of a prospectively maintained database of 433 procedures performed in a 10 year period. Diagnostic performance of EUS-FNA was determined in 133 procedures with a definite diagnosis. RESULTS CEA value was determined in significantly fewer procedures (58.6%) than EUS diagnosis was stated (83.4%; p < 0.0001), cyst fluid appearance recorded (89.4%) or adequate sample for cytology obtained (76.7%; p < 0.005). Median CEA was significantly higher in mucinous cysts than non-mucinous (175 ng/ml vs 3 ng/ml, p < 0.0001) and in malignant cysts compared to benign (8945 ng/ml vs 93 ng/ml, p < 0.001). On an intention-to-diagnose analysis, a CEA cut-off of 110 ng/ml was significantly less accurate (42.8%) than EUS diagnosis (67.7%), cytology (58.6%) or aspirate appearance (66.9%; p < 0.05 for all comparisons). However, the combination of EUS diagnosis, cytology and CEA provided higher sensitivity (91%), specificity (75%) and accuracy (85.7%) than each component test alone (p < 0.05 for all comparisons). Median amylase was significantly higher in benign compared to high-risk mucinous cysts ((11,429IU/L vs. 113IU/L; p < 0.05. CONCLUSION The combination of EUS, cytology and CEA performed well. Malignant cysts had a higher CEA value than benign cysts. On an intention to diagnose basis a CEA cut-off of 110 ng/ml performed poorly.
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Affiliation(s)
- K W Oppong
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK.
| | - M F Dawwas
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - R M Charnley
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - V Wadehra
- Department of Cellular Pathology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - K Elamin
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - S White
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - M Nayar
- HPB Unit, Freeman Hospital, Newcastle upon Tyne, UK; Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
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Falconi M, Crippa S, Chari S, Conlon K, Kim SW, Levy P, Tanaka M, Werner J, Wolfgang CL, Pezzilli R, Castillo CFD. Quality assessment of the guidelines on cystic neoplasms of the pancreas. Pancreatology 2015; 15:463-469. [PMID: 26100659 DOI: 10.1016/j.pan.2015.05.478] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 05/05/2015] [Accepted: 05/28/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Though cystic pancreatic neoplasms (CPNs) are being increasingly detected, their evaluation and management are still debated and have lead to publication of multiple guidelines for diagnostic work-up, indications for resection, and non-operative management with follow-up strategies of CPNs. AIMS To analyze available guidelines in order to evaluate their overall quality and clinical applicability, indications for surgical resection and its extent, modalities and timing of follow-up when non-operative management is indicated. METHODS After a systematic search of the English literature, we selected eight guidelines for assessment according to the Appraisal of Guidelines, Research and Evaluation in Europe (AGREE) II instrument. RESULTS One guideline received the lower AGREE score regarding the "scope and purpose", "rigor of development" and "clarity and presentation" domains, whereas one received the best score for "stakeholder involvement" domain. No differences were found among different guidelines regarding the "applicability". The overall quality assessment score showed that only two guidelines were significantly lower than the others. According to the practical utilization recommendation score, four guidelines were considered as having full applicability in clinical practice. CONCLUSION Existing guidelines provide adequate guidance, at least with the present knowledge, for the management of cystic pancreatic lesions; however, not any one was satisfactory to all aspects related to the management of CPN. An update of the existing guidelines should be considered if and when more evidence-based data are available.
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Affiliation(s)
- Massimo Falconi
- Division of Pancreatic Surgery, Università Politecnica delle Marche, Ospedali Riuniti, Ancona, Italy
| | - Stefano Crippa
- Division of Pancreatic Surgery, Università Politecnica delle Marche, Ospedali Riuniti, Ancona, Italy
| | - Suresh Chari
- Pancreas Interest Group, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Kevin Conlon
- Department of Surgery, Trinity College, Dublin, Ireland
| | - Sun-Whe Kim
- 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, Hospital Beaujon, APHP, Clichy Cedex, Faculté Denis Diderot, DHU Unity, France
| | - Masao Tanaka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Jens Werner
- Department of Surgery, Ludwig-Maximilian University of Munich, Munich, Germany
| | - Christopher L Wolfgang
- Department of Surgery and The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University, Baltimore, MD, USA
| | - Raffaele Pezzilli
- Pancreas Unit, Department of Digestive System, Sant'Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy.
| | - Carlos Fernandez-Del Castillo
- Pancreas and Biliary Program, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Kim TS, Fernandez-del Castillo C. Diagnosis and Management of Pancreatic Cystic Neoplasms. Hematol Oncol Clin North Am 2015; 29:655-74. [PMID: 26226903 DOI: 10.1016/j.hoc.2015.04.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Incidentally discovered pancreatic cystic lesions are increasingly common, affecting up to 10% to 15% of patients undergoing cross-sectional imaging. Although some pancreatic cystic neoplasms harbor invasive malignancy or the potential to progress over time, a majority are benign and can be observed safely. Accurate diagnosis is key to appropriate management. Diagnosis requires a multidisciplinary and multimodal approach. This review discusses each type of pancreatic cystic neoplasm and the current data on diagnosis and treatment.
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Affiliation(s)
- Teresa S Kim
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, GRB-425, Boston, MA 02114, USA
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Yuan CH, Tao M, Jia YM, Xiong JW, Zhang TL, Xiu DR. Duodenum-preserving resection and Roux-en-Y pancreatic jejunostomy in benign pancreatic head tumors. World J Gastroenterol 2014; 20:16786-16792. [PMID: 25469053 PMCID: PMC4248228 DOI: 10.3748/wjg.v20.i44.16786] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 04/17/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
This study was conducted to explore the feasibility of partial pancreatic head resection and Roux-en-Y pancreatic jejunostomy for the treatment of benign tumors of the pancreatic head (BTPH). From November 2006 to February 2009, four patients (three female and one male) with a mean age of 34.3 years (range: 21-48 years) underwent partial pancreatic head resection and Roux-en-Y pancreatic jejunostomy for the treatment of BTPH (diameters of 3.2-4.5 cm) using small incisions (5.1-7.2 cm). Preoperative symptoms include one case of repeated upper abdominal pain, one case of drowsiness and two cases with no obvious preoperative symptoms. All four surgeries were successfully performed. The mean operative time was 196.8 min (range 165-226 min), and average blood loss was 138.0 mL (range: 82-210 mL). The mean postoperative hospital stay was 7.5 d (range: 7-8 d). In one case, the main pancreatic duct was injured. Pathological examination confirmed that one patient suffered from mucinous cystadenoma, one exhibited insulinoma, and two patients had solid-pseudopapillary neoplasms. There were no deaths or complications observed during the perioperative period. All patients had no signs of recurrence of the BTPH within a follow-up period of 48-76 mo and had good quality of life without diabetes. Partial pancreatic head resection with Roux-en-Y pancreatic jejunostomy is feasible in selected patients with BTPH.
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Lee LS. Incidental Cystic Lesions in the Pancreas: Resect? EUS? Follow? CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2014; 12:333-49. [PMID: 24903582 DOI: 10.1007/s11938-014-0019-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pancreatic cysts challenge clinicians due to their increased incidental identification on radiology imaging, the limitations of currently available diagnostic tools, and potential for malignancy. Following initial identification of an incidental pancreatic cyst, a dedicated pancreatic protocol abdominal CT scan or MRI pancreas with MRCP should be performed. Surgical resection is recommended for all surgical candidates with MD-IPMN, mixed or combined type IPMN, mucinous cystic neoplasm, and solid pseudopapillary neoplasm. Serous cystadenoma may be followed with serial imaging unless the patient develops symptoms, the cyst is larger than 4 cm or rapidly growing, or diagnostic uncertainty remains despite thorough evaluation. Surveillance is also recommended for BD-IPMN without the following features concerning malignancy: obstructive jaundice with a cyst in the head of the pancreas; solid component; nodule; main pancreatic duct ≥10 mm; or cytology suspected or positive for malignancy. BD-IPMN ≥3 cm without concerning features may also be followed carefully, although surgical resection should be considered in surgically fit patients. EUS-FNA for cyst wall cytology, CEA, amylase, and occasionally k-ras mutation are also likely aids in the diagnosis of pancreatic cysts beyond radiologic imaging. This author typically recommends EUS-FNA to further evaluate cysts larger than 1 cm without definitive indication for resection. EUS is also appropriate in patients with solid component, nodule, or size ≥3 cm to aid in decision making, especially in older patients who may be less suitable surgical candidates. A multidisciplinary approach with a team of dedicated gastrointestinal radiologists, pancreatic surgeons, gastrointestinal pathologists, and gastroenterologists is essential for managing patients with pancreatic cysts.
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Affiliation(s)
- Linda S Lee
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA,
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Teshima CW, Sandha GS. Endoscopic ultrasound in the diagnosis and treatment of pancreatic disease. World J Gastroenterol 2014; 20:9976-9989. [PMID: 25110426 PMCID: PMC4123377 DOI: 10.3748/wjg.v20.i29.9976] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 04/23/2014] [Indexed: 02/06/2023] Open
Abstract
Endoscopic ultrasound (EUS) is an important part of modern gastrointestinal endoscopy and now has an integral role in the diagnostic evaluation of pancreatic diseases. Furthermore, as EUS technology has advanced, it has increasingly become a therapeutic procedure, and the prospect of multiple applications of interventional EUS for the pancreas is truly on the near horizon. However, this review focuses on the established diagnostic and therapeutic roles of EUS that are used in current clinical practice. In particular, the diagnostic evaluation of acute pancreatitis, chronic pancreatitis, cystic pancreatic lesions and solid masses of the pancreas are discussed. The newer enhanced imaging modalities of elastography and contrast enhancement are evaluated in this context. The main therapeutic aspects of pancreatic EUS are then considered, namely celiac plexus block and celiac plexus neurolysis for pain control in chronic pancreatitis and pancreas cancer, and EUS-guided drainage of pancreatic fluid collections.
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Adler D, Schmidt CM, Al-Haddad M, Barthel JS, Ljung BM, Merchant NB, Romagnuolo J, Shaaban AM, Simeone D, Pitman MB, Layfield LJ. Clinical evaluation, imaging studies, indications for cytologic study and preprocedural requirements for duct brushing studies and pancreatic fine-needle aspiration: The Papanicolaou Society of Cytopathology Guidelines. Cytojournal 2014; 11:1. [PMID: 25191515 PMCID: PMC4153337 DOI: 10.4103/1742-6413.133326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 03/07/2014] [Indexed: 12/19/2022] Open
Abstract
The Papanicolaou Society of Cytopathology has developed a set of guidelines for pancreaticobiliary cytology including indications for endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) biopsy, techniques for EUS-FNA, terminology and nomenclature to be used for pancreaticobiliary disease, ancillary testing and postbiopsy management. All documents are based on expertise of the authors, literature review, discussions of the draft document at national and international meetings and synthesis of online comments of the draft document. This document selectively presents the results of these discussions. This document summarizes recommendations for the clinical and imaging work-up of pancreatic and biliary tract lesions along with indications for cytologic study of these lesions. Prebrushing and FNA requirements are also discussed.
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Affiliation(s)
- Douglas Adler
- Address: Division of Gastroenterology, Department of Internal Medicine at the University of Utah School of Medicine, Indianapolis, Indiana
| | - C Max Schmidt
- Department of Surgery and Biochemistry/Molecular Biology, Indiana University, School of Medicine, Indianapolis, Indiana
| | - Mohammad Al-Haddad
- Department of Medicine, Division of Gastroenterology, Indiana University, Indianapolis, Indiana
| | | | - Britt-Marie Ljung
- Department of Pathology and Laboratory Medicine, University of California, San Francisco, California
| | - Nipun B Merchant
- Department of Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Joseph Romagnuolo
- Department of Medicine, Division of Gastroenterology, Medical University of South Carolina, Charleston, South Carolina
| | - Akram M Shaaban
- Department of Radiology, University of Utah, School of Medicine, Salt Lake City, Utah
| | - Diane Simeone
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Lester J Layfield
- Department of Pathology and Anatomical Sciences, University of Missouri, Columbia, Missouri
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Buscarini E, Pezzilli R, Cannizzaro R, De Angelis C, Gion M, Morana G, Zamboni G, Arcidiacono P, Balzano G, Barresi L, Basso D, Bocus P, Calculli L, Capurso G, Canzonieri V, Casadei R, Crippa S, D'Onofrio M, Frulloni L, Fusaroli P, Manfredi G, Pacchioni D, Pasquali C, Rocca R, Ventrucci M, Venturini S, Villanacci V, Zerbi A, Falconi M. Italian consensus guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms. Dig Liver Dis 2014; 46:479-93. [PMID: 24809235 DOI: 10.1016/j.dld.2013.12.019] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 12/07/2013] [Accepted: 12/30/2013] [Indexed: 12/11/2022]
Abstract
This report contains clinically oriented guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms in patients fit for treatment. The statements were elaborated by working groups of experts by searching and analysing the literature, and then underwent a consensus process using a modified Delphi procedure. The statements report recommendations regarding the most appropriate use and timing of various imaging techniques and of endoscopic ultrasound, the role of circulating and intracystic markers and the pathologic evaluation for the diagnosis and follow-up of cystic pancreatic neoplasms.
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Affiliation(s)
| | | | | | - Raffaele Pezzilli
- Pancreas Unit, Department of Digestive Diseases and Internal Medicine, S. Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Claudio De Angelis
- Gastroenterology and Hepatology Department, A.O. San Giovanni Battista/Molinette, University of Turin, Turin, Italy
| | - Massimo Gion
- Department of Clinical Pathology, AULSS 12, Venice, Italy
| | - Giovanni Morana
- Department of Diagnostic Radiology, Ospedale Cà Foncello, Treviso, Italy
| | | | - Paolo Arcidiacono
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute, Italy
| | - Gianpaolo Balzano
- Department of Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Luca Barresi
- Gastroenterology and Endoscopy Unit, ISMETT, Palermo, Italy
| | - Daniela Basso
- Department of Laboratory Medicine, University Hospital, Padua, Italy
| | - Paolo Bocus
- Gastroenterology Unit, Ospedale Sacro Cuore-Don Calabria, Negrar, Verona, Italy
| | - Lucia Calculli
- Department of Radiology, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Gabriele Capurso
- Digestive and Liver Disease Unit, Faculty of Medicine and Psychology, Sapienza University of Rome at S. Andrea Hospital, Rome, Italy
| | | | - Riccardo Casadei
- Department of Surgery, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Stefano Crippa
- Department of Surgery, Pancreas Unit, Università Politecnica delle Marche, Ancona, Italy
| | - Mirko D'Onofrio
- Department of Radiology, University Hospital G.B. Rossi, University of Verona, Verona, Italy
| | - Luca Frulloni
- Department of Surgical and Gastroenterological Sciences, University of Verona, Verona, Italy
| | - Pietro Fusaroli
- Department of Clinical Medicine, University of Bologna, Bologna, Italy
| | | | | | - Claudio Pasquali
- Surgery Unit IV, Department of Medical and Surgical Sciences, University of Padua, Padua, Italy
| | - Rodolfo Rocca
- Gastroenterology Unit, Mauriziano Hospital, Turin, Italy
| | - Maurizio Ventrucci
- Department of Internal Medicine and Gastroenterology, Bentivoglio Hospital, Bologna, Italy
| | - Silvia Venturini
- Department of Diagnostic Radiology, Ospedale Cà Foncello, Treviso, Italy
| | | | - Alessandro Zerbi
- Pancreatic Surgery, Department of Surgery, Humanitas Clinical and Research Center, Milan, Italy
| | - Massimo Falconi
- Department of Surgery, Pancreas Unit, Università Politecnica delle Marche, Ancona, Italy
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31
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Abdeljawad K, Vemulapalli KC, Schmidt CM, Dewitt J, Sherman S, Imperiale TF, Al-Haddad M. Prevalence of malignancy in patients with pure main duct intraductal papillary mucinous neoplasms. Gastrointest Endosc 2014; 79:623-9. [PMID: 24094923 DOI: 10.1016/j.gie.2013.08.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 08/20/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND Risk of malignancy in main duct intraductal papillary mucinous neoplasm (MD-IPMN) ranges from 36% to 100% in the literature. Although surgical resection is recommended for all MD-IPMNs, the risk of malignancy based on main pancreatic duct (MPD) size alone remains unclear. OBJECTIVE To assess the prevalence of malignancy in symptomatic and asymptomatic patients with pure MD-IPMN based on MPD size. DESIGN Single-center retrospective study of prospectively collected data. SETTINGS Tertiary referral center. PATIENTS AND INTERVENTIONS Fifty-two patients with pure low-risk MD-IPMN. Clinical, endoscopic, radiographic, and pathologic data were reviewed. MAIN OUTCOME MEASUREMENTS Prevalence of malignancy in patients with pure MD-IPMN based on histopathology of resected lesions. RESULTS Sixteen asymptomatic patients had pure MD-IPMN on surgical pathology, 4 (25%) with malignant disease, compared with 25 of 36 symptomatic patients (69%) with pure MD-IPMN. Logistic regression identified symptoms and MPD size as predictors of malignancy. Receiver operating characteristic curve analysis demonstrated that MPD size (optimal cutoff of 8 mm) produced the greatest area under the curve to discriminate between benign and malignant MD-IPMN (.83; 95% CI, .72-.94). MPD size greater than 8 mm has a relative risk of 2.8 for malignancy (95% CI, 1.6-4.9). LIMITATIONS Retrospective, single-center study at a tertiary referral hospital. Study population included only patients who underwent surgical resection. CONCLUSION Asymptomatic MD-IPMN patients with a duct size of no more than 8 mm have a lower prevalence of malignancy and may represent a distinct group of patients with less aggressive biologic behavior. Further studies are needed to confirm our observations.
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Affiliation(s)
- Khaled Abdeljawad
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Krishna C Vemulapalli
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John Dewitt
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stuart Sherman
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Thomas F Imperiale
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mohammad Al-Haddad
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Adler D, Max Schmidt C, Al-Haddad M, Barthel JS, Ljung BM, Merchant NB, Romagnuolo J, Shaaban AM, Simeone D, Bishop Pitman M, Field A, Layfield LJ. Clinical evaluation, imaging studies, indications for cytologic study, and preprocedural requirements for duct brushing studies and pancreatic FNA: the Papanicolaou Society of Cytopathology recommendations for pancreatic and biliary cytology. Diagn Cytopathol 2014; 42:325-32. [PMID: 24554480 DOI: 10.1002/dc.23095] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 01/08/2014] [Indexed: 12/21/2022]
Abstract
The Papanicolaou Society of Cytopathology has developed a set of guidelines for pancreaticobiliary cytology including indications for endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) biopsy, techniques for EUS-FNA, terminology and nomenclature to be used for pancreaticobiliary disease, ancillary testing, and post-biopsy management. All documents are based on expertise of the authors, literature review, discussions of the draft document at national and international meetings, and synthesis of online comments of the draft document. This document selectively presents the results of these discussions. This document summarizes recommendations for the clinical and imaging work-up of pancreatic and biliary tract lesions along with indications for cytologic study of these lesions. Prebrushing and FNA requirements are also discussed.
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Affiliation(s)
- Douglas Adler
- Department of Medicine, Division of Gastroenterology, University of Utah School of Medicine, Salt Lake City, Utah
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Intraductal oncocytic papillary neoplasm: a rare pancreatic mass. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2014; 27:387-8. [PMID: 23862166 DOI: 10.1155/2013/738012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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34
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Pancreatic cysts: more answers, more questions. Am J Gastroenterol 2014; 109:131-3. [PMID: 24402534 DOI: 10.1038/ajg.2013.447] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 11/19/2013] [Indexed: 12/11/2022]
Abstract
Management of incidental pancreatic cysts has been a conundrum for the clinician owing to uncertain implications for the presence of cancer or progression to pancreatic malignancy. Asymptomatic pancreatic cysts are being detected in increasing numbers, especially in elderly patients getting radiologic imaging studies for evaluation of other non-pancreatic symptoms and signs. As a result, various radiologic, endoscopic, and pathologic criteria have been developed to help stratify the risk of malignancy in these patients and optimize strategies for patient care including surveillance or resection. In this issue, Wu and co-workers (Am J Gastroenterol, this issue) present their study assessing the prediction of malignancy in cystic neoplasms of the pancreas.
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De Angelis C, Brizzi RF, Pellicano R. Endoscopic ultrasonography for pancreatic cancer: current and future perspectives. J Gastrointest Oncol 2013; 4:220-30. [PMID: 23730519 DOI: 10.3978/j.issn.2078-6891.2013.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 01/18/2013] [Indexed: 12/13/2022] Open
Abstract
A suspected pancreatic lesion can be a difficult challenge for the clinician. In the last years we have witnessed tumultuous technological improvements of the radiological and nuclear medicine imaging. Taking this into account, we will try to delineate the new role of endoscopic ultrasound (EUS) in pancreatic imaging and to place it in a shareable diagnostic and staging algorithm of pancreatic cancer (PC). To date the most accurate imaging techniques for the PC remain contrast-enhanced computed tomography (CT) and EUS. The latter has the highest accuracy in detecting small lesions, in assessing tumor size and lymph nodes involvement, but helical CT or an up-to-date magnetic resonance imaging (MRI) must be the first choice in patients with a suspected pancreatic lesion. After this first step there is place for EUS as a second diagnostic level in several cases: negative results on CT/MRI scans and persistent strong clinical suspicion of PC, doubtful results on CT/MRI scans or need for cyto-histological confirmation. In the near future there will be great opportunities for the development of diagnostic and therapeutic EUS and pancreatic pathology could be the best testing bench.
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Affiliation(s)
- Claudio De Angelis
- Department of Gastroenterology and Hepatology, Endoscopy and Endosonography Center, San Giovanni Battista Hospital (Molinette), University of Turin, Italy
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Farrell JJ, Fernández-del Castillo C. Pancreatic cystic neoplasms: management and unanswered questions. Gastroenterology 2013; 144:1303-15. [PMID: 23622140 DOI: 10.1053/j.gastro.2013.01.073] [Citation(s) in RCA: 181] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 01/27/2013] [Accepted: 01/30/2013] [Indexed: 02/08/2023]
Abstract
Approximately 10% of persons 70 years old or older are now diagnosed with pancreatic cysts, but it is not clear which ones require additional analysis, interventions, or follow-up. Primary care doctors rely on gastroenterologists for direction because no one wants to miss a diagnosis of pancreatic cancer, but meanwhile there is pressure to limit use of diagnostic tests and limit costs. We review the different cystic neoplasms of the pancreas and diagnostic strategies based on clinical features and imaging data. We discuss surgical and nonsurgical management of the most common cystic neoplasms, based on the recently revised Sendai guidelines. Intraductal papillary mucinous neoplasm (particularly the branch duct variant) is the lesion most frequently identified incidentally. We report what is known about its pathology, its risk of developing into pancreatic ductal adenocarcinoma, the pros and cons of current guidelines for management, and the potential role of endoscopic ultrasound in determining cancer risk. We also review surgical treatment and strategies for surveillance of pancreatic cysts.
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Affiliation(s)
- James J Farrell
- Yale Pancreas Center and Interventional Endoscopy, Yale School of Medicine, New Haven, Connecticut, USA.
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37
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Kucera JN, Kucera S, Perrin SD, Caracciolo JT, Schmulewitz N, Kedar RP. Cystic lesions of the pancreas: radiologic-endosonographic correlation. Radiographics 2013; 32:E283-301. [PMID: 23150863 DOI: 10.1148/rg.327125019] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cystic lesions of the pancreas are relatively common findings at cross-sectional imaging; however, classification of these lesions on the basis of imaging features alone can sometimes be difficult. Complementary evaluation with endoscopic ultrasonography and fine-needle aspiration may be helpful in the diagnosis of these lesions. Cystic lesions of the pancreas may range from benign to malignant and include both primary cystic lesions of the pancreas (including intraductal papillary mucinous neoplasms, mucinous cystic neoplasms, serous cystadenomas, pseudocysts, and true epithelial cysts) and solid neoplasms undergoing cystic degeneration (including neuroendocrine tumors, solid pseudopapillary neoplasms, and, rarely, adenocarcinoma and its variants). Familiarity with the imaging features of these lesions and the basic treatment algorithms is essential for radiologists, as collaboration with gastroenterologists and surgeons is often necessary to obtain an early and accurate diagnosis.
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Affiliation(s)
- Jennifer N Kucera
- Department of Radiology, University of South Florida College of Medicine, 12901 Bruce B. Downs Blvd, Box 17, Tampa, FL 33612, USA.
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38
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Abstract
Incidentally discovered cystic tumors of the pancreas (CTP) are an increasingly frequent entity. It is essential to differentiate lesions whose malignant potential is either nil or negligible (pseudocyst, serous cystadenoma, simple cysts) from lesions with intermediate malignant potential (intraductal papillary mucinous tumor of the pancreas [IPMN] involving the secondary ducts, cystic endocrine tumor) or those with high malignant potential (mucinous cystadenoma, solid pseudopapillary tumors and IPMN involving the main pancreatic duct). The approach to defining malignant potential is based on diagnostic CT scan, magnetic resonance imaging (MRI), and endoscopic ultrasound (EUS), often complemented by EUS-guided cyst puncture for biochemical and cytological analysis of cyst fluid. Surgery for diagnostic purposes should be avoided because of its significant morbidity. For pseudocysts, simple cysts and serous cystadenomas, abstention is the general rule. Resection, preserving as much pancreatic parenchyma as possible, is the rule for IPMN involving the main pancreatic duct, mucinous cystadenomas, solid and pseudopapillary tumors, and cystic endocrine tumors. Resection is rarely indicated at the outset for IPMN involving secondary pancreatic ducts; morphologic observation is the general rule and preventive excision may be indicated secondarily. Good collaboration between surgeons, radiologists and endosonographists is necessary for optimal management of CTP.
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Abstract
Pancreatic cystic neoplasms represent a wide spectrum of invariably benign to precancerous and malignant tumors. Endoscopic ultrasound-guided pancreatic cyst ablation with ethanol and/or paclitaxel offers a nonoperative treatment for patients refusing or not eligible for surgery. Histopathology after resection in these patients has shown variable degrees of cyst epithelial ablation ranging from 0% to 100%. Future research investigating the safety of this procedure, modifications of reported ablation techniques, choice and number of the lavage agents used, and criteria to optimize selection of the appropriate pancreatic cysts for treatment is needed.
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Affiliation(s)
- John DeWitt
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, 550 North University Boulevard, UH 4100, Indianapolis, IN 46202, USA.
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