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Wang L, Nie F, Dong T, Li M, Li Y, Yin C. Role of contrast-enhanced ultrasound with time-intensity curve analysis for differentiating hypovascular solid pancreatic lesions. Eur Radiol 2023:10.1007/s00330-023-09393-7. [PMID: 36725721 DOI: 10.1007/s00330-023-09393-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 12/08/2022] [Accepted: 12/23/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To evaluate the clinical value of contrast-enhanced ultrasound (CEUS) with time-intensity curve (TIC) in distinguishing different types of hypovascular solid pancreatic lesions. METHODS A total of 89 patients with 90 pancreatic lesions (all confirmed by surgery or biopsy pathology) that manifested hypoenhancement on contrast-enhanced ultrasound (CEUS) were included in this study. Six peak enhancement patterns were proposed for differentiating hypovascular pancreatic lesions. CEUS qualitative and TIC-based quantitative parameters were analyzed, and each lesion was scored based on the statistically significant qualitative parameters to evaluate the diagnostic ability of CEUS for hypovascular solid pancreatic lesions. RESULTS Qualitative parameters such as peak enhancement pattern II/III/IV, penetrating vessels, centripetal enhancement, and early washout were reliable indicators of malignant lesions, and lesions scored based on these qualitative parameters, with a score ≥ 2, were highly suspected to be malignant lesions. Pattern I had an accuracy of 83.33% for predicting mass-forming pancreatitis (MFP), pattern V had an accuracy of 96.67% for predicting solid pseudopapillary tumors of the pancreas (SPTP), and pattern VI had an accuracy of 81.11% for predicting neuroendocrine tumors/carcinomas (NETs/NECs). For quantitative analysis, nodule/pancreatic parenchyma echo intensity reduction ratio was significantly greater in malignant lesions. CONCLUSIONS CEUS qualitative and TIC-based quantitative parameters have clinical value in distinguishing malignant from benign hypovascular pancreatic lesions. KEY POINTS • Contrast-enhanced ultrasound helps clinicians assess patients with pancreatic lesions. • Six peak enhancement patterns are proposed for differentiating pancreatic hypovascular lesions. • Qualitative parameters such as peak enhancement pattern II/III/IV, penetrating vessels, centripetal enhancement, early washout, and quantitative parameter nodule/pancreatic parenchyma echo intensity reduction ratio were important characteristics to discriminate malignant from hypovascular benign lesions.
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Affiliation(s)
- Lan Wang
- Ultrasound Medical Center, Lanzhou University Second Hospital, Chengguan District, Cuiyingmen No.82, Lanzhou, 730030, China.,Gansu Province Clinical Research Center for Ultrasonography, Lanzhou, China
| | - Fang Nie
- Ultrasound Medical Center, Lanzhou University Second Hospital, Chengguan District, Cuiyingmen No.82, Lanzhou, 730030, China. .,Gansu Province Clinical Research Center for Ultrasonography, Lanzhou, China.
| | - Tiantian Dong
- Ultrasound Medical Center, Lanzhou University Second Hospital, Chengguan District, Cuiyingmen No.82, Lanzhou, 730030, China.,Gansu Province Clinical Research Center for Ultrasonography, Lanzhou, China
| | - Ming Li
- Ultrasound Medical Center, Lanzhou University Second Hospital, Chengguan District, Cuiyingmen No.82, Lanzhou, 730030, China.,Gansu Province Clinical Research Center for Ultrasonography, Lanzhou, China
| | - Yuanyuan Li
- Ultrasound Medical Center, Lanzhou University Second Hospital, Chengguan District, Cuiyingmen No.82, Lanzhou, 730030, China.,Gansu Province Clinical Research Center for Ultrasonography, Lanzhou, China
| | - Ci Yin
- Ultrasound Medical Center, Lanzhou University Second Hospital, Chengguan District, Cuiyingmen No.82, Lanzhou, 730030, China.,Gansu Province Clinical Research Center for Ultrasonography, Lanzhou, China
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2
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Bell PD, Singhi AD. Integrating Molecular Analysis into the Pathologic Evaluation of Pancreatic Cysts. Surg Pathol Clin 2022; 15:455-468. [PMID: 36049828 DOI: 10.1016/j.path.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
The development of cross-sectional imaging techniques has enhanced the detection of pancreatic cystic lesions (PCLs). PCLs are found in approximately 2% of the general population, often as incidentally detected lesions on computed tomography or MRI during the evaluation of other medical conditions. Broadly, PCLs are classified as mucinous or nonmucinous. Mucinous PCLs include mucinous cystic neoplasms and intraductal papillary mucinous neoplasms. Nonmucinous PCLs include pseudocysts, serous cystadenomas, solid pseudopapillary neoplasms, and cystic pancreatic neuroendocrine tumors, as well as cystic acinar cell carcinoma, cystic degeneration of pancreatic ductal adenocarcinoma, lymphoepithelial cyst, and others.
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Affiliation(s)
- Phoenix D Bell
- Department of Pathology, University of Pittsburgh Medical Center, 200 Lothrop St. Pittbsurgh, PA 15213, USA.
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, 200 Lothrop St. Pittbsurgh, PA 15213, USA
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3
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Abstract
Early detection of high-risk pancreatic cystic lesions enables potentially curative surgical resection, and early detection of lesions without worrisome features may lead to appropriate surveillance. Regrettably, differentiating premalignant and malignant cysts from nonmalignant ones remains challenging. However, emerging additional diagnostic tools, including the needle biopsy with microforceps and needle-based confocal laser endomicroscopy, are of exciting potential along with cyst fluid analysis".
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Affiliation(s)
- Sahin Coban
- Department of Gastroenterology, Mount Auburn Hospital, 330 Mt Auburn St, Cambridge, MA 02138, USA.
| | - Omer Basar
- Department of Gastroenterology, The University of Missouri, Columbia, MO 65211, USA
| | - William R Brugge
- Department of Gastroenterology, Harvard Medical School, Mount Auburn Hospital, 330 Mt Auburn St, Cambridge, MA 02138, USA
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4
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Buerlein RCD, Shami VM. Management of pancreatic cysts and guidelines: what the gastroenterologist needs to know. Ther Adv Gastrointest Endosc 2021; 14:26317745211045769. [PMID: 34589706 PMCID: PMC8474323 DOI: 10.1177/26317745211045769] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/25/2021] [Indexed: 12/15/2022] Open
Abstract
The prevalence of pancreatic cysts has increased significantly over the last
decade, partly secondary to increased quality and frequency of cross-sectional
imaging. While the majority never progress to cancer, a small number will and
need to be followed. The management of pancreatic cysts can be both confusing
and intimidating due to the multiple guidelines with varying recommendations.
Despite the differences in the specifics of the guidelines, they all agree on
several high-risk features that should get the attention of any clinician when
assessing a pancreatic cyst: presence of a mural nodule or solid component,
dilation of the main pancreatic duct (or presence of main duct intraductal
papillary mucinous neoplasm), pancreatic cyst size ⩾3–4 cm, or positive cytology
on pancreatic cyst fluid aspiration. Other important criteria to consider
include rapid cyst growth (⩾5 mm/year), elevated serum carbohydrate antigen 19-9
levels, new-onset diabetes mellitus, or acute pancreatitis thought to be related
to the cystic lesion.
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Affiliation(s)
| | - Vanessa M Shami
- University of Virginia Digestive Health, 1215 Lee Street, Charlottesville, VA 22903, USA
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5
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Reappraisal of a 2-Cm Cut-off Size for the Management of Cystic Pancreatic Neuroendocrine Neoplasms: A Multicenter International Study. Ann Surg 2021; 273:973-981. [PMID: 31348038 DOI: 10.1097/sla.0000000000003508] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of this study was to characterize an international cohort of resected cystic pancreatic neuroendocrine neoplasms (cPanNENs) and identify preoperative predictors of aggressive behavior. BACKGROUND The characteristics of cPanNENs are unknown and their clinical management remains unclear. An observational strategy for asymptomatic cPanNENs ≤2 cm has been proposed by recent guidelines, but evidence is scarce and limited to single-institutional series. METHODS Resected cPanNENs (1995-2017) from 16 institutions worldwide were included. Solid lesions (>50% solid component), functional tumors, and MEN-1 patients were excluded. Aggressiveness was defined as lymph node (LN) involvement, G3 grading, distant metastases, and/or recurrence. RESULTS Overall, 263 resected cPanNENs were included, among which 177 (63.5%) were >2 cm preoperatively. A preoperative diagnosis of cPanNEN was established in 162 cases (61.6%) and was more frequent when patients underwent endoscopic ultrasound [EUS, odds ratio (OR) 2.69, 95% confidence interval (CI) 1.52-4.77] and somatostatin-receptor imaging (OR 3.681, 95% CI 1.809-7.490), and for those managed in specialized institutions (OR 3.12, 95% CI 1.57-6.21). Forty-one cPanNENs (15.6%) were considered aggressive. In the whole cohort, LN involvement on imaging, age >65 years, preoperative size >2 cm, and pancreatic duct dilation were independently associated with aggressive behavior. In asymptomatic patients, older age and a preoperative size >2 cm remained independently associated with aggressiveness. Only 1 of 61 asymptomatic cPanNENs ≤2 cm displayed an aggressive behavior. CONCLUSIONS The diagnostic accuracy of cPanNENs is increased by the use of EUS and somatostatin-receptor imaging and is higher in specialized institutions. Preoperative size >2 cm is independently associated with aggressive behavior. Consequently, a watch-and-wait policy for sporadic asymptomatic cPanNENs ≤2 cm seems justified and safe for most patients.
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6
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Gao H, Wang W, Zhang W, Xu H, Wu C, Li H, Ni Q, Yu X, Liu L. The distinctive characteristics of the micro-vasculature and immune cell infiltration in cystic pancreatic neuroendocrine tumors. J Endocrinol Invest 2021; 44:1011-1019. [PMID: 32856225 DOI: 10.1007/s40618-020-01396-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 08/15/2020] [Indexed: 01/13/2023]
Abstract
PURPOSE Hypervascularity is a main characteristic of pancreatic neuroendocrine tumors (PanNETs), and cystic PanNETs (CPanNETs) are unique type of PanNETs in which the microenvironment remains unknown. We aim to compare the micro-vasculature features and immune cell infiltration between CPanNETs and solid PanNETs (SPanNETs). METHODS Data of 301 SPanNET and 36 CPanNET patients from a high-volume institution were evaluated. CD4, CD8, CD11c, CD15, CD20, CD68, CD34 and α-SMA expression levels were assessed by immunohistochemistry and immunofluorescent double staining. The microvessel density (MVD) and microvessel integrity (MVI) were examined. RESULTS MVD and MVI expression levels in CPanNETs were significantly higher than those in SPanNETs (p = 0.025 and 0.0092, respectively). CPanNETs had higher proportions of T1 (p = 0.023) and G1 (p = 0.052) than SPanNETs. In SPanNETs, higher MVD occurred in stages T1, N0 and G1 than in the T2/T3, N1 and G2 subgroups. In CPanNETs, CD34-MVD was uncorrelated with the T stage or grade. Higher CD34-MVD, but not MVI, was associated with better DFS (HR 0.3209, 95% CI 0.1259-0.8176, p = 0.004). There were significantly more peritumoral infiltrating immune cells than their intratumoral counterparts (p < 0.001 for each) in CPanNETs and SPanNETs. The mean number of peritumoral CD68 + TAM in CPanNETs was significantly lower than that in SPanNETs (p = 0.008). The counts of other peritumoral immune cells did not significantly differ between CPanNETs and SPanNETs. CONCLUSIONS CPanNETs had a microenvironment distinct from that of SPanNETs, including higher CD34-MVD, higher MVI and lower TAM. This specific microenvironment structure may partially help predicting the prognosis of patients with PanNET.
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Affiliation(s)
- H Gao
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
- Department of Pancreatic Surgery, Shanghai Pancreatic Cancer Institute, Shanghai, 200032, People's Republic of China
- Pancreatic Cancer Institute, Fudan University Shanghai Cancer Center, Fudan University, 270 Dong An Road, Shanghai, 200032, People's Republic of China
| | - W Wang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
- Department of Pancreatic Surgery, Shanghai Pancreatic Cancer Institute, Shanghai, 200032, People's Republic of China
- Pancreatic Cancer Institute, Fudan University Shanghai Cancer Center, Fudan University, 270 Dong An Road, Shanghai, 200032, People's Republic of China
| | - W Zhang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
- Department of Pancreatic Surgery, Shanghai Pancreatic Cancer Institute, Shanghai, 200032, People's Republic of China
- Pancreatic Cancer Institute, Fudan University Shanghai Cancer Center, Fudan University, 270 Dong An Road, Shanghai, 200032, People's Republic of China
| | - H Xu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
- Department of Pancreatic Surgery, Shanghai Pancreatic Cancer Institute, Shanghai, 200032, People's Republic of China
- Pancreatic Cancer Institute, Fudan University Shanghai Cancer Center, Fudan University, 270 Dong An Road, Shanghai, 200032, People's Republic of China
| | - C Wu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
- Department of Pancreatic Surgery, Shanghai Pancreatic Cancer Institute, Shanghai, 200032, People's Republic of China
- Pancreatic Cancer Institute, Fudan University Shanghai Cancer Center, Fudan University, 270 Dong An Road, Shanghai, 200032, People's Republic of China
| | - H Li
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
- Department of Pancreatic Surgery, Shanghai Pancreatic Cancer Institute, Shanghai, 200032, People's Republic of China
- Pancreatic Cancer Institute, Fudan University Shanghai Cancer Center, Fudan University, 270 Dong An Road, Shanghai, 200032, People's Republic of China
| | - Q Ni
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, People's Republic of China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China
- Department of Pancreatic Surgery, Shanghai Pancreatic Cancer Institute, Shanghai, 200032, People's Republic of China
- Pancreatic Cancer Institute, Fudan University Shanghai Cancer Center, Fudan University, 270 Dong An Road, Shanghai, 200032, People's Republic of China
| | - X Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, People's Republic of China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China.
- Department of Pancreatic Surgery, Shanghai Pancreatic Cancer Institute, Shanghai, 200032, People's Republic of China.
- Pancreatic Cancer Institute, Fudan University Shanghai Cancer Center, Fudan University, 270 Dong An Road, Shanghai, 200032, People's Republic of China.
| | - L Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai, 20032, People's Republic of China.
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, People's Republic of China.
- Department of Pancreatic Surgery, Shanghai Pancreatic Cancer Institute, Shanghai, 200032, People's Republic of China.
- Pancreatic Cancer Institute, Fudan University Shanghai Cancer Center, Fudan University, 270 Dong An Road, Shanghai, 200032, People's Republic of China.
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7
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Cheng Y, Wu D, Wang L, Liu H, Xiong Y, Xu J, Hu S, Zhan H. Cystic Pancreatic Neuroendocrine Tumors Represent a Distinct Clinical Entity with Less Aggressive Biological Behaviors. J Surg Res 2020; 260:134-140. [PMID: 33340866 DOI: 10.1016/j.jss.2020.11.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/26/2020] [Accepted: 11/01/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Pancreatic neuroendocrine tumors (pNETs) uncommonly present as cystic lesions. There is a gap in knowledge of their clinicopathological characteristics and biological behaviors. Previous reported studies remained inconsistent and controversial. The purpose of this study is to investigate the clinicopathological features of cystic pNET and determine if it represents a distinct clinical entity by comparing its characteristics with those of solid pNETs. METHODS Patients with pNETs who underwent surgical resections from January 2014 to April 2019 at Qilu Hospital of Shandong University were reviewed retrospectively. Demographics, clinical characteristics, surgical data, and oncological as well as histological characteristics of cystic pNETs and their solid counterparts were collected and analyzed. RESULTS A total of 122 patients were included in this study, and 10.7% (13/122) patients were cystic. There is no significant difference between cystic pNETs and solid pNETs in age (43.6 ± 15.8 versus 50.9 ± 14.5 y, P = 0.093) and sex distribution (P = 0.085). Cystic pNETs are more likely to be asymptomatic (61.5% versus 23.9%, P = 0.008) and nonfunctional (92.3% versus 52.7%, P = 0.006) than solid pNETs. However, the tumor size (4.8 ± 4.5 versus 2.8 ± 1.9 cm, P = 0.124), proportion of multiple endocrine neoplasia type 1 (92.3% versus 98.2%, P = 0.289), and tumor location (P = 0.154) are similar in both groups. Compared with solid pNETs, cystic pNETs have a lower Ki-67 index and incidence of liver metastasis, but the difference is not significant. CONCLUSIONS Cystic pNETs are more likely to be nonfunctional and indolent and seem to exhibit less aggressive biological behaviors than solid pNETs. Conservative approach should be considered for certain selected patients.
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Affiliation(s)
- Yugang Cheng
- Division of Pancreatic Surgery, Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Dong Wu
- Division of Pancreatic Surgery, Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Lei Wang
- Division of Pancreatic Surgery, Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Han Liu
- Division of Pancreatic Surgery, Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Yacheng Xiong
- Division of Pancreatic Surgery, Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Jianwei Xu
- Division of Pancreatic Surgery, Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Sanyuan Hu
- Division of Pancreatic Surgery, Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, China
| | - Hanxiang Zhan
- Division of Pancreatic Surgery, Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, China.
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Ozaki K, Ikeno H, Kaizaki Y, Maeda K, Higuchi S, Kosaka N, Kimura H, Gabata T. Pearls and pitfalls of imaging features of pancreatic cystic lesions: a case-based approach with imaging-pathologic correlation. Jpn J Radiol 2020; 39:118-142. [PMID: 32840742 DOI: 10.1007/s11604-020-01032-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022]
Abstract
A variety of neoplastic and non-neoplastic lesions of the pancreas can present with a predominantly cystic architecture. These lesions are increasingly being detected as incidental findings on routine cross-sectional imaging following technological advances in these techniques and their widespread use. The different histopathological behaviors show various common and uncommon imaging findings, and some cases show similar appearance in spite of different histopathology. Each lesion requires specific management because of the differing risk of progression to malignancy, and an accurate imaging diagnosis is crucial. The typical imaging characteristics that differentiate pancreatic cystic lesions have been well described and fully summarized. However, in addition to a small percentage of cases that shows uncommon imaging findings, a substantial percentage of cystic lesions shows overlapping imaging findings that can lead to radiological misdiagnosis. For appropriate diagnosis and optimal treatment strategy, it is important to know the uncommon and overlapping imaging findings of these lesions, in addition to familiarity with the typical aspects. In this article, we reconfirm the well-known characteristic imaging features of pancreatic cystic lesions and present several diagnostically challenging cases, focusing on the uncommon and overlapping imaging findings.
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Affiliation(s)
- Kumi Ozaki
- Department of Radiology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka-Shimoaizuki, Eiheiji, Fukui, 910-1193, Japan.
| | - Hiroshi Ikeno
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Yasuharu Kaizaki
- Department of Diagnostic Pathology, Fukui Prefectural Hospital, Fukui, Japan
| | - Kazuya Maeda
- Department of Surgery, Fukui Prefectural Hospital, Fukui, Japan
| | - Shohei Higuchi
- Department of Pathology, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Nobuyuki Kosaka
- Department of Radiology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka-Shimoaizuki, Eiheiji, Fukui, 910-1193, Japan
| | - Hirohiko Kimura
- Department of Radiology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka-Shimoaizuki, Eiheiji, Fukui, 910-1193, Japan
| | - Toshifumi Gabata
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
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Khalil A, Ewald J, Marchese U, Autret A, Garnier J, Niccoli P, Piana G, Poizat F, Giovannini M, Delpero JR, Turrini O. A single-center experience with pancreatic cystic neuroendocrine tumors. World J Surg Oncol 2020; 18:208. [PMID: 32799893 PMCID: PMC7429455 DOI: 10.1186/s12957-020-01994-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/06/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Pancreatic neuroendocrine tumors (PNET) are rare, with a significant malignant potential. This study aimed to determine outcomes of patients with resected PNETs according to the cystic component and confirm the accuracy of preoperative staging. METHODS From 1997 to 2016, 106 patients underwent resection of PNETs, including 73 purely solid (S-PNETs, 69%), 21 mixed (M-PNETs, 20%), and 12 purely cystic lesions (C-PNETs, 11%). To ensure consistent comparisons of overall (OS) and disease-free (DFS) survival outcomes between the 3 groups, the patients were matched according to the World Health Organization (WHO) grade and tumor height. RESULTS Overall, the rate of correlation between the preoperative and pathological diagnoses was low in the C-PNET group (33%, P = 0.03). None of the 24 patients (23%) with metastatic disease at the time of surgery were in the C-PNET group. Furthermore, significantly more parenchyma-sparing resections (P = 0.039) and fewer enlarged resections (P = 0.019) were achieved in the C-PNET group. C-PNET group had a significantly lower node invasion rate than the S-PNET and M-PNET groups (8% vs. 41% and 24%, P = 0.004). Although median OS was comparable in all 3 groups before (P = 0.3) and after (P = 0.18) matching, higher median DFS was observed in the C-PNET group than in the other groups after matching (P = 0.038). CONCLUSION C-PNET was associated with a better prognosis than PNET with a solid component. The results support a wait-and-see policy in cases wherein a reliable preoperative diagnosis remains challenging.
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Affiliation(s)
- Ange Khalil
- Department of Surgery, ENETS co-E IPC NET Center, Institut Paoli-Calmettes, 232 Boulevard Sainte Marguerite, 13009, Marseille, France.
| | - Jacques Ewald
- Department of Surgery, ENETS co-E IPC NET Center, Institut Paoli-Calmettes, 232 Boulevard Sainte Marguerite, 13009, Marseille, France
| | - Ugo Marchese
- Department of Surgery, ENETS co-E IPC NET Center, Institut Paoli-Calmettes, 232 Boulevard Sainte Marguerite, 13009, Marseille, France
| | - Aurélie Autret
- Department of Biostatistics, Institut Paoli-Calmettes, Marseille, France
| | - Jonathan Garnier
- Department of Surgery, ENETS co-E IPC NET Center, Institut Paoli-Calmettes, 232 Boulevard Sainte Marguerite, 13009, Marseille, France
| | - Patricia Niccoli
- Department of Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Gilles Piana
- Department of Radiology, Institut Paoli-Calmettes, Marseille, France
| | - Flora Poizat
- Department of Pathology, Institut Paoli-Calmettes, Marseille, France
| | - Marc Giovannini
- Department of Endoscopy, Institut Paoli-Calmettes, Marseille, France
| | - Jean-Robert Delpero
- Department of Surgery, ENETS co-E IPC NET Center, Institut Paoli-Calmettes, 232 Boulevard Sainte Marguerite, 13009, Marseille, France
| | - Olivier Turrini
- Department of Surgery, CNRS, Inserm, CRCM, Institut Paoli-Calmettes, Aix-Marseille University, Marseille, France
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10
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Noda K, Kuroki T, Yamashita M, Hirayama T, Natsuda K, Kobayashi S, Tokunaga T, Yamanouchi K, Takeshita H, Miura S, Maeda S. Nondegenerated cystic neuroendocrine tumor of the pancreas: a case report. Surg Case Rep 2020; 6:154. [PMID: 32601808 PMCID: PMC7324457 DOI: 10.1186/s40792-020-00918-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/19/2020] [Indexed: 11/20/2022] Open
Abstract
Background Pancreatic neuroendocrine tumors (PNETs) are typically solid neoplasms but, in very rare cases, present as cystic lesions. We describe a case of a cystic neuroendocrine tumor that developed as a small cystic lesion. Case presentation In 2011, a 66-year-old Japanese woman underwent computed tomography (CT) that revealed a cystic lesion in the tail of the pancreas measuring 9 mm. She did not have any symptoms. She underwent a CT scan every year thereafter. The cystic lesion gradually increased and was 40 mm in 2019; endoscopic retrograde pancreatography (ERP) was then performed. Cytological examination demonstrated class IIIb adenocarcinoma, and we conducted laparoscopic distal pancreatectomy. Pathological examination showed PNET. Conclusion Although cystic change of PNET is generally caused by ischemia or necrosis inside the tumor, in our case, PNET occurred as a small cyst that increased without changing form.
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Affiliation(s)
- Keisuke Noda
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, 2-1001-1, Kubara, Omura City, Nagasaki, 856-8562, Japan.
| | - Tamotsu Kuroki
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, 2-1001-1, Kubara, Omura City, Nagasaki, 856-8562, Japan
| | - Mampei Yamashita
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, 2-1001-1, Kubara, Omura City, Nagasaki, 856-8562, Japan
| | - Takanori Hirayama
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, 2-1001-1, Kubara, Omura City, Nagasaki, 856-8562, Japan
| | - Koji Natsuda
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, 2-1001-1, Kubara, Omura City, Nagasaki, 856-8562, Japan
| | - Shinichiro Kobayashi
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, 2-1001-1, Kubara, Omura City, Nagasaki, 856-8562, Japan
| | - Takayuki Tokunaga
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, 2-1001-1, Kubara, Omura City, Nagasaki, 856-8562, Japan
| | - Kosho Yamanouchi
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, 2-1001-1, Kubara, Omura City, Nagasaki, 856-8562, Japan
| | - Hiroaki Takeshita
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, 2-1001-1, Kubara, Omura City, Nagasaki, 856-8562, Japan
| | - Shiro Miura
- Department of Pathology, National Hospital Organization Nagasaki Medical Center, Omura, Japan
| | - Shigeto Maeda
- Department of Surgery, National Hospital Organization Nagasaki Medical Center, 2-1001-1, Kubara, Omura City, Nagasaki, 856-8562, Japan
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11
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Kumar T, Gupta B, Das P, Madhusudhan KS. The rare case of a cystic pancreatic neuroendocrine tumor. AUTOPSY AND CASE REPORTS 2020; 10:e2020171. [PMID: 33344296 PMCID: PMC7703451 DOI: 10.4322/acr.2020.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The pancreatic neuroendocrine tumors (PanNETs) most commonly present as solid neoplasms; however, very rarely, they may present primarily as cystic neoplasms. Most of the cystic PanNETs are non-secreting tumors, and the radiological features are not well defined. Hence pre-operative diagnosis is usually challenging and the tumors are misdiagnosed as mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, serous cystic neoplasms, solid pseudopapillary neoplasms, and non-neoplastic cysts. However, the management depends on the accurate diagnosis of these cystic lesions, which poses a dilemma. Herein, we report the case of a cystic PanNET in the tail of the pancreas, which was clinically and radiologically misdiagnosed as a mucinous cystic neoplasm. This case is reported to highlight this issue to the medical community regarding the diagnostic difficulty in such rare non-functioning pancreatic neuroendocrine tumors.
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Affiliation(s)
- Tarun Kumar
- All India Institute of Medical Sciences, Department of Pathology. Patna, Bihar, India
| | - Brijnandan Gupta
- All India Institute of Medical Sciences, Department of Pathology. New Delhi, India
| | - Prasenjit Das
- All India Institute of Medical Sciences, Department of Pathology. New Delhi, India
| | - Kumble S Madhusudhan
- All India Institute of Medical Sciences, Department of Radiology. New Delhi, India
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12
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Abdelkader A, Hunt B, Hartley CP, Panarelli NC, Giorgadze T. Cystic Lesions of the Pancreas: Differential Diagnosis and Cytologic-Histologic Correlation. Arch Pathol Lab Med 2019; 144:47-61. [PMID: 31538798 DOI: 10.5858/arpa.2019-0308-ra] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
CONTEXT.— Pancreatic cystic lesions (PCLs) are very common, and their detection is increasing with the advances in imaging techniques. Because of the major implications for management, distinguishing between neoplastic and nonneoplastic PCLs is critical. Neoplastic cysts with potential to progress into cancer include mucinous PCLs (intraductal papillary mucinous neoplasms and mucinous cystic neoplasms) and nonmucinous cysts (solid pseudopapillary tumors, serous cystic neoplasms, and neuroendocrine tumors with cystic degeneration). Nonneoplastic cysts with no risk of malignant transformation include pseudocysts, retention cysts, lymphoepithelial cysts, cystic pancreatic lymphangioma, and duplication cyst/ciliated foregut cysts. The role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology with cyst fluid analysis in the diagnosis of PCLs has evolved during the last decade; however, a definitive diagnosis on cytologic specimens is hampered by the sparse cellularity and can be challenging. EUS-FNA can play an important role to differentiate low-risk from high-risk pancreatic cysts and to distinguish between patients with cysts who need clinical follow-up versus those who require surgery. OBJECTIVE.— To provide an integrative approach to diagnose pancreatic cystic lesions using EUS-FNA cytology and cyst fluid analysis, along with clinical, radiologic, histologic, genetic, and molecular characteristics. DATA SOURCES.— The review and analysis of the latest literature describing pancreatic cystic lesions. CONCLUSIONS.— Accurate diagnosis of PCLs requires a multidisciplinary and multimodal team approach, including the integration of clinical findings, imaging, cytology, cyst fluid analysis, and molecular testing.
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Affiliation(s)
- Amrou Abdelkader
- From the Department of Pathology, Medical College of Wisconsin, Milwaukee (Drs Abdelkader, Hunt, Hartley, and Giorgadze); and the Department of Pathology, Albert Einstein College of Medicine, The Bronx, New York (Dr Panarelli)
| | - Bryan Hunt
- From the Department of Pathology, Medical College of Wisconsin, Milwaukee (Drs Abdelkader, Hunt, Hartley, and Giorgadze); and the Department of Pathology, Albert Einstein College of Medicine, The Bronx, New York (Dr Panarelli)
| | - Christopher P Hartley
- From the Department of Pathology, Medical College of Wisconsin, Milwaukee (Drs Abdelkader, Hunt, Hartley, and Giorgadze); and the Department of Pathology, Albert Einstein College of Medicine, The Bronx, New York (Dr Panarelli)
| | - Nicole C Panarelli
- From the Department of Pathology, Medical College of Wisconsin, Milwaukee (Drs Abdelkader, Hunt, Hartley, and Giorgadze); and the Department of Pathology, Albert Einstein College of Medicine, The Bronx, New York (Dr Panarelli)
| | - Tamara Giorgadze
- From the Department of Pathology, Medical College of Wisconsin, Milwaukee (Drs Abdelkader, Hunt, Hartley, and Giorgadze); and the Department of Pathology, Albert Einstein College of Medicine, The Bronx, New York (Dr Panarelli)
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13
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Zhu JK, Wu D, Xu JW, Huang X, Jiang YY, Edil BH, Li M, Hu SY, Zhan HX. Cystic pancreatic neuroendocrine tumors: A distinctive subgroup with indolent biological behavior? A systematic review and meta-analysis. Pancreatology 2019; 19:738-750. [PMID: 31160191 DOI: 10.1016/j.pan.2019.05.462] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/24/2019] [Accepted: 05/26/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES The clinicopathological features and biological behaviors of cystic pancreatic neuroendocrine tumors (pNETs) are unclear and controversial. Here we performed a systematic review and meta-analysis to investigate the unique characteristics of cystic pNETs, to determine whether they represent a distinct clinical entity. METHODS We selected comparative studies published since January 2000 that explore the differences between clinicopathological features of cystic and solid pNETs. Demographic information, pathological characteristics, and survival information were analyzed. RESULT The 12 selected studies comprised 355 and 1530 patients diagnosed with cystic and solid pNETs, respectively. Compared with solid pNETs, cystic pNETs were less likely to be functional (odds ratio, OR = 0.31, 95% confidence interval (CI) 0.19-0.50, p < 0.00001), more likely to affect males (OR = 1.56, 95% CI 1.22-2.00, p = 0.0005), and significantly associated with multiple endocrine neoplasia type 1 (OR = 2.71). Cystic pNETs were more likely to present with G1 and G2 rather than G3 (OR = 1.66). Cystic pNETs were associated with less frequent distant organs and lymph node metastasis, microvascular invasion, perineural invasion, and a low Ki-67 index and mitotic count. There were no significant differences between 5- and 10-year overall survival. However, the 5-year disease-free survival (DFS) and 10-year DFS rate of patients with cystic pNETs was significantly higher compared with those with solid pNETs (94.6% vs 83.5%, OR = 3.00; 92.7% vs 63.6%, OR = 5.92, respectively). CONCLUSIONS Cystic pNETs represent a distinct subgroup of pNETs that present with an indolent biological behavior, and patients experience better DFS. Observation and surveillance should be considered in some selected cases.
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Affiliation(s)
- Jian-Kang Zhu
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Dong Wu
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Jian-Wei Xu
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Xin Huang
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Yuan-Yuan Jiang
- Department of Pulmonary and Critical Care Medicine, Qilu Hospital Shandong University, Jinan, 250012, China
| | - Barish H Edil
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Min Li
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; Department of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - San-Yuan Hu
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, 250012, China
| | - Han-Xiang Zhan
- Department of General Surgery, Qilu Hospital, Shandong University, Jinan, Shandong Province, 250012, China.
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14
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Carr RA, Bletsis P, Roch AM, House MG, Zyromski NJ, Nakeeb A, Schmidt CM, Ceppa EP. Cystic pancreatic neuroendocrine tumors: A more favorable lesion? Pancreatology 2019; 19:372-376. [PMID: 30704851 DOI: 10.1016/j.pan.2019.01.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 01/14/2019] [Accepted: 01/20/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic neuroendocrine tumors (PNETs) are predominantly solid lesions with malignant potential. Cystic PNETs are a small subset in which data are scarce. The aim of this study was to compare clinical and biologic differences between cystic and solid PNETs. METHODS Patients with PNETs undergoing pancreatectomy between 1988 and 2016 at a high-volume center were reviewed retrospectively. Demographic, clinical, and histopathologic data were collected and analyzed. RESULTS 347 patients with PNETs were identified; 27% (n = 91) were cystic. Patients with cystic PNETs were generally older (59 vs. 55 years, p = 0.05). Cystic PNETs were more commonly non-functional (95% vs. 82%, p = 0.004), asymptomatic (44% vs. 28%, p = 0.009), and located in the pancreatic body/tail (81% vs. 60%, p < 0.001) than solid PNETs. Although cystic and solid PNETs had similar sizes and pathologic stage at the time of resection, Ki-67 proliferation index (Ki-67 ≤ 9%: 98% vs. 85%; p = 0.007), and histologic grade (grade I: 84% vs. 59%; p = 0.009) had less aggressive features in cystic PNETs. CONCLUSION In addition to reporting a higher than previously published incidence of cystic PNET (27%), this study found significant differences in multiple clinicopathologic variables between cystic and solid PNETs. Cystic PNET may be a distinct and possibly less aggressive subtype of PNET yet have similar pathologic stage, recurrence, and survival to solid PNETs. Cystic PNETs require further attention to better understand the true natural history.
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Affiliation(s)
- Rosalie A Carr
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Panagiotis Bletsis
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alexandra M Roch
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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15
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Haq I, Krishna SG, Patel B, Thambi-Pillai T, Xie C, Odegaard K, Buohy K, Atiq M. The Impact of Repeating Endosonography with Confocal Endomicroscopy for the Diagnosis of Cystic Neuroendocrine Tumor. Case Rep Gastrointest Med 2019; 2019:5187874. [PMID: 30755806 PMCID: PMC6348892 DOI: 10.1155/2019/5187874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 12/30/2018] [Indexed: 11/17/2022] Open
Abstract
Cystic pancreatic neuroendocrine tumors represent around 13% of all neuroendocrine tumors (Hurtado-Pardo 2017). There has been an increase in the incidence of cases due to improvement in imaging modalities. This is a case of a 68-year-old male with the incidental finding of a pancreatic cyst on CT. Initial Endoscopic Ultrasound with Fine Needle Aspiration (EUS-FNA) showed sonographic and cytology features suggestive of a pancreatic pseudocyst. However the cyst persisted with no change in size after aspiration leading to a follow-up EUS- FNA, which was combined with needle based confocal laser endomicroscopy (nCLE). The nCLE features were consistent with a cystic pancreatic neuroendocrine tumor, which was later confirmed on histology after surgical resection.
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Affiliation(s)
- Iqra Haq
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
| | - Somashekar G. Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bhaveshkumar Patel
- Department of Gastroenterology, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
| | - Thavam Thambi-Pillai
- Department of Surgery, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
| | - Chencheng Xie
- Department of Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
| | - Karah Odegaard
- Department of Pathology, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
| | - Kimberlee Buohy
- Department of Pathology, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
| | - Muslim Atiq
- Department of Gastroenterology, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
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16
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Nakashima Y, Ohtsuka T, Nakamura S, Mori Y, Nakata K, Miyasaka Y, Ishigami K, Matsuda R, Oda Y, Nakamura M. Clinicopathological characteristics of non-functioning cystic pancreatic neuroendocrine tumors. Pancreatology 2019; 19:50-56. [PMID: 30497875 DOI: 10.1016/j.pan.2018.11.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/28/2018] [Accepted: 11/21/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES The biological features of cystic pancreatic neuroendocrine tumors (PNETs) remain unclear. The aim of this study was to clarify the clinicopathological characteristics of non-functioning PNETs (NF-PNETs) with a cystic component. METHODS The medical records of 75 patients with NF-PNETs who had undergone resection in our institution were retrospectively reviewed. Clinicopathological factors were compared between PNETs with and without a cystic component. Expression of somatostatin 2 receptor (SSTR-2) was also analyzed. RESULTS Cystic PNETs were diagnosed in 14 patients (19%). The proportion of men was significantly higher for cystic than solid PNETs (79% vs. 44%, P < 0.05) and cystic PNETs were significantly larger than solid PNETs (25 mm vs. 17 mm, P < 0.01). However, there were no significant differences in the prevalence of lymph node metastases (14% vs. 10%, P = 0.64), hepatic metastasis (7% vs. 3%, P = 0.54), or disease-free survival rate (both 86%, P = 0.29) between PNETs with and without a cystic component. SSTR-2 expression was more frequently observed in PNETs with a cystic component than in those without (100% vs. 70%, P < 0.01). CONCLUSIONS Although cystic PNETs were larger upon diagnosis than solid PNETs in this study, prognosis after surgical resection did not differ significantly between these types of PNET. Somatostatin receptor scintigraphy and somatostatin analogues may be more useful for diagnosing and treating cystic PNETs, respectively.
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Affiliation(s)
- Yohei Nakashima
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - So Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhisa Mori
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Miyasaka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kosei Ishigami
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryota Matsuda
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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17
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Hurtado-Pardo L, A Cienfuegos J, Ruiz-Canela M, Panadero P, Benito A, Hernández Lizoain JL. Cystic pancreatic neuroendocrine tumors (cPNETs): a systematic review and meta-analysis of case series. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 109:778-787. [PMID: 29072081 DOI: 10.17235/reed.2017.5044/2017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cystic pancreatic neuroendocrine tumors represent 13% of all neuroendocrine tumors. The aim of this study is to analyze the phenotype and biologic behavior of resected cystic neuroendocrine tumors. A systematic review and meta-analysis were conducted until September 2016 using a search in Medline, Scopus, and EMBASE with the terms "cystic pancreatic endocrine neoplasm", "cystic islets tumors" and "cystic islets neoplasms". From the 795 citations recovered 80 studies reporting on 431 patients were selected. 87.1% (n = 387) were sporadic tumors and 10.3% (n = 40) corresponded to multiple endocrine neoplasia endocrine type 1. Were diagnosed incidentally 44.6% (n = 135). Cytology was found to have a sensitivity of 78.5%. Were non-functional tumors 85% (n = 338), and among the functional tumors, insulinoma was the most frequent. According to the European Neuroendocrine Tumor Society staging, 87.8% were limited to the pancreas (I-IIb), and 12.2% were advanced (III-IV). Disease-free survival at 5 years in stages (I-IIIa) and (IIIb-IV) was 91.5% and 54.2%, respectively; and was significantly lower (p = 0.0001) in functional tumors. In patients with multiple endocrine neoplasia there was a higher incidence of functional (62.5%) and multifocal (28.1%) tumors. Disease-free survival at 5 and 10 years was 60%. Cystic pancreatic neuroendocrine tumors exhibit phenotypical characteristics which are different to those of solid neuroendocrine tumors.
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Affiliation(s)
| | | | - Miguel Ruiz-Canela
- Department of Preventive Medicine and Public Healt, Medical School. University of Navarra, España
| | - Pablo Panadero
- Anatomía Patológica, Clínica Universidad de Navarra, España
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18
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Pancreatic Cystic Lesions: Pathogenesis and Malignant Potential. Diseases 2018; 6:diseases6020050. [PMID: 29899320 PMCID: PMC6023528 DOI: 10.3390/diseases6020050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/06/2018] [Accepted: 06/07/2018] [Indexed: 01/17/2023] Open
Abstract
Pancreatic cancer remains one of the most lethal cancers despite extensive research. Further understanding of precursor lesions may enhance the ability to treat and prevent pancreatic cancer. Pancreatic cystic lesions (PCLs) with malignant potential include: mucinous PCLs (intraductal papillary mucinous neoplasms and mucinous cystic neoplasm), solid pseudopapillary tumors and cystic neuroendocrine tumors. This review summarizes the latest literature describing what is known about the pathogenesis and malignant potential of these PCLs, including unique epidemiological, radiological, histological, genetic and molecular characteristics.
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19
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Yasumoto M, Okabe Y, Sugiyama G, Naito Y, Nakayama M, Hisaka T, Ishikawa H, Horiuchi H, Kunou Y, Ushijima T, Ishida Y, Tsuruta O, Torimura T. A case of pancreatic neuroendocrine tumor with multiple cystic components of various sizes. Clin J Gastroenterol 2017; 11:87-91. [PMID: 29270782 DOI: 10.1007/s12328-017-0798-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 11/04/2017] [Indexed: 11/28/2022]
Abstract
The patient was a 51-year-old woman who, while undergoing a thorough health checkup, was found to have a tumor (measuring 60 mm in diameter) in the tail of the pancreas by abdominal ultrasonography. Contrast-enhanced computed tomography revealed delayed contrast enhancement; the tumor also contained numerous low-absorption areas showing poor contrast enhancement. On magnetic resonance imaging, the tumor was visualized as having high signal intensity areas inside the tumor on T2-weighted images. Positron emission tomography revealed an abnormal accumulation in the area corresponding to the tumor. Endoscopic ultrasonography (EUS) revealed a relatively hyperechoic solid area, with a number of echo-free areas of various sizes that assumed a honeycomb appearance. EUS-guided fine needle aspiration was carried out targeting the solid area within the tumor, which led to a diagnosis of pancreatic neuroendocrine tumor (PNET). Histopathological examination of the resected specimen revealed that the tumor was composed of numerous cysts of various sizes and solid components. The cysts contained no evidence of necrosis or bleeding. Immunohistochemically, the cystic as well as solid components were CD56 (+), synaptophysin (+) and chromogranin A (+) with MIB1 labeling index of 5%. On the basis of these findings, the final diagnosis was PNET (G2).
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Affiliation(s)
- Makiko Yasumoto
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Yoshinobu Okabe
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan.
| | - Gen Sugiyama
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Yoshiki Naito
- Department of Pathology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Masamichi Nakayama
- Department of Pathology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Toru Hisaka
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Hiroto Ishikawa
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Hiroyuki Horiuchi
- Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Yukiko Kunou
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Tomoyuki Ushijima
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Yusuke Ishida
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Osamu Tsuruta
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Takuji Torimura
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
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20
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Sagami R, Nishikiori H, Ikuyama S, Murakami K. Rupture of small cystic pancreatic neuroendocrine tumor with many microtumors. World J Gastroenterol 2017; 23:6911-6919. [PMID: 29085235 PMCID: PMC5645625 DOI: 10.3748/wjg.v23.i37.6911] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 07/26/2017] [Accepted: 08/15/2017] [Indexed: 02/06/2023] Open
Abstract
Pancreatic neuroendocrine tumors (pNETs) are particularly rare. The various forms of PNETs, such as cystic degeneration, make differentiation from other similar pancreatic lesions difficult. We can detect small lesions by endoscopic ultrasound (EUS) and obtain preoperative pathological diagnosis by EUS-guided fine needle aspiration (FNA). We describe, here, an interesting case of pNET in a 42-year-old woman with no family history. Computed tomography and magnetic resonance imaging revealed an 18 mm × 17 mm cystic lesion with a nodule in the pancreatic tail. Two microtumors about 7 mm in diameter in the pancreatic body detected only by EUS, cystic rim and nodules all showed similar enhancement on contrast-harmonic EUS. Preoperative EUS-FNA of the microtumor was performed, diagnosing multiple pNETs. Macroscopic examination of the resected pancreatic body and tail showed that the cystic lesion had morphologically changed to a 13-mm main nodule, and 11 new microtumors (diameter 1-3 mm). Microscopically, all microtumors represented pNETs. From the findings of a broken peripheral rim on the main lesion with fibrosis, rupture of the cystic pNET was suspected. Postoperatively, pituitary adenoma and parathyroid adenoma were detected. The final diagnosis was multiple grade 1 pNETs with multiple endocrine neoplasia type 1. To the best of our knowledge, no case of spontaneous rupture of a cystic pNET has previously been reported in the English literature. Therefore, this case of very rare pNET with various morphological changes is reported.
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Affiliation(s)
- Ryota Sagami
- Department of Gastroenterology, Oita San-ai Medical Center, Oita 8701151, Japan
| | - Hidefumi Nishikiori
- Department of Gastroenterology, Oita San-ai Medical Center, Oita 8701151, Japan
| | - Shoichiro Ikuyama
- Department of Internal Medicine and Clinical Investigation, Oita San-ai Medical Center, Oita 8701151, Japan
| | - Kazunari Murakami
- Department of Gastroenterology, Faculty of Medicine, Oita University, Yuhu 8795503, Japan
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21
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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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22
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Izumi H, Yazawa N, Furukawa D, Masuoka Y, Yamada M, Mashiko T, Kawashima Y, Ogawa M, Kawaguchi Y, Mine T, Hirabayashi K, Nakagohri T. Laparoscopic splenopancreatectomy for an endocrine tumor with cystic changes: a case report. Clin Case Rep 2017; 5:328-332. [PMID: 28265400 PMCID: PMC5331262 DOI: 10.1002/ccr3.844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 11/19/2016] [Accepted: 01/09/2017] [Indexed: 11/25/2022] Open
Abstract
The biological behavior of a cystic pancreatic endocrine neoplasm is less aggressive than that of pancreatic neuroendocrine neoplasms, and its prognosis is better. Limited surgery should be considered for cystic pancreatic endocrine neoplasms that are not accompanied preoperatively by lymph node or distant metastasis.
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Affiliation(s)
- Hideki Izumi
- Department of Gastrointestinal Surgery Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259-1193 Japan
| | - Naoki Yazawa
- Department of Gastrointestinal Surgery Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259-1193 Japan
| | - Daisuke Furukawa
- Department of Gastrointestinal Surgery Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259-1193 Japan
| | - Yoshihito Masuoka
- Department of Gastrointestinal Surgery Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259-1193 Japan
| | - Misuzu Yamada
- Department of Gastrointestinal Surgery Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259-1193 Japan
| | - Taro Mashiko
- Department of Gastrointestinal Surgery Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259-1193 Japan
| | - Yohei Kawashima
- Department of Internal Medicine Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259-1193 Japan
| | - Masami Ogawa
- Department of Internal Medicine Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259-1193 Japan
| | - Yoshiaki Kawaguchi
- Department of Internal Medicine Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259-1193 Japan
| | - Tetsuya Mine
- Department of Internal Medicine Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259-1193 Japan
| | - Kenichi Hirabayashi
- Department of Pathology Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259-1193 Japan
| | - Toshio Nakagohri
- Department of Gastrointestinal Surgery Tokai University School of Medicine 143 Shimokasuya Isehara Kanagawa 259-1193 Japan
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Farrell JJ. Prevalence, Diagnosis and Management of Pancreatic Cystic Neoplasms: Current Status and Future Directions. Gut Liver 2016; 9:571-89. [PMID: 26343068 PMCID: PMC4562774 DOI: 10.5009/gnl15063] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cystic neoplasms of the pancreas are found with increasing prevalence, especially in elderly asymptomatic individuals. Although the overall risk of malignancy is very low, the presence of these pancreatic cysts is associated with a large degree of anxiety and further medical investigation due to concerns about malignancy. This review discusses the different cystic neoplasms of the pancreas and reports diagnostic strategies based on clinical features and imaging data. Surgical and nonsurgical management of the most common cystic neoplasms, based on the recently revised Sendai guidelines, is also discussed, with special reference to intraductal papillary mucinous neoplasm (IPMN; particularly the branch duct variant), which is the lesion most frequently identified incidentally. IPMN pathology, its risk for development into pancreatic ductal adenocarcinoma, the pros and cons of current guidelines for management, and the potential role of endoscopic ultrasound in determining cancer risk are discussed. Finally, surgical treatment, strategies for surveillance of pancreatic cysts, and possible future directions are discussed.
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Affiliation(s)
- James J Farrell
- Yale Center for Pancreatic Diseases, Interventional Endoscopy, Yale School of Medicine, New Haven, CT, USA
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24
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Cloyd JM, Kopecky KE, Norton JA, Kunz PL, Fisher GA, Visser BC, Dua MM, Park WG, Poultsides GA. Neuroendocrine tumors of the pancreas: Degree of cystic component predicts prognosis. Surgery 2016; 160:708-13. [PMID: 27216830 DOI: 10.1016/j.surg.2016.04.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/18/2016] [Accepted: 04/01/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Although most pancreatic neuroendocrine tumors are solid, approximately 10% are cystic. Some studies have suggested that cystic pancreatic neuroendocrine tumors are associated with a more favorable prognosis. METHODS A retrospective review of all patients with pancreatic neuroendocrine tumors who underwent operative resection between 1999 and 2014 at a single academic medical center was performed. Based on cross-sectional imaging performed before operation, pancreatic neuroendocrine tumors were classified according to the size of the cystic component relative to the total tumor size: purely cystic (100%), mostly cystic (≥50%), mostly solid (<50%), and purely solid (0%). Clinicopathologic characteristics and recurrence-free survival were assessed between groups. RESULTS In the study, 214 patients met inclusion criteria: 8 with purely cystic tumors, 7 with mostly cystic tumors, 15 with mostly solid tumors, and 184 with purely solid tumors. The groups differed in terms of tumor size (1.5 ± 0.5, 3.0 ± 1.7, 3.7 ± 2.6, and 4.0 ± 3.5 cm), lymph node positivity (0%, 0%, 26.7%, and 34.2%), intermediate or high grade (0%, 16.7%, 20.0%, and 31.0%), synchronous liver metastases (0%, 14.3%, 20.0%, and 26.6%) and need for pancreaticoduodenectomy (0%, 0%, 6.7%, and 25.0%), respectively. No cases of purely cystic pancreatic neuroendocrine tumors were associated with synchronous liver or lymph node metastasis, intermediate/high grade, recurrence, or death due to disease. Among patients presenting without metastatic disease, 10-year recurrence-free survival was 100% in patients with purely and mostly cystic tumors versus 53.0% in patients with purely and mostly solid tumors; however, this difference did not reach statistical significance. CONCLUSION Pancreatic neuroendocrine tumors demonstrate a spectrum of biologic behavior with an increasing cystic component being associated with more favorable clinicopathologic features and prognosis. Purely cystic pancreatic neuroendocrine tumors may represent 1 subset that can be safely observed without immediate resection.
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Affiliation(s)
| | | | | | | | | | | | | | - Walter G Park
- Department of Medicine and Gastroenterology, Stanford University, CA
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25
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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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26
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A Single Centre Analysis of Clinical Characteristics and Treatment of Endocrine Pancreatic Tumours. Int J Surg Oncol 2015; 2015:538948. [PMID: 26167298 PMCID: PMC4475697 DOI: 10.1155/2015/538948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 05/17/2015] [Accepted: 05/27/2015] [Indexed: 11/17/2022] Open
Abstract
Background. Endocrine Pancreatic Tumours (PENs) are rare and can be nonfunctioning or functioning. They carry a good prognosis overall though high grade lesions show a relatively shorter survival. The aim of the current study is to describe a single centre analysis of the clinical characteristics and surgical treatment of PENs. Patients and Methods. This is a cohort analysis of 40 patients of PENs who underwent surgery at Sir Ganga Ram Hospital, New Delhi, India, from 1995 to 2013. Patient particulars, clinical features, surgical interventions, postoperative outcome, and followup were done and reviewed. The study group was divided based on grade (G1, G2, and G3) and functionality (nonfunctioning versus functioning) for comparison. Results. PENs comprised 6.3% of all pancreatic neoplasms (40 of 634). Twenty-eight patients (70%) had nonfunctioning tumours. Eighteen PENs (45%) were carcinomas (G3), all of which were nonfunctioning. 14 (78%) of these were located in the pancreatic head and uncinate process (P = 0.09). The high grade (G3) lesions were significantly larger in size than the lower grade (G1 + G2) tumours (7.0 ± 3.5 cms versus 3.1 ± 1.6 cms, P = 0.007). Pancreatoduodenectomy was performed in 18 (45%), distal pancreatectomy in 10 (25%), and local resection in 8 (20%) and nonresective procedures were performed in 4 patients (10%). Fourteen patients (35%) had postoperative complications. All G3 grade tumours which were resected had positive lymph nodes (100%) and 10 had angioinvasion (71%). Eight neoplasms (20%) were cystic, all being grade G3 carcinomas, while the rest were solid. The overall disease related mortality attributable to PEN was 14.3% (4 of 28) and for malignant PENs was 33.3% (4 of 12) after a mean follow-up period of 49.6 months (range: 2–137 months). Conclusion. Majority of PENs are nonfunctioning. They are more likely malignant if they are nonfunctioning and large in size, show cystic appearance, and are situated in the pancreatic head. Early surgery leads to good long term survival with acceptable postoperative morbidity.
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Chen L, Nassar A, Kommineni VT, Zarka MA, Zhang J, Faigel D, Nguyen C, Halfdanarson TR, Pannala R. Endoscopic ultrasonography-guided fine-needle aspiration cytology of surgically confirmed cystic pancreatic neuroendocrine tumors: a Mayo Clinic experience. J Am Soc Cytopathol 2015; 4:335-343. [PMID: 31051748 DOI: 10.1016/j.jasc.2015.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 04/08/2015] [Accepted: 04/09/2015] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) cytology is widely used to evaluate solid and cystic pancreatic lesions preoperatively. Pancreatic neuroendocrine tumors (PanNETs) are typically solid, but when they are cystic, differentiation from other pancreatic cystic neoplasms can be challenging. We examined cases of cystic PanNETs (cPanNETs) from 3 Mayo Clinic Hospitals focusing on the EUS-FNA cytology. MATERIALS AND METHODS A total of 21 EUS-FNA cases of cPanNETs with histology confirmation were identified from the Mayo Clinic Health System database. The patients' demographic data, clinical, radiological, and EUS characteristics were obtained. EUS-FNA cytology and surgical pathology were reviewed. RESULTS Among the 21 patients with cPanNETs, only 2 of 21 cases had suggestion of cPanNET on preoperative imaging (computed tomography/magnetic resonance imaging). On EUS, most cPanNETs (16/ of 21) had ≥1 high-risk stigmata or worrisome feature per the Sendai Consensus guidelines. None of the cases had an elevated carcinoembryonic antigen level. EUS-FNA cytology was positive or suspicious for cPanNET in 15 of 21 cases (71.4%). Immunohistochemical stains of neuroendocrine markers were performed on all the positive or suspicious cases and showed positivity for ≥1 neuroendocrine marker. All cases had surgical resection and the diagnosis of cPanNET was confirmed on each case. CONCLUSIONS Although computed tomography/magnetic resonance imaging has a low specificity for detecting cPanNETs, high-risk features on EUS and low carcinoembryonic antigen levels should raise the suspicion for cPanNET. EUS-FNA cytology along with immunohistochemical stains has a high accuracy in establishing the preoperative diagnosis of cPanNET.
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Affiliation(s)
- Longwen Chen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 13400 E. Shea Boulevard, Scottsdale, Arizona.
| | - Aziza Nassar
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida
| | | | - Matthew A Zarka
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 13400 E. Shea Boulevard, Scottsdale, Arizona
| | - Jun Zhang
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, New York
| | - Douglas Faigel
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Cuong Nguyen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | | | - Rahul Pannala
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
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Abstract
Pancreatic neuroendocrine neoplasms (Pan-NENs) are rare but clinically important lesions. Pan-NENs are known for and often categorized by their capacity to produce clinical syndromes mediated by the production of hormones. Despite sometimes presenting dramatically from excessive hormone production, not all Pan-NENs produce functional hormone, and they can pose diagnostic challenges to practicing pathologists. Distinguishing Pan-NENs from mimics can be crucial, because Pan-NENs carry different prognoses and have unique treatments available due to their specific biological properties. This article reviews the current categorization and features of Pan-NENs.
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Affiliation(s)
- J N Rosenbaum
- Department of Surgical Pathology, University of Wisconsin Hospital and Clinics, Room A4/204-3224, 600 Highland Ave., Madison, WI 53792-3224, USA
| | - Ricardo Vincent Lloyd
- Department of Surgical Pathology, University of Wisconsin Hospital and Clinics, Room A4/204-3224, 600 Highland Ave., Madison, WI 53792-3224, USA.
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29
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Abstract
Pancreatic neuroendocrine tumors (PNETs) are rare pancreatic neoplasms comprising only 1% to 2% of all pancreatic tumors. In recent years, the number of incidentally discovered PNETs has greatly increased given the widespread use of axial imaging. However, a significant proportion of PNETs may not be visualized on conventional imaging such as computed tomography, magnetic resonance imaging, and somatostatin receptor scintigraphy. Endoscopic ultrasound (EUS) has become an integral part of the diagnosis of PNETs because of its high sensitivity for detecting, localizing, and diagnosing PNETs. EUS-guided tissue acquisition provides histologic and immunologic confirmation, and may also allow prognostication about tumor behavior. In addition to preoperative assessment of these tumors, EUS has also been shown to have an important role in nonoperative management of small nonfunctional PNETs. Finally, recent developments suggest that interventional EUS may be used to aid intraoperative localization of PNETs and to deliver therapeutic agents for the treatment of PNETs. This review will discuss the endoscopic diagnosis and treatment of PNETs, with focus on recent advances in the utility of EUS in the clinical management of these tumors.
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30
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Koh YX, Chok AY, Zheng HL, Tan CS, Goh BKP. A systematic review and meta-analysis of the clinicopathologic characteristics of cystic versus solid pancreatic neuroendocrine neoplasms. Surgery 2014; 156:83-96.e2. [PMID: 24878455 DOI: 10.1016/j.surg.2014.03.026] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 03/11/2014] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Cystic pancreatic neuroendocrine neoplasms (PNENs) are rare neoplasms, and presently, it is uncertain whether their behavior is similar or distinct from their solid counterparts. This study aimed to review systematically the present literature to compare the clinicopathologic characteristics of cystic PNENs versus their solid counterparts to determine whether cystic PNENs are likely to be a distinct entity from solid PNENs. METHODS Comparative studies of solid versus cystic PNENs studies were reviewed. Cystic and solid PNENs were compared on the basis of several clinicopathologic characteristics. RESULTS Seven nonrandomized case control studies compared 152 cystic versus 915 solid PNENs. Pooled analysis demonstrated that the likelihood of PNENs to be located in the head/uncinate of the pancreas was lower for cystic than solid neoplasms (27.7% vs 45.5%, odds ratio [OR] 0.452, 95% confidence interval [95% CI] 0.304-0.673, P < .001). Cystic PNENs were less likely to be functional (14% vs 24.4%, OR 0.405, 95% CI 0.221-0.742, P = .003) and were more likely to be benign/uncertain rather than malignant compared with solid PNENs (90.3% vs 65.9%, OR 3.151, 95% CI 1.297-7.652, P = .011). Cystic PNENs were more likely to have a mitotic count <2 per 10 hpf and a Ki67 index <2% (93.3% vs 72.7%, OR 4.897, 95% CI 2.139-11.209, P < .001 and 82.4% vs 54.1%, OR 4.079, 95% CI 2.177-7.641, P < .001), respectively. Cystic neoplasms were also less likely to have regional lymph node metastases than solid neoplasms (11.2% vs 28.9%, OR 0.387, 95% CI 0.219-0.685, P = .001).In this meta-analysis, there was no difference in the 5-year overall survival and 5-year disease-free survival between cystic vs solid PNENs (92.0% vs 86.8%, P .214) and (98.1% vs 83.9%, P = .185). CONCLUSION These findings suggest that cystic PNENs tend to be biologically less aggressive compared with their solid counterparts; more data, however, with respect to molecular analysis are required to establish whether cystic and solid PNENs were distinct pathologic entities.
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Affiliation(s)
- Ye-Xin Koh
- Division of Surgery, Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore
| | - Aik-Yong Chok
- Division of Surgery, Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore
| | - Hui-Li Zheng
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Chuen-Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Brian K P Goh
- Division of Surgery, Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore.
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31
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Morales-Oyarvide V, Yoon WJ, Ingkakul T, Forcione DG, Casey BW, Brugge WR, Fernández-del Castillo C, Pitman MB. Cystic pancreatic neuroendocrine tumors: the value of cytology in preoperative diagnosis. Cancer Cytopathol 2014; 122:435-44. [PMID: 24591417 DOI: 10.1002/cncy.21403] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 12/13/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cystic pancreatic neuroendocrine tumors (cPanNETs) account for 13% to 17% of PanNETs. Although the value of endoscopic ultrasound (EUS) imaging and cyst fluid analysis (CFA) in their preoperative diagnosis has been well described, limited information is available about the diagnostic role of cytology samples obtained from fine-needle aspiration (FNA). METHODS Cytopathology records between 1992 and 2013 were searched for all reports of cysts interpreted as PanNET. Patient demographics, clinical and radiologic information, CFA, histopathology, and cytopathology findings were recorded. Performance characteristics of cytology and EUS for the accurate diagnosis of cPanNET were calculated. RESULTS In total, 35 FNAs from 33 patients with cPanNETs were identified, and 34 EUS were performed. Cytology made a specific diagnosis of a cPanNET in 71% of the biopsies compared with a specific diagnosis by EUS in 38% of cases. An interpretation of suspicious for cPanNET was given in 77% of cases by cytology and in 47% by EUS. Cytology identified 86% of the lesions as high-risk pancreatic cysts compared with 56% by EUS. Diagnostic morphology was present on both cytology and cell block preparations in 60% of aspirates, on cytology only in 20%, and on cell block only in 20%. CFA was performed on 51% cyst fluids. All cysts but 1 revealed low carcinoembryonic antigen levels (range, 0.2 to >500 ng/mL; mean, 29.5 ng/mL), and amylase levels were <500 U/L in all but 2 cases (range, 16-1493 U/L; mean, 205 U/L). CONCLUSIONS Cytology is the most accurate test for preoperative diagnosis of cPanNETs. EUS is insufficiently accurate for independent diagnosis, and carcinoembryonic antigen and amylase analyses are noncontributory.
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Affiliation(s)
- Vicente Morales-Oyarvide
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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32
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Goh BKP, Tan DMY, Thng CH, Lee SY, Low ASC, Chan CY, Wong JS, Lee VTW, Cheow PC, Chow PKH, Chung AYF, Wong WK, Ooi LLPJ. Are the Sendai and Fukuoka consensus guidelines for cystic mucinous neoplasms of the pancreas useful in the initial triage of all suspected pancreatic cystic neoplasms? A single-institution experience with 317 surgically-treated patients. Ann Surg Oncol 2014; 21:1919-26. [PMID: 24504924 DOI: 10.1245/s10434-014-3501-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND The Sendai Consensus Guidelines (SCG) were formulated in 2006 and updated in Fukuoka in 2012 (FCG) to guide management of cystic mucinous neoplasms of the pancreas. This study aims to evaluate the clinical utility of the SCG and FCG in the initial triage of all suspected pancreatic cystic neoplasms. STUDY DESIGN Overall, 317 surgically-treated patients with a suspected pancreatic cystic neoplasm were classified according to the SCG as high risk (HR(SCG)) and low risk (LR(SCG)), and according to the FCG as high risk (HR(FCG)), worrisome (W(FCG)), and low risk (LR(FCG)). Cystic lesions of the pancreas (CLP) were classified as potentially malignant/malignant or benign according to the final pathology. RESULTS The presence of symptoms, proximal lesions with obstructive jaundice, elevated serum carcinoembryonic antigen/carbohydrate antigen 19-9 (CEA/CA 19-9), size ≥3 cm, presence of solid component, main pancreatic duct dilatation, thickened enhancing walls, and change in ductal caliber with distal atrophy were predictive of a potentially malignant/malignant CLP on univariate analyses. The positive predictive value (PPV) and negative predictive value (NPV) of HR(SCG) and HR(ICG2012) for a potentially malignant/malignant lesion was 67 and 88 %, and 88 and 92.5 %, respectively. There were no malignant lesions in both LR groups but some potentially malignant lesions such as cystic pancreatic neuroendocrine neoplasms with uncertain behavior were classified as LR. CONCLUSION The updated FCG was superior to the SCG for the initial triage of all suspected pancreatic cystic neoplasms. CLP in the LR(FCG) group can be safely managed conservatively, and those in the HR(FCG) group should undergo resection.
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Affiliation(s)
- Brian K P Goh
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Outram Road, Singapore, Singapore,
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Magnetic resonance imaging of cystic pancreatic lesions in adults: an update in current diagnostic features and management. ACTA ACUST UNITED AC 2013; 39:48-65. [DOI: 10.1007/s00261-013-0048-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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34
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Endosonographic and cyst fluid characteristics of cystic pancreatic neuroendocrine tumours: a multicentre case series. Dig Liver Dis 2013; 45:750-3. [PMID: 23582348 DOI: 10.1016/j.dld.2013.02.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 02/18/2013] [Accepted: 02/27/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic neuroendocrine tumours are uncommon neoplasms which may rarely be cystic. Differentiation from other more common cystic neoplasms may be difficult. AIMS To describe the morphologic, cytologic, and cyst fluid characteristics of cystic pancreatic neuroendocrine tumours. METHODS Retrospective analysis of consecutive patients referred for endosonographic evaluation of pancreatic cysts at four centres. RESULTS 27 patients (12 males) with cystic pancreatic neuroendocrine tumours were identified. Prior to endosonography, this tumour was suspected in only 2 patients based on presenting symptoms (7.4%). The median cyst size was 35 mm (range 8-80 mm). Wall thickening was identified in 13 cases. The median carcinoembryonic antigen level was 1.25 (range 0.6-500). Fine needle aspiration cytology in 17 of 24 patients confirmed neuroendocrine tumour (71%). In 8 of 9 patients who had needle targeting of the cyst wall, cytology was consistent with neuroendocrine tumour (88.9%). 18 patients underwent surgical resection. CONCLUSIONS Cystic pancreatic neuroendocrine tumour was rarely suspected, including by cross-sectional imaging. Wall thickening was identified in approximately half of cases on endosonography. Cyst fluid was typically non-viscous with very low carcinoembryonic antigen levels. Targeting the wall during fine needle aspiration had a high diagnostic yield and should be performed.
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Pancreatic neuroendocrine tumor with cystlike changes: evaluation with MDCT. AJR Am J Roentgenol 2013; 200:W283-90. [PMID: 23436873 DOI: 10.2214/ajr.12.8941] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The objective of our study was to determine the prevalence and CT appearance of cystlike changes of pancreatic neuroendocrine tumor (NET), particularly of small (≤ 3 cm) tumors. MATERIALS AND METHODS The clinical records, images, and pathologic reports of 74 consecutive patients (average age, 55.5 years) with surgically resected pancreatic NETs who underwent preoperative CT were retrospectively reviewed. The size and location of the pancreatic NETs were recorded. The tumors were classified on the basis of CT appearance as small (≤ 3 cm) or large (> 3 cm) and as solid, partially (≤ 50% or > 50%) cystic, or purely (≈ 100%) cystic. Peripheral contrast enhancement on CT was characterized, and lymph node and liver metastases found by pathologic examination were recorded. RESULTS A total of 78 pancreatic NETs were reviewed. Five were not visualized on CT, leaving 73 pancreatic NETs in 69 patients (multiple tumors were visualized on CT of three patients) for analysis. The mean size of the 73 tumors was 3.0 ± 2.6 (SD) cm (range, 0.7-13.1 cm); 52 tumors were 3 cm or smaller and 21 tumors were larger than 3 cm. Gross pathologic results confirmed that 13 of the 73 (17.8%) tumors were predominantly (> 50% or ≈ 100%) cystic: 10 of the 52 (19.2%) tumors 3 cm or smaller and three of the 21 (14.3%) tumors larger than 3 cm. Peripheral contrast enhancement was seen in 11 of the 13 (85%) predominantly cystic pancreatic NETs. Compared with solid pancreatic NETs, predominantly cystic pancreatic NETs were less commonly associated with lymph node and liver metastases. CONCLUSION Cystic pancreatic NETs are not rare and should be included in the differential diagnosis of a cystic pancreatic mass, particularly if the cystic mass is associated with peripheral contrast enhancement. A minority of cystic pancreatic NETs can present with no peripheral enhancement.
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Incidental neuroendocrine tumors of the pancreas: MDCT findings and features of malignancy. AJR Am J Roentgenol 2013; 200:355-62. [PMID: 23345357 DOI: 10.2214/ajr.11.8037] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The objective of our study was to evaluate the MDCT features of incidentally detected neuroendocrine tumors (NETs) of the pancreas, identify features that can predict tumor biology or aggressiveness and long-term outcome, and determine the incidence of "nonbenign" behavior. MATERIALS AND METHODS In this retrospective study, 60 histologically verified pancreatic NETs incidentally detected with contrast-enhanced MDCT were included. Various MDCT features such as size, morphology, enhancement, and presence of calcifications were evaluated and were correlated with tumor biology on histopathology. The sensitivity, specificity, predictive values, and accuracy were calculated for MDCT features in predicting nonbenign biology and risk of recurrence. RESULTS A total of 32 of 60 (53%) NETs were nonbenign: most were large (mean, 29.1 mm) with a solid or complex pattern. NET size of 3 cm or larger yielded a positive predictive value of 61% for nonbenign tumors and 100% when calcification was present. In 12 patients with recurrence, 92% of NETs were nonbenign. The presence of calcification, local invasion, main pancreatic duct dilatation, vascular invasion, and lymph node enlargement along with angioinvasion and a Ki-67 index greater than 2% on histology were associated with a nonbenign diagnosis and a higher risk of recurrence. CONCLUSION Approximately 50% of incidental NETs show uncertain or malignant behavior. Solid tumors 3 cm or larger are commonly nonbenign; however, about 30% of tumors smaller than that size cutoff can be malignant. Nonbenign tumors and those with invasive features on MDCT have a higher incidence of recurrence.
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Abstract
Pancreatic neuroendocrine tumors (PanNETs) are typically solid neoplasms but in rare instances may present as cystic lesions. This unusual presentation can make clinical diagnosis challenging. In addition, the clinical and histopathologic characteristics of cystic PanNETs are poorly defined. We identified 53 cystic PanNETs in our single-institution experience of 491 surgically resected PanNETs. Similar to solid PanNETs, cystic PanNETs developed with an equal sex distribution and over a wide age range (23 to 91 y; mean, 52 y). The unusual cystic appearance made radiologic differentiation from other cystic pancreatic neoplasms difficult with a misdiagnosis in 23 of 53 (43%) cases. An association between cystic PanNETs and multiple endocrine neoplasia type 1 or multifocal disease [5 of 53 (9%) and 7 of 53 (13%), respectively] was not observed as compared with solid PanNETs (P=0.34 and P=0.31, respectively). Grossly, cystic PanNETs were predominantly located in the tail of the pancreas (n=28, 53%) and were similar in size (mean, 3.3 cm) to solid PanNETs (mean, 4.1 cm; P=0.12). All cysts were unilocular (n=53, 100%) and filled with clear to straw-colored fluid. Larger cysts were sometimes noted to be hemorrhagic. Histologically, the cysts were lined by a thin fibrous band that separated the cyst from the neoplastic cells. In comparison with their solid counterparts, cystic PanNETs were less likely to demonstrate tumor necrosis (6%; P=0.04), perineural invasion (8%; P<0.001), vascular invasion (4%; P<0.001), regional lymph node metastasis (13%; P<0.001), and synchronous distant metastasis (4%; P=0.015). The neoplastic cells of the cystic PanNETs were well differentiated (n=53, 100%) with a low mitotic rate and low Ki-67 proliferation index (range, 0.2% to 11%; mean, 1.8%). On the basis of both the American Joint Cancer Committee and European Neuroendocrine Tumor Society staging systems, the majority of cystic PanNETs presented at a lower pathologic stage as compared with solid PanNETs. In summary, cystic PanNETs are a distinctive subgroup of PanNETs with unique clinical, radiographic, and pathologic features.
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Sakorafas GH, Smyrniotis V, Reid-Lombardo KM, Sarr MG. Primary pancreatic cystic neoplasms of the pancreas revisited. Part IV: rare cystic neoplasms. Surg Oncol 2012; 21:153-63. [PMID: 21816607 DOI: 10.1016/j.suronc.2011.06.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 05/16/2011] [Accepted: 06/29/2011] [Indexed: 02/07/2023]
Abstract
Primary pancreatic cystic neoplasms are being recognized with increasing frequency due to modern imaging techniques. In addition to the more common cystic neoplasms-serous cystadenoma, primary mucinous cystic neoplasm, and intraductal papillary mucinous neoplasm-there are many other less common neoplasms that appear as cystic lesions. These cystic neoplasms include solid pseudopapillary neoplasm of the pancreas (the most common rare cystic neoplasm), cystic neuroendocrine neoplasm, cystic degeneration of otherwise solid neoplasms, and then the exceedingly rare cystic acinar cell neoplasm, intraductal tubular neoplasm, angiomatous neoplasm, lymphoepithelial cysts (not true neoplasms), and few others of mesenchymal origin. While quite rare, the pancreatic surgeon should at the least consider these unusual neoplasms in the differential diagnosis of potentially benign or malignant cystic lesions of the pancreas. Moreover, each of these unusual neoplasms has their own natural history/tumor biology and may require a different level of operative aggressiveness to obtain the optimal outcome.
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Affiliation(s)
- George H Sakorafas
- 4th Department of Surgery, Medical School, University of Athens, Attikon University Hospital, Athens, 12462, Greece.
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Gaujoux S, Tang L, Klimstra D, Gonen M, Brennan MF, D’Angelica M, DeMatteo R, Fong Y, Jarnagin W, Allen PJ. The outcome of resected cystic pancreatic endocrine neoplasms: A case-matched analysis. Surgery 2012; 151:518-25. [DOI: 10.1016/j.surg.2011.09.037] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Accepted: 09/22/2011] [Indexed: 02/07/2023]
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Atiq M, Bhutani MS, Bektas M, Lee JE, Gong Y, Tamm EP, Shah CP, Ross WA, Yao J, Raju GS, Wang X, Lee JH. EUS-FNA for pancreatic neuroendocrine tumors: a tertiary cancer center experience. Dig Dis Sci 2012; 57:791-800. [PMID: 21964743 DOI: 10.1007/s10620-011-1912-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Accepted: 09/02/2011] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Pancreatic neuroendocrine tumors (PNET) are fairly uncommon. Recent data highlight the importance of EUS in diagnosis of PNET. With this background, we decided to review our experience from a tertiary cancer center with regard to the presentation and clinical features of PNET and the diagnostic utility of EUS-FNA in this scenario. METHODS We identified patients who underwent EUS at our institution between January 1st 2001 and December 31st 2009 for a suspected PNET. Data on clinical features, cross-sectional imaging findings, EUS findings, and cytology results were collected. RESULTS A total of 81 patients were referred for EUS-FNA for a suspected PNET. Mean age was 58.1 years. There were 41 (50.6%) males. PNET was found incidentally in 38 (46.9%) patients. Computed tomography scanning identified a pancreatic mass in 72 out of 79 (91.1%) cases. Mean diameter of the largest lesion seen on EUS was 27.5 mm (range: 6.9-80 mm). The most common site (34; 42%) was the head of the pancreas. EUS-FNA correctly confirmed a PNET in 73 out of 81 cases with diagnostic accuracy of 90.1%. Seven (8.6%) out of 81 patients had functional lesions, including three gastrinomas and four insulinomas. Liver metastases were found in 31 out of 81 (38.3%) cases. Of the 31 patients with liver metastasis, the mean diameter of lesions on EUS was 33.9 mm compared with 23.5 mm in patients without liver metastasis (P = 0.005). CONCLUSION EUS-FNA is a reliable modality for further characterization of suspected lesions and for establishing a tissue diagnosis. The occurrence of complications of EUS-FNA in this setting is low. Non-functional PNET are more frequently encountered than functional PNET.
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Affiliation(s)
- Muslim Atiq
- Department of Gastroenterology, MD Anderson Cancer Center, 1515-Holcombe Blvd., Unit #1466, Houston, TX 77030, USA
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Paik KY, Choi SH, Heo JS, Choi DW. Solid tumors of the pancreas can put on a mask through cystic change. World J Surg Oncol 2011; 9:79. [PMID: 21771323 PMCID: PMC3155900 DOI: 10.1186/1477-7819-9-79] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 07/19/2011] [Indexed: 12/17/2022] Open
Abstract
Background Solid pancreatic tumors such as pancreatic ductal adenocarcinoma (PDAC), solid pseudopapillary tumor (SPT), and pancreatic endocrine tumor (PET) may occasionally manifest as cystic lesions. In this study, we have put together our accumulated experience with cystic manifestations of various solid tumors of the pancreas. Methods From 2000 to 2006, 376 patients with pancreatic solid tumor resections were reviewed. Ten (2.66%) of these tumors appeared on radiological imaging studies as cystic lesions. We performed a retrospective review of medical records and pathologic findings of these 10 cases. Results Of the ten cases in which solid tumors of the pancreas manifested as cystic lesions, six were PDAC with cystic degeneration, two were SPT undergone complete cystic change, one was cystic PET, and one was a cystic schwannoma. The mean tumor size of the cystic portion in PDAC was 7.3 cm, and three patients were diagnosed as 'pseudocyst' with or without cancer. Two SPT were found incidentally in young women and were diagnosed as other cystic neoplasms. One cystic endocrine tumor was preoperatively suspected as intraductal papillary mucinous neoplasm or mucinous cystic neoplasm. Conclusions Cystic changes of pancreas solid tumors are extremely rare. However, the possibility of cystic manifestation of pancreas solid tumors should be kept in mind.
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Affiliation(s)
- Kwang Yeol Paik
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Goh BKP, Chow PKH, Tan YM, Cheow PC, Chung YFA, Soo KC, Wong WK, Ooi LLPJ. Validation of five contemporary prognostication systems for primary pancreatic endocrine neoplasms: results from a single institution experience with 61 surgically treated cases. ANZ J Surg 2010; 81:79-85. [PMID: 21299804 DOI: 10.1111/j.1445-2197.2010.05403.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Presently, several systems for the prognostication of pancreatic endocrine neoplasms (PENs) exist and the most appropriate classification system has not been clearly defined. This study aims to validate the performance of the 2004 World Health Organization (WHO), European Neuroendocrine Tumor Society (ENETS), Memorial Sloan-Kettering Cancer Center (MSKCC), American Joint Committee for Cancer (AJCC) TNM staging and Bilimoria criteria in a cohort of patients with PENs who underwent surgery at a single institution. METHODS This study is a retrospective review of 61 consecutive patients who underwent surgical treatment for PEN. Actuarial disease-specific survival (DSS) of all 61 patients and recurrence-free survival (RFS) of 53 patients who had curative resection were analysed. RESULTS On univariate analyses, tumour size ≥50 mm, non-curative resection, lymph node involvement, presence of distant metastases, presence of necrosis, mitotic count ≥2/10 hpf and poor differentiation were associated with decreased DSS. Tumour size ≥50 mm, lymph node involvement, lymphovascular invasion, presence of necrosis and mitotic count ≥2/10 hpf were associated with decreased actuarial RFS. All five staging systems were useful in stratifying the 61 patients according to actuarial DSS. However, the MSKCC grading and ENETS grading systems were not statistically significant in stratifying DSS in the 61 patients. In the 53 patients who underwent curative resection, the WHO, ENETS, MSKCC, AJCC staging and the MSKCC grading systems were successful in stratifying the patients according to actuarial RFS. However, the Bilimoria scoring and ENETS grading systems were not useful in prognosticating these 53 patients. CONCLUSION All five classification systems were useful for the prognostication of surgically treated PENs in our patient cohort.
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Affiliation(s)
- Brian K P Goh
- Department of Surgery, Singapore General Hospital, Singapore.
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Kimura N, Komuro K, Uchino S, Yagihashi S, Ishidate T, Ishizaka M. Multiple endocrine neoplasia type 1-associated cystic pancreatic endocrine neoplasia and multifocal cholesterol granulomas. Pathol Int 2010; 60:321-5. [DOI: 10.1111/j.1440-1827.2010.02516.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
OBJECTIVES Pancreatic endocrine tumors (PETs) are infrequent, which makes large experiences unlikely. Our aim was to describe a large single-center experience with PETs and the use of endoscopic ultrasound (EUS) and a cancer staging system (TNM). METHODS This study involves a retrospective analysis of 86 patients (44 men; age, 58 +/- 14 years) who underwent EUS-fine needle aspiration (EUS-FNA). Immunohistochemistry was used. Lesions were classified as recommended by TNM classification. RESULTS Typical EUS features were well-demarcated, hypoechoic, solid, homogeneous lesions. Ninety percent had the diagnosis obtained by EUS-FNA. Twelve PETs (14%) were functioning, 8 (9.3%) were cystic, and 14 (16%) were 10 mm or smaller. Nonfunctional PETs and larger lesions were more advanced. The TNM stage was I in 24, II in 10, III in 18, and IV in 34 patients. Sixteen patients (27%) died, and 30 patients (52%) had progression/recurrence during the follow-up (34 +/- 27 months). TNM stage and surgery with curative intent were related to progression. The overall 5-year survival was 60%. The mean survival time was 94 +/- 12 months for stage I, 52 +/- 12 months for stage III, and 54 +/- 7 months for stage IV (P = 0.06). CONCLUSIONS Nonfunctional PETs were more common and advanced. The EUS-FNA has a high accuracy for diagnosing PETs. Progression and poorer survival were associated with TNM stage.
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Charfi S, Marcy M, Bories E, Pesanti C, Caillol F, Giovannini M, Viret F, Robert Delpero J, Xerri L, Monges G. Cystic pancreatic endocrine tumors: an endoscopic ultrasound-guided fine-needle aspiration biopsy study with histologic correlation. Cancer 2009; 117:203-10. [PMID: 19365841 DOI: 10.1002/cncy.20024] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Cystic pancreatic endocrine tumors (PETs) are rare neoplasms with a preoperative diagnostic challenge. The aim of this study was to evaluate the preoperative diagnostic strategy for these tumors and to assess the clinical and pathologic characteristics. METHODS Six cases of cystic PET were retrospectively enrolled. Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) was performed in 4 cases. All cytomorphologic data from conventional smears, ThinPrep preparations, and cell block preparations were reported in detail. RESULTS There were 3 male and 3 female patients with a mean age of 52.3 years. Tumor size ranged from 10 mm to 60 mm (mean, 29.8 mm). EUS-FNAB contributed to an accurate diagnosis in all cases. Cytologically, loosely cohesive aggregates and single cells were predominant. Cells were small and typically plasmacytoid, with occasional cytoplasmic vacuolization. Nuclei were round or oval, uniform, with finely and evenly distributed chromatin. Immunocytochemistry confirmed the endocrine differentiation. Histologic findings were typical for endocrine proliferation. All tumors were well differentiated. CONCLUSIONS Cystic PET is an unusual finding that presents diagnostic challenges for both endoscopists and cytologists. EUS-FNAB with the Thinprep preparation technique and cell block material were found to be helpful in improving diagnostic accuracy. Immunocytochemical staining with endocrine markers confirmed the diagnosis.
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Affiliation(s)
- Slim Charfi
- Department of Pathology, Paoli-Calmettes Institute, Marseille, France.
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Marsh WL, Colonna J, Yearsley M, Bloomston M, Frankel WL. Calponin is expressed in serous cystadenomas of the pancreas but not in adenocarcinomas or endocrine tumors. Appl Immunohistochem Mol Morphol 2009; 17:216-9. [PMID: 19391217 DOI: 10.1097/pai.0b013e31818c1aa6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The diagnosis of serous microcystic adenoma (SMA) is usually straightforward. For small biopsies and/or unusual variants, the differential diagnosis includes other pancreatic or metastatic neoplasms showing cystic or clear cell features. We evaluated immunostains for potential use in the diagnosis of SMA. Cases of SMA were identified from archival files. Tissue cores (2 per block) were arrayed to create a microarray of cores measuring 2mm each. Additionally, microarrays previously constructed from 56 pancreatic adenocarcinomas (PACs) and 64 pancreatic endocrine tumors (PENs) were studied. The microarrays were stained with calponin, chromogranin, CD10, alpha-inhibin, and monoclonal neuron-specific enolase (m-NSE). Subsequently, some were stained with MUC6, melan-A, D2-40, h-caldesmon, smooth muscle actin, and smooth muscle myosin. For SMAs, staining was seen with calponin (85.2%), alpha-inhibin (96.2%), and m-NSE (96.2%). Focal weak staining was seen with MUC6 (65%). All SMAs were negative with chromogranin, CD10, melan-A, D2-40, h-caldesmon, smooth muscle actin, and smooth muscle myosin. In contrast, calponin was negative in all PACs and PENs. Staining for alpha-inhibin was absent in PACs and present in 4.1% of PENs; whereas immunoreactivity for m-NSE was present in 26.8% of PACs and 73.7% of PENs. Chromogranin staining was present in 9.1% of PACs and 100% of PENs. An immunohistochemical profile of staining with calponin, alpha-inhibin, and m-NSE and absent staining with chromogranin supports the diagnosis of SMA, and distinguishes SMA from PAC and PEN. Calponin and alpha-inhibin are the most useful positive markers for SMA, and are negative in most entities in the differential diagnosis.
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Affiliation(s)
- William L Marsh
- Department of Pathology, Ohio State University Medical Center, Columbus, OH 43210, USA
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Ng DZW, Goh BKP, Tham EHW, Young SM, Ooi LLPJ. Cystic Neoplasms of the Pancreas: Current Diagnostic Modalities and Management. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2009. [DOI: 10.47102/annals-acadmedsg.v38n3p251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cystic neoplasm of the pancreas is a relatively uncommon condition covering a wide spectrum of pathology. The increasing incidence as a result of routine imaging tests in asymptomatic patients presents a diagnostic and therapeutic problem to the clinician. This paper discusses the role of the various investigative modalities in the management of cystic neoplasia of the pancreas.
Key words: Frantz tumour, Intraductal papillary mucinous neoplasm, Mucinous cystadenoma, Mucinous cystadenocarcinoma, Mucinous neoplasm of the pancreas, Solid pseudopapillary neoplasm
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Ballarin R, Masetti M, Losi L, Di Benedetto F, Di Sandro S, De Ruvo N, Montalti R, Romano A, Guerrini GP, De Blasiis MG, Spaggiari M, Gerunda GE. Cystic pancreatic neuroendocrine neoplasms with uncertain malignant potential: report of two cases. Surg Today 2009; 39:162-7. [PMID: 19198998 DOI: 10.1007/s00595-008-3806-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2008] [Accepted: 04/24/2008] [Indexed: 01/01/2023]
Abstract
Neuroendocrine tumors of the pancreas (NETP) represent only 1%-2% of all pancreatic neoplasms. They can be classified as functioning or non-functioning, respectively, according to the presence or absence of paraneoplastic syndrome. Case 1 concerned a 70-year-old woman with a cystic lesion of the pancreatic head and body. All tumor markers were negative. The patient underwent a distal pancreatectomy. The histology revealed a well-differentiated endocrine tumor with uncertain malignant potential. Case 2 was a 61-year-old man with chronic polyserositis. The serum tumor markers were negative, while he was strongly positive for intracystic tumor markers carcinoembryonic antigen, carbohydrate antigen (CA) 19-9, and CA 125. The patient underwent a cephalo-pancreatic duodenectomy. The preoperative differential diagnosis of cystic NETP is still a challenge due to the high rate of the nonfunctional variant. Although cystic NETPs are well differentiated, they are still tumors with a malignant potential, and therefore an early diagnosis and radical surgical resection could be associated with a better long-term survival.
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Affiliation(s)
- Roberto Ballarin
- Liver and Multivisceral Transplant Center and Hepatobiliopancreatic Surgery, University of Modena and Reggio Emilia, 71 Via del Pozzo, 41100, Modena, Italy
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Das A, Wells CD, Nguyen CC. Incidental cystic neoplasms of pancreas: what is the optimal interval of imaging surveillance? Am J Gastroenterol 2008; 103:1657-62. [PMID: 18564119 DOI: 10.1111/j.1572-0241.2008.01893.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The optimal interval of imaging studies for surveillance of incidental pancreatic cystic neoplasms is not known. OBJECTIVE A retrospective analysis of longitudinal medical records of patients with pancreatic cystic neoplasms was performed to examine the natural history of incidentally detected cystic pancreatic neoplasms with respect to the development of significant growth and to identify predictors of such growth. RESULTS After excluding patients with small (<10 mm) cysts (N = 144) and inadequate clinical follow-up of less than 6 months (N = 79) and those with a clinical diagnosis of pancreatic pseudocysts, serous cystadenoma, main duct intraductal papillary mucinous neoplasm (N = 29), and neuroendocrine tumor (N = 3), in total, 166 cysts in 150 patients were available for analysis. The working diagnoses on these cysts (based on clinical, radiological features, aspiration cytology, cyst fluid analysis, and surgical pathology data when available) were mucinous cystic neoplasm in 117 and branch-type intraductal papillary mucinous neoplasm in 49. The mean standard error (SE) initial size of these cysts was 2 (0.1) cm. Over a median period of follow-up of 32 (IQR [inter-quartile range] 19-48) months, 89% of all the cysts did not show significant growth during the follow-up. In a multivariate Cox proportional hazards model, the initial size of the cystic lesion was an independent predictor of significant growth during follow-up (relative risk 1.28, 95% confidence interval [CI] 1.08-1.61, P= 0.01); the only other significant variable was the presence of intracystic or mural nodule (relative risk 38.6, 95% CI 2.3-654, P= 0.01). CONCLUSION Most incidentally detected cystic neoplasms of the pancreas did not have significant growth during follow-up. Such growth is unlikely to occur before 2 yr of the baseline evaluation, and we suggest that the optimal imaging interval during follow-up of these patients should be at 2 yr from the baseline evaluation, particularly in cystic lesions 3.0 cm or less in size and without intracystic or mural nodules.
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Affiliation(s)
- Ananya Das
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona 85259, USA
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Cystic pancreatic endocrine neoplasms: a distinct tumor type? J Am Coll Surg 2008; 206:1154-8. [PMID: 18501813 DOI: 10.1016/j.jamcollsurg.2007.12.040] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Revised: 10/31/2007] [Accepted: 12/03/2007] [Indexed: 01/17/2023]
Abstract
BACKGROUND Cystic pancreatic endocrine neoplasms (CPENs) are considered rare, and their behavior is thought to be similar to that of solid pancreatic endocrine neoplasms (PENs). This study aims to describe the characteristics of CPENs in a large patient cohort. STUDY DESIGN We performed a retrospective review of 170 patients who underwent resections for PENs at Massachusetts General Hospital from 1977 to 2006. Twenty-nine patients (51% men, mean age 53) with CPENs were compared with 141 patients with solid PENs. Differences in clinical presentation, pathologic and radiographic features, and survival were described. RESULTS CPENs comprised 17% of all PENs (29 of 170) and 5.4% of all resected cystic pancreatic neoplasms(29 of 535). Ten (34%) were purely cystic and 19 (66%) were partially cystic. Compared with solid PENs, CPENs were larger (49 mm versus 23.5 mm, p < 0.05), more likely symptomatic (73% versus 45%, p < 0.05), and more likely nonfunctional (80% versus 50%, p < 0.05). They expressed synaptophysin (100%), chromogranin (82%), and cytokeratin (CK)-19 (24%). Multiple endocrine neoplasia type 1 (MEN-1) was 3.5 times more common in CPENs than in solid tumors (21% versus 6%, p < 0.05). No significant difference was found in location, propensity for metastasis, invasion, or 5-year survival (87% versus 77%, p=0.38). CONCLUSIONS This series, the largest report of CPENs in the literature, shows that CPENs are more common than previously thought, so they should be included in the differential of the cystic lesions of the pancreas. CPENs are larger and more likely to be symptomatic then solid PENs. They are also more likely to be associated with MEN-1 and to be nonfunctional, suggesting they may be a distinct tumor type.
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