1
|
Brandi N, Renzulli M. Towards a Simplified and Cost-Effective Diagnostic Algorithm for the Surveillance of Intraductal Papillary Mucinous Neoplasms (IPMNs): Can We Save Contrast for Later? Cancers (Basel) 2024; 16:905. [PMID: 38473267 DOI: 10.3390/cancers16050905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/14/2024] Open
Abstract
The increased detection of pancreatic cysts in recent years has triggered extensive diagnostic investigations to clarify their potential risk of malignancy, resulting in a large number of patients undergoing numerous imaging follow-up studies for many years. Therefore, there is a growing need for optimization of the current surveillance protocol to reduce both healthcare costs and waiting lists, while still maintaining appropriate sensibility and specificity. Imaging is an essential tool for evaluating patients with intraductal papillary mucinous neoplasms (IPMNs) since it can assess several predictors for malignancy and thus guide further management recommendations. Although contrast-enhanced magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) has been widely recommended by most international guidelines, recent results support the use of unenhanced abbreviated-MRI (A-MRI) protocols as a surveillance tool in patients with IPMN. In fact, A-MRI has shown high diagnostic performance in malignant detection, with high sensitivity and specificity as well as excellent interobserver agreement. The aim of this paper is, therefore, to discuss the current available evidence on whether the implementation of an abbreviated-MRI (A-MRI) protocol for cystic pancreatic lesion surveillance could improve healthcare economics and reduce waiting lists in clinical practice without significantly reducing diagnostic accuracy.
Collapse
Affiliation(s)
- Nicolò Brandi
- Department of Radiology, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Department of Radiology, AUSL Romagna, 48018 Faenza, Italy
| | - Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| |
Collapse
|
2
|
Youssef FF, Liu L, Lin W, Bustamante R, Earles A, Savides T, Fehmi S, Kwong W, Gupta S, Anand G. Pancreatic cyst features predict future development of pancreatic cancer: results of a nested case-control study. Gastrointest Endosc 2024; 99:262.e1-262.e9. [PMID: 37858759 PMCID: PMC10865337 DOI: 10.1016/j.gie.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/17/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND AND AIMS Risk factors for pancreatic cancer among patients with pancreatic cysts are incompletely characterized. The primary aim of this study was to evaluate risk factors for development of pancreatic cancer among patients with pancreatic cysts. METHODS We conducted a retrospective case-control study of U.S. veterans with a suspected diagnosis of branch-duct intraductal papillary mucinous neoplasm from 1999 to 2013. RESULTS Age (hazard ratio [HR], 1.03 per year; 95% confidence interval [CI], 1.00-1.06), larger cyst size at cyst diagnosis (HR, 1.03 per mm; 95% CI, 1.01-1.04), cyst growth rate (HR, 1.22 per mm/y; 95% CI, 1.14-1.31), and pancreatic duct dilation (5-9.9 mm: HR, 3.78; 95% CI, 1.90-7.51; ≥10 mm: HR, 13.57; 95% CI, 5.49-33.53) were found to be significant predictors for pancreatic cancer on multivariable analysis. CONCLUSIONS Age, cyst size, cyst growth rate, and high-risk or worrisome features were associated with a higher risk of developing pancreatic cancer. Applying current and developing novel strategies is required to optimize early detection of pancreatic cancer after cyst diagnosis.
Collapse
Affiliation(s)
- Fady F Youssef
- Department of Medicine, Division of Gastroenterology, Jennifer Moreno Veterans Affairs Healthcare System, San Diego, California, USA; Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Lin Liu
- Department of Medicine, Division of Gastroenterology, Jennifer Moreno Veterans Affairs Healthcare System, San Diego, California, USA; Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Wenyi Lin
- Department of Medicine, Division of Gastroenterology, Division of Biostatistics, Herbert Wertheim School of Public Health and Longevity Science, University of California San Diego, San Diego, California
| | - Ranier Bustamante
- Department of Medicine, Division of Gastroenterology, Jennifer Moreno Veterans Affairs Healthcare System, San Diego, California, USA
| | - Ashley Earles
- Department of Medicine, Division of Gastroenterology, Jennifer Moreno Veterans Affairs Healthcare System, San Diego, California, USA
| | - Thomas Savides
- Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Syed Fehmi
- Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Wilson Kwong
- Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Samir Gupta
- Department of Medicine, Division of Gastroenterology, Jennifer Moreno Veterans Affairs Healthcare System, San Diego, California, USA; Division of Gastroenterology, University of California San Diego, San Diego, California
| | - Gobind Anand
- Department of Medicine, Division of Gastroenterology, Jennifer Moreno Veterans Affairs Healthcare System, San Diego, California, USA; Division of Gastroenterology, University of California San Diego, San Diego, California
| |
Collapse
|
3
|
Jeong D, Morse B, Polk SL, Chen DT, Li J, Hodul P, Centeno BA, Costello J, Jiang K, Machado S, El Naqa I, Farah PT, Huynh T, Raghunand N, Mok S, Dam A, Malafa M, Qayyum A, Fleming JB, Permuth JB. Pancreatic Cyst Size Measurement on Magnetic Resonance Imaging Compared to Pathology. Cancers (Basel) 2024; 16:206. [PMID: 38201633 PMCID: PMC10778543 DOI: 10.3390/cancers16010206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/27/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND While multiple cyst features are evaluated for stratifying pancreatic intraductal papillary mucinous neoplasms (IPMN), cyst size is an important factor that can influence treatment strategies. When magnetic resonance imaging (MRI) is used to evaluate IPMNs, no universally accepted sequence provides optimal size measurements. T2-weighted coronal/axial have been suggested as primary measurement sequences; however, it remains unknown how well these and maximum all-sequence diameter measurements correlate with pathology size. This study aims to compare agreement and bias between IPMN long-axis measurements on seven commonly obtained MRI sequences with pathologic size measurements. METHODS This retrospective cohort included surgically resected IPMN cases with preoperative MRI exams. Long-axis diameter tumor measurements and the presence of worrisome features and/orhigh-risk stigmata were noted on all seven MRI sequences. MRI size and pathology agreement and MRI inter-observer agreement involved concordance correlation coefficient (CCC) and intraclass correlation coefficient (ICC), respectively. The presence of worrisome features and high-risk stigmata were compared to the tumor grade using kappa analysis. The Bland-Altman analysis assessed the systematic bias between MRI-size and pathology. RESULTS In 52 patients (age 68 ± 13 years, 22 males), MRI sequences produced mean long-axis tumor measurements from 2.45-2.65 cm. The maximum MRI lesion size had a strong agreement with pathology (CCC = 0.82 (95% CI: 0.71-0.89)). The maximum IPMN size was typically observed on the axial T1 arterial post-contrast and MRCP coronal series and overestimated size versus pathology with bias +0.34 cm. The radiologist interobserver agreement reached ICCs 0.74 to 0.91 on the MRI sequences. CONCLUSION The maximum MRI IPMN size strongly correlated with but tended to overestimate the length compared to the pathology, potentially related to formalin tissue shrinkage during tissue processing.
Collapse
Affiliation(s)
- Daniel Jeong
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (B.M.); (J.C.); (A.Q.)
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, 3011 Holly Drive, Tampa, FL 33612, USA;
| | - Brian Morse
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (B.M.); (J.C.); (A.Q.)
| | - Stuart Lane Polk
- College of Medicine, University of South Florida, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
| | - Dung-Tsa Chen
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (D.-T.C.); (J.L.)
| | - Jiannong Li
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (D.-T.C.); (J.L.)
| | - Pamela Hodul
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (P.H.); (S.M.); (A.D.); (M.M.); (J.B.F.)
| | - Barbara A. Centeno
- Department of Anatomic Pathology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (B.A.C.); (K.J.)
| | - James Costello
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (B.M.); (J.C.); (A.Q.)
| | - Kun Jiang
- Department of Anatomic Pathology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (B.A.C.); (K.J.)
| | - Sebastian Machado
- Department of Clinical Science, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (S.M.); (P.T.F.)
| | - Issam El Naqa
- Department of Machine Learning, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
| | - Paola T. Farah
- Department of Clinical Science, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (S.M.); (P.T.F.)
| | - Tri Huynh
- College of Medicine, University of Florida, 1600 SW Archer Rd, Gainesville, FL 32610, USA;
| | - Natarajan Raghunand
- Department of Cancer Physiology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
| | - Shaffer Mok
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (P.H.); (S.M.); (A.D.); (M.M.); (J.B.F.)
| | - Aamir Dam
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (P.H.); (S.M.); (A.D.); (M.M.); (J.B.F.)
| | - Mokenge Malafa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (P.H.); (S.M.); (A.D.); (M.M.); (J.B.F.)
| | - Aliya Qayyum
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (B.M.); (J.C.); (A.Q.)
| | - Jason B. Fleming
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (P.H.); (S.M.); (A.D.); (M.M.); (J.B.F.)
| | - Jennifer B. Permuth
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, 3011 Holly Drive, Tampa, FL 33612, USA;
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA; (P.H.); (S.M.); (A.D.); (M.M.); (J.B.F.)
| |
Collapse
|
4
|
Mathew M, Virarkar M, Sun J, Thai K, Saleh M, Menendez-Santos M, Bedi D, Lee JE, Katz M, Kundra V, Bhosale P. Real-Time Ultrasound-Computed Tomography Fusion with Volume Navigation to Assess Pancreatic Cystic Lesions. Curr Oncol 2023; 30:8375-8385. [PMID: 37754523 PMCID: PMC10529455 DOI: 10.3390/curroncol30090608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/24/2023] [Accepted: 09/08/2023] [Indexed: 09/28/2023] Open
Abstract
Transabdominal ultrasound is a promising imaging modality for pancreatic cystic lesions. This study aims to determine if transabdominal ultrasonography with CT fusion (TAUS-f) using volume navigation can be used to measure pancreatic cystic lesions (PCLs) compared to CT alone. We evaluated 33 patients prospectively with known PCLs. The readers evaluated each PCL's size and imaging characteristics on TAUS-f and CT alone. These were compared to endoscopic ultrasonography reports. A total of 43 PCLs from 32 patients were evaluated. The detection rate by TAUS-f was 93%. Two of the three undetected PCLs were in the tail of the pancreas. Inter-reader variabilities for TAUS-f and CT were 0.005 cm and 0.03 cm, respectively. Subgroup analysis by size and location demonstrated that inter-modality variability between TAUS-f and CT was smallest for lesions < 1.5 cm with a size difference of -0.13 cm for each reader and smallest in the pancreatic head with a size difference of -0.16 cm and -0.17 cm for readers 1 and 2. We found that TAUS-f effectively evaluates PCLs compared to CT alone, thus suggesting that it should be considered part of the surveillance algorithm for a subset of patients.
Collapse
Affiliation(s)
- Manoj Mathew
- Department of Radiology, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA;
| | - Mayur Virarkar
- Department of Radiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA;
| | - Jia Sun
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.S.); (M.K.)
| | - Khoan Thai
- Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (M.S.); (D.B.); (V.K.); (P.B.)
| | - Mohammed Saleh
- Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (M.S.); (D.B.); (V.K.); (P.B.)
| | - Manuel Menendez-Santos
- Department of Radiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA;
| | - Deepak Bedi
- Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (M.S.); (D.B.); (V.K.); (P.B.)
| | - Jeffrey E. Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
| | - Matthew Katz
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (J.S.); (M.K.)
| | - Vikas Kundra
- Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (M.S.); (D.B.); (V.K.); (P.B.)
| | - Priya Bhosale
- Department of Radiology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA (M.S.); (D.B.); (V.K.); (P.B.)
| |
Collapse
|
5
|
Ryoo DY, Koehler B, Rath J, Shah ZK, Chen W, Esnakula AK, Hart PA, Krishna SG. A Comparison of Single Dimension and Volume Measurements in the Risk Stratification of Pancreatic Cystic Lesions. J Clin Med 2023; 12:5871. [PMID: 37762812 PMCID: PMC10531933 DOI: 10.3390/jcm12185871] [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: 07/24/2023] [Revised: 08/25/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
The incidence of pancreatic cystic lesions (PCLs) has been rising due to improvements in imaging. Of these, intraductal papillary mucinous neoplasms (IPMNs) are the most common and are thought to contribute to almost 20% of pancreatic adenocarcinomas. All major society guidelines for the management of IPMNs use size defined by maximum diameter as the primary determinant of whether surveillance or surgical resection is recommended. However, there is no consensus on how these measurements should be obtained or whether a single imaging modality is superior. Furthermore, the largest diameter may fail to capture the complexity of PCLs, as most are not perfectly spherical. This article reviews current PCL measurement techniques in CT, MRI, and EUS and posits volume as a possible alternative to the largest diameter.
Collapse
Affiliation(s)
- Da Yeon Ryoo
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.Y.R.); (B.K.)
| | - Bryn Koehler
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.Y.R.); (B.K.)
| | - Jennifer Rath
- Department of Radiology, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (J.R.); (Z.K.S.)
| | - Zarine K. Shah
- Department of Radiology, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (J.R.); (Z.K.S.)
| | - Wei Chen
- Department of Pathology, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (W.C.); (A.K.E.)
| | - Ashwini K. Esnakula
- Department of Pathology, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (W.C.); (A.K.E.)
| | - Phil A. Hart
- Division of Gastroenterology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA;
| | - Somashekar G. Krishna
- Division of Gastroenterology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA;
| |
Collapse
|
6
|
Chhoda A, Schmidt J, Farrell JJ. Surveillance of Pancreatic Cystic Neoplasms. Gastrointest Endosc Clin N Am 2023; 33:613-640. [PMID: 37245939 DOI: 10.1016/j.giec.2023.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Pancreatic cystic neoplasms (PCNs) are increasingly detected because of the widespread use of cross-sectional imaging and overall aging population. While the majority of these cysts are benign, some can progress to advanced neoplasia (defined as high-grade dysplasia and invasive cancer). As the only widely accepted treatment for PCNs with advanced neoplasia is surgical resection, accurate preoperative diagnosis, and stratification of malignant potential for deciding about surgery, surveillance or doing nothing remains a clinical challenge. Surveillance strategies for pancreatic cysts (PCNs) combine clinical evaluation and imaging to assess changes in cyst morphology and symptoms that may indicate advanced neoplasia. PCN surveillance heavily relies on various consensus clinical guidelines that focus on high-risk morphology, surgical indications, and surveillance intervals and modalities. This review will focus on current concepts in the surveillance of newly diagnosed PCNs, especially on low-risk presumed intraductal papillary mucinous neoplasms (those without worrisome features and high-risk stigmata), and appraise current clinical surveillance guidelines.
Collapse
Affiliation(s)
- Ankit Chhoda
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Julie Schmidt
- Yale Multidisciplinary Pancreatic Cyst Clinic (Yale MPaCC), Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University School of Medicine, New Haven, CT, USA
| | - James J Farrell
- Yale Multidisciplinary Pancreatic Cyst Clinic (Yale MPaCC), Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University School of Medicine, New Haven, CT, USA.
| |
Collapse
|
7
|
Hesse F, Ritter J, Hapfelmeier A, Braren R, Phillip V. Comparison of Magnetic Resonance Imaging and Endoscopic Ultrasound in the Sizing of Intraductal Papillary Mucinous Neoplasia of the Pancreas. Pancreas 2023; 52:e315-e320. [PMID: 37906550 DOI: 10.1097/mpa.0000000000002264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
OBJECTIVES Because IPMNs are potentially malignant, surveillance of IPMN is recommended by magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS). The aim of the study was the evaluation of the concordance between EUS and MRI regarding cyst size. METHODS Retrospective data analysis was done for patients with IPMN in whom EUS and MRI were performed simultaneously (≤60 days). The measured cyst size of both procedures was compared by Bland-Altman plots. Agreement of cyst localization and dilation of main pancreatic duct was assessed using kappa statistics. RESULTS Fifty-nine cases were evaluated (median age, 71 years; 65% female; median time interval between both investigations, 17 days). The mean difference of IPMN maximal diameter between EUS and MRI was 0.55 mm with a prediction interval of -9.20 to +10.29 mm for 95% of the expected differences. There was strong interobserver agreement regarding cyst localization ( κ = 0.669, P = 1.06e -13 ) and the width of main pancreatic duct (<5, 5-9, and ≥10 mm; κ = 0.676 caput, κ = 0.823 corpus). CONCLUSIONS We found a clinically relevant difference in cyst size comparing EUS and MRI. Therefore, alternating EUS and MRI for follow-up of the "worrisome feature" size growth is not reasonable.
Collapse
Affiliation(s)
| | - Jessica Ritter
- Institute of Diagnostic and Interventional Radiology, Technical University of Munich, School of Medicine and Health, Department Clinical Medicine, University Hospital rechts der Isar
| | | | - Rickmer Braren
- Institute of Diagnostic and Interventional Radiology, Technical University of Munich, School of Medicine and Health, Department Clinical Medicine, University Hospital rechts der Isar
| | | |
Collapse
|
8
|
Johansson K, Mustonen H, Nieminen H, Haglund C, Lehtimäki TE, Seppänen H. MRI follow-up for pancreatic intraductal papillary mucinous neoplasm: an ultrashort versus long protocol. Abdom Radiol (NY) 2022; 47:727-737. [PMID: 34923598 PMCID: PMC8807431 DOI: 10.1007/s00261-021-03382-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 11/24/2021] [Accepted: 12/08/2021] [Indexed: 12/19/2022]
Abstract
Purpose To evaluate whether an ultrashort-protocol (USP) MRI including only T2-weighted HASTE axial and 3D MRCP SPACE sequences adequately measures the largest diameter of the largest cyst and the main pancreatic duct (MPD) and identifies worrisome features (WF) and high-risk stigmata (HRS) when compared to longer protocols (LP, long protocol; SP, short protocol; S-LP, short or long protocol). We also calculated reductions in costs associated with USP. Methods This retrospective study included 183 IPMN patients. Two radiologists compared two imaging sets (USP versus S-LP) per patient, comparing the mean values of the largest cyst and MPD and agreement regarding the presence or absence of cystic or MPD mural nodules and solid pancreatic tumors. The interobserver agreement for cystic mural nodules and WF/HRS was evaluated, using the Bland-Altman plot and Cohen’s Kappa. Results A total of 112 IPMN patients were evaluated. For detecting cysts or MPD nodules, WF/HRS, and solid pancreatic tumors, USP and S-LP coincided in 94.9%, 99.1%, 92.4%, and 99.1% of cases, respectively. Both USP and S-LP identified all true cystic mural nodules. The mean size of the largest cyst and MPD was 19.48/19.67 mm and 3.24/3.33 mm using USP versus S-LP, while the mean differences for USP versus S-LP were 0.19 mm and 0.08 mm. The USP cost was 39% of LP cost and 77% of SP. Interobserver agreement was moderate to strong. Conclusions For IPMN surveillance, an ultrashort-protocol MRI provides nearly identical information to the more expensive longer protocols. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00261-021-03382-4.
Collapse
Affiliation(s)
- Katarina Johansson
- Department of Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, P.O. Box 340, 00029, Helsinki, Finland.
| | - Harri Mustonen
- Department of Surgery, University of Helsinki and Helsinki University Hospital, PO Box 440, 00029, Helsinki, Finland
| | - Heini Nieminen
- Department of Surgery, University of Helsinki and Helsinki University Hospital, PO Box 440, 00029, Helsinki, Finland
| | - Caj Haglund
- Department of Surgery, University of Helsinki and Helsinki University Hospital, PO Box 440, 00029, Helsinki, Finland
- Translational Cancer Medicine Research Program, University of Helsinki, Helsinki, Finland
| | - Tiina E Lehtimäki
- Department of Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, P.O. Box 340, 00029, Helsinki, Finland
| | - Hanna Seppänen
- Department of Surgery, University of Helsinki and Helsinki University Hospital, PO Box 440, 00029, Helsinki, Finland
- Translational Cancer Medicine Research Program, University of Helsinki, Helsinki, Finland
| |
Collapse
|
9
|
Pancreatic cystic neoplasms: a review of current recommendations for surveillance and management. Abdom Radiol (NY) 2021; 46:3946-3962. [PMID: 33742217 DOI: 10.1007/s00261-021-03030-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/25/2021] [Accepted: 02/27/2021] [Indexed: 12/12/2022]
Abstract
Pancreatic cystic neoplasms (PCN) comprise of a diverse array of pancreatic cysts, including intraductal papillary mucinous neoplasms (IPMN), mucinous cystic neoplasms (MCN), serous cystic neoplasms (SCN), cystic neuroendocrine tumors (cNET), and many others. Increasing use of cross-sectional imaging has resulted in greater numbers of PCNs discovered incidentally. The overall risk of malignancy is low, but can vary considerably between different classes of PCNs. Furthermore, many pancreatic cysts are indeterminate on imaging, and the inability to reliably predict the course of disease remains a challenge for radiologists. Due to the variability in disease course and a lack of high-quality studies on PCNs, there is no universal consensus when it comes to balancing optimal surveillance while avoiding the risk for overtreatment. Currently, there are three widely accepted international guidelines outlining guidelines for surveillance and management of PCNs: the American Gastroenterological Association (AGA) in 2015, the International Association of Pancreatology (IAP) last revised in 2017, and the European Study Group on Cystic Tumours of the Pancreas (European) last revised in 2018. In 2017, the American College of Radiology released its own comprehensive set of recommendations for managing indeterminate pancreatic cysts that are detected incidentally on CT or MRI. The purpose of this paper is to describe the key differences between the ACR recommendations and the aforementioned three sets of guidelines regarding cyst management, imaging surveillance, performance, and cost-effectiveness.
Collapse
|
10
|
Huynh T, Ali K, Vyas S, Dezsi K, Strickland D, Basinski T, Chen DT, Jiang K, Centeno B, Malafa M, Klapman JB, Hodul PJ, Jeong D, Permuth JB. Comparison of imaging modalities for measuring the diameter of intraductal papillary mucinous neoplasms of the pancreas. Pancreatology 2020; 20:448-453. [PMID: 32113936 PMCID: PMC7346718 DOI: 10.1016/j.pan.2020.02.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 02/05/2020] [Accepted: 02/18/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMNs) are pre-malignant pancreatic cysts detected by imaging. Cyst size is one of many features evaluated on computed tomography (CT), magnetic resonance imaging (MRI), or endoscopic ultrasonography (EUS) to help guide IPMN management. Our objective was to determine which imaging modality best predicts pathological cyst size. METHODS We analyzed records for 57 IPMN cases surgically treated at Moffitt Cancer Center from 2008 to 2016 for whom pre-operative CT, MRI, and EUS IPMN cyst size and post-operative pathological cyst size values were available. Long axis cyst diameter measurements were compared to each other and corresponding pathological cyst measurements using within-subjects ANOVA, Bland-Altman analysis, and linear regression. Consensus measurements were also performed on CT and MRI images. RESULTS Cyst size measured via CT and MRI overestimated pathological size by 0.33 cm and 0.27 cm, respectively, whereas EUS underestimated pathological size by 0.05 cm and had the narrowest 95% limit of agreement (LOA). Among pathologically-confirmed cysts <3 cm, MRI overestimated pathological size by 0.30 cm (P = 0.049) and had the widest LOA, followed by EUS and CT. Among cysts ≥3 cm, EUS underestimated pathological size by 0.35 cm (P = 0.059) and MRI and CT overestimated pathological size by 0.23 cm and 0.51 cm, respectively. CONCLUSIONS In this small retrospective study, EUS cyst size measurements correlated best with pathologic specimens compared to CT and MRI, especially for cysts < 3 cm. Larger prospective studies are needed to determine which imaging modalities are best to risk-stratify IPMNs and guide surgical versus. Non-surgical management.
Collapse
Affiliation(s)
- Tri Huynh
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Karla Ali
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Shraddha Vyas
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Kaleena Dezsi
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Destiny Strickland
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Toni Basinski
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Dung-Tsa Chen
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, USA
| | - Kun Jiang
- Department of Pathology, Moffitt Cancer Center, Tampa, FL, USA
| | - Barbara Centeno
- Department of Pathology, Moffitt Cancer Center, Tampa, FL, USA
| | - Mokenge Malafa
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jason B Klapman
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Pamela J Hodul
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Daniel Jeong
- Department of Diagnostic Radiology, Moffitt Cancer Center, Tampa, FL, USA
| | - Jennifer B Permuth
- Department of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, USA; Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, USA.
| |
Collapse
|
11
|
Abstract
Pancreatic cancer (PC) is an increasingly common disease worldwide. Having a better understanding of worldwide and regional epidemiologic features and risk factors of PC is essential to identify new approaches for prevention, early diagnosis, surveillance, and treatment. In this article, we review the epidemiologic features and risk factors for PC and discuss opportunities and challenges of PC future treatment.
Collapse
Affiliation(s)
- Wenhao Luo
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jinxin Tao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Lianfang Zheng
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China.,Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| |
Collapse
|
12
|
Aghdassi AA, Schauer B, Duscha D, Ittermann T, Pickartz T, Budde C, Simon P, Moskwa P, Kromrey ML, Bülow R, Völzke H, Kühn J, Lerch MM. Comparability of size measurements of the pancreas in magnetic resonance imaging and transabdominal ultrasound. Clin Anat 2019; 33:431-439. [PMID: 31883163 DOI: 10.1002/ca.23551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/20/2019] [Accepted: 12/12/2019] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Transabdominal ultrasound (US) and magnetic resonance imaging (MRI) are commonly used for the examination of the pancreas in clinical routine. We therefore were interested in the concordance of these two imaging methods for the size measurement of the pancreas and how age, gender, and body mass index (BMI) affect the organ size. METHODS A total of 342 participants from the Study of Health in Pomerania underwent whole-body MRI and transabdominal US on the same day, and the diameter of the pancreatic head, body, and tail were measured. The agreement between US and MRI measurements was assessed by Bland and Altman plots. Intraclass correlation coefficients were used to compare observers. A multivariable regression model was applied using the independent variables age, gender, and body mass index. RESULTS Compared to MRI, abdominal US returned smaller values for each segment of the pancreas, with a high level of inconsistency between these two methods. The mean difference was 0.39, 0.18, and 0.54 cm for the head, body, and tail, respectively. A high interobserver variability was detected for US. Multivariable analysis showed that pancreatic size in all three segments increased with BMI in both genders whereas pancreatic head and tail size decreased with age, an effect more marked in women. CONCLUSIONS Agreement of pancreatic size measurements is poor between US and MRI. These limitations should be considered when evaluating morphologic features for pathologic conditions or setting limits of normal size. Adjustments for BMI, gender, and age may also be warranted.
Collapse
Affiliation(s)
- Ali A Aghdassi
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Birgit Schauer
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - David Duscha
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Till Ittermann
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Tilman Pickartz
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Christoph Budde
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Peter Simon
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Patryk Moskwa
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Marie L Kromrey
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Robin Bülow
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Henry Völzke
- Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Jens Kühn
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Markus M Lerch
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| |
Collapse
|
13
|
Overbeek KA, Alblas M, Gausman V, Kandel P, Schweber AB, Brooks C, Van Riet PA, Wallace MB, Gonda TA, Cahen DL, Bruno MJ. Development of a stratification tool to identify pancreatic intraductal papillary mucinous neoplasms at lowest risk of progression. Aliment Pharmacol Ther 2019; 50:789-799. [PMID: 31429105 PMCID: PMC6772152 DOI: 10.1111/apt.15440] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/11/2019] [Accepted: 07/06/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Because most pancreatic intraductal papillary mucinous neoplasms (IPMNs) will never become malignant, currently advocated long-term surveillance is low-yield for most individuals. AIM To develop a score chart identifying IPMNs at lowest risk of developing worrisome features or high-risk stigmata. METHODS We combined prospectively maintained pancreatic cyst surveillance databases of three academic institutions. Patients were included if they had a presumed side-branch IPMN, without worrisome features or high-risk stigmata at baseline (as defined by the 2012 international Fukuoka guidelines), and were followed ≥ 12 months. The endpoint was development of one or more worrisome features or high-risk stigmata during follow-up. We created a multivariable prediction model using Cox-proportional logistic regression analysis and performed an internal-external validation. RESULTS 875 patients were included. After a mean follow-up of 50 months (range 12-157), 116 (13%) patients developed worrisome features or high-risk stigmata. The final model included cyst size (HR 1.12, 95% CI 1.09-1.15), cyst multifocality (HR 1.49, 95% CI 1.01-2.18), ever having smoked (HR 1.40, 95% CI 0.95-2.04), history of acute pancreatitis (HR 2.07, 95% CI 1.21-3.55), and history of extrapancreatic malignancy (HR 1.34, 95% CI 0.91-1.97). After validation, the model had good discriminative ability (C-statistic 0.72 in the Mayo cohort, 0.71 in the Columbia cohort, 0.64 in the Erasmus cohort). CONCLUSION In presumed side branch IPMNs without worrisome features or high-risk stigmata at baseline, the Dutch-American Risk stratification Tool (DART-1) successfully identifies pancreatic lesions at low risk of developing worrisome features or high-risk stigmata.
Collapse
Affiliation(s)
- Kasper A. Overbeek
- Department of Gastroenterology & HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Maaike Alblas
- Department of Public HealthErasmus University Medical CenterRotterdamThe Netherlands
| | - Valerie Gausman
- Department of MedicineNYU – Langone Medical CenterNew YorkUSA
| | - Pujan Kandel
- Department of Gastroenterology and HepatologyMayo ClinicJacksonvilleUSA
| | - Adam B. Schweber
- Division of Digestive and Liver Diseases, Department of MedicineColumbia University Medical CenterNew YorkUSA
| | - Christian Brooks
- Division of Digestive and Liver Diseases, Department of MedicineColumbia University Medical CenterNew YorkUSA
| | - Priscilla A. Van Riet
- Department of Gastroenterology & HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | | | - Tamas A. Gonda
- Division of Digestive and Liver Diseases, Department of MedicineColumbia University Medical CenterNew YorkUSA
| | - Djuna L. Cahen
- Department of Gastroenterology & HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology & HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| |
Collapse
|
14
|
Singhi AD, Koay EJ, Chari ST, Maitra A. Early Detection of Pancreatic Cancer: Opportunities and Challenges. Gastroenterology 2019; 156:2024-2040. [PMID: 30721664 PMCID: PMC6486851 DOI: 10.1053/j.gastro.2019.01.259] [Citation(s) in RCA: 405] [Impact Index Per Article: 81.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/08/2019] [Accepted: 01/15/2019] [Indexed: 12/17/2022]
Abstract
Most patients with pancreatic ductal adenocarcinoma (PDAC) present with symptomatic, surgically unresectable disease. Although the goal of early detection of PDAC is laudable and likely to result in significant improvement in overall survival, the relatively low prevalence of PDAC renders general population screening infeasible. The challenges of early detection include identification of at-risk individuals in the general population who would benefit from longitudinal surveillance programs and appropriate biomarker and imaging-based modalities used for PDAC surveillance in such cohorts. In recent years, various subgroups at higher-than-average risk for PDAC have been identified, including those with familial risk due to germline mutations, a history of pancreatitis, patients with mucinous pancreatic cysts, and elderly patients with new-onset diabetes. The last 2 categories are discussed at length in terms of the opportunities and challenges they present for PDAC early detection. We also discuss current and emerging imaging modalities that are critical to identifying early, potentially curable PDAC in high-risk cohorts on surveillance.
Collapse
Affiliation(s)
- Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eugene J Koay
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas; Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Anirban Maitra
- Sheikh Ahmed Center for Pancreatic Cancer Research, University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Translational Molecular Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
15
|
Kim M, Park JM, Lee SJ, Kang CD, Kang M, Kim JH, Lee S, Cho SW. [Pancreatic Neuroendocrine Tumor Presenting as Acute Pancreatitis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 71:98-102. [PMID: 29471608 DOI: 10.4166/kjg.2018.71.2.98] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We report a case of acute pancreatitis secondary to pancreatic neuroendocrine tumor. A 46-year old man presented with upper abdominal pain. The serum amylase and lipase were elevated. Abdominal computed tomography (CT) and magnetic resonance cholangiopancreatography revealed a 1.7 cm sized mass at the pancreas body with a dilatation of the upstream pancreatic duct and mild infiltrations of peripancreatic fat. An endoscopic ultrasound-guided fine needle biopsy was performed for the pancreatic mass, but only necrotic tissue was observed on the pathologic examination. A chest and neck CT scan revealed anterior mediastinal, paratracheal, and cervical lymph node enlargement, which were indicative of metastasis. An ultrasound-guided core needle biopsy was performed for the enlarged neck lymph node, and pathologic examination revealed a metastatic poorly differentiated carcinoma. Immunohistochemical analysis showed positive staining for synaptophysin, chromogranin A, and CD 56, indicative of a neuroendocrine carcinoma.
Collapse
Affiliation(s)
- Minjeong Kim
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Jin Myung Park
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Sung Joon Lee
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Chang Don Kang
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - MyungHo Kang
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Ji Hyun Kim
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Seungkoo Lee
- Department of Anatomic Pathology, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Seong Whi Cho
- Department of Radiology, Kangwon National University School of Medicine, Chuncheon, Korea
| |
Collapse
|
16
|
DiMaio CJ. Current Guideline Controversies in the Management of Pancreatic Cystic Neoplasms. Gastrointest Endosc Clin N Am 2018; 28:529-547. [PMID: 30241642 DOI: 10.1016/j.giec.2018.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pancreatic cystic lesions are a common clinical entity. The majority are neoplastic and have the potential for malignant transformation. To assist with patient management, a number of clinical guidelines have been developed over the past decade. However, controversies exist in regards to the various guidelines and treatment strategies they offer. This article will review the various clinical guidelines for management of pancreatic cysts, describe the limitations of these guidelines, and present future directions for improvement in clinical decision making for patients diagnosed with a pancreatic cystic neoplasm.
Collapse
Affiliation(s)
- Christopher J DiMaio
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1069, New York, NY 10029, USA.
| |
Collapse
|
17
|
Levink I, Bruno MJ, Cahen DL. Management of Intraductal Papillary Mucinous Neoplasms: Controversies in Guidelines and Future Perspectives. ACTA ACUST UNITED AC 2018; 16:316-332. [PMID: 30196428 PMCID: PMC6153570 DOI: 10.1007/s11938-018-0190-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose of review Management of intraductal papillary mucinous neoplasm (IPMN) is currently based on consensus, in the absence of evidence-based guidelines. In recent years, several consensus guidelines have been published, with distinct management strategies. In this review, we will discuss these discrepancies, in order to guide treating physicians in clinical management. Recent findings The detection rate of pancreatic cysts has increased substantially with the expanded use of high-quality imaging techniques to up to 45%. Of these cysts, 24–82% are IPMNs, which harbour a malignant potential. Timely detection of high-risk lesions is therefore of great importance. Surgical management is based on the presence of clinical and morphological high-risk features, yet the majority of resected specimens appear to be low risk. Summary International collaboration and incentive large-scale prospective registries of individuals undergoing cyst surveillance are needed to accumulate unbiased data and develop evidence-based guidelines. Additionally, development of non-invasive, accurate diagnostic tools (e.g. biomarkers) is needed to differentiate between neoplastic and non-neoplastic pancreatic cysts and detect malignant transformation at an early stage (i.e. high-grade dysplasia).
Collapse
Affiliation(s)
- Ijm Levink
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - D L Cahen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| |
Collapse
|
18
|
Kolb JM, Argiriadi P, Lee K, Liu X, Bagiella E, Gupta S, Lucas AL, Kim MK, Kumta NA, Nagula S, Sarpel U, DiMaio CJ. Higher Growth Rate of Branch Duct Intraductal Papillary Mucinous Neoplasms Associates With Worrisome Features. Clin Gastroenterol Hepatol 2018. [PMID: 29535058 DOI: 10.1016/j.cgh.2018.02.050] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS For patients with branch duct intraductal papillary mucinous neoplasms (BD-IPMNs, cysts), it is a challenge to identify those at high risk for malignant lesions. We sought to identify factors associated with development of pancreatic cancer, focusing on neoplasm growth rate. METHODS We performed a retrospective study of 189 patients with BD-IPMNs who underwent at least 2 contrast-enhanced cross-sectional imaging studies, 1 year or more apart, at a tertiary referral center from January 2003 through 2013. Patients with cysts that had Fukuoka worrisome or high-risk features were excluded. Two radiologists reviewed all images. Cyst size was recorded at the initial and final imaging studies and growth rate was calculated. We collected patient demographic data, cyst characteristics, and clinical outcomes; univariate logistic regression models were used to determine the odds of developing worrisome features. The primary outcomes were to determine growth rate of low-risk BD-IPMNs and to assess whether cyst growth rate correlates high-risk features of IPMNs. RESULTS Based on image analyses, cysts were initially a median 11 mm (range, 3-31 mm) and their final size was 12.5 mm (range, 3-42 mm). After a median follow-up time of 56 months (range, 12-163 months), the median cyst growth rate was 0.29 mm/year. Twelve patients developed worrisome features, no patients developed high-risk features, 4 patients had surgical resection, and no cancers developed. The rate of BD-IPMN growth was greater in patients who developed worrisome features than those who did not (2.84 mm/year vs 0.23 mm/year; P < .001). The odds of developing worrisome features increased for each unit (mm) increase in cyst size (odds ratio, 1.149; 95% CI, 1.035-1.276, P = .009). CONCLUSION In a retrospective analysis of images from patients with BD-IPMN, we found low-risk BD-IPMNs to grow at an extremely low rate (less than 0.3 mm/year). BD-IPMNs in only about 6% of patients developed worrisome features, and none developed high-risk features or invasive cancers. BD-IPMNs that developed worrisome features were associated with a significantly higher rate of growth than lesions with low-risk features. Low risk BD-IPMNs that grow more than 2.5 mm/year might require surveillance.
Collapse
Affiliation(s)
- Jennifer M Kolb
- Department of Medicine, Mount Sinai Medical Center, New York, New York
| | - Pamela Argiriadi
- Department of Radiology, Mount Sinai Medical Center, New York, New York
| | - Karen Lee
- Department of Radiology, Mount Sinai Medical Center, New York, New York
| | - Xiaoyu Liu
- Department of Population Health Science and Policy, Mount Sinai Medical Center, New York, New York
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Mount Sinai Medical Center, New York, New York
| | - Shivani Gupta
- Division of Gastroenterology, Mount Sinai Medical Center, New York, New York
| | - Aimee L Lucas
- Division of Gastroenterology, Mount Sinai Medical Center, New York, New York
| | - Michelle Kang Kim
- Division of Gastroenterology, Mount Sinai Medical Center, New York, New York
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Medical Center, New York, New York
| | - Satish Nagula
- Division of Gastroenterology, Mount Sinai Medical Center, New York, New York
| | - Umut Sarpel
- Division of Surgical Oncology, Mount Sinai Medical Center, New York, New York
| | | |
Collapse
|
19
|
El Chafic A, El Hajj II, DeWitt J, Schmidt CM, Siddiqui A, Sherman S, Aggarwal A, Al-Haddad M. Does cyst growth predict malignancy in branch duct intraductal papillary mucinous neoplasms? Results of a large multicenter experience. Dig Liver Dis 2018; 50:961-968. [PMID: 29866630 DOI: 10.1016/j.dld.2018.04.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 04/15/2018] [Accepted: 04/16/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cyst growth of BD-IPMNs on follow-up imaging remains a concerning sign. AIMS To describe cyst size changes over time in BD-IPMNs, and determine whether cyst growth rate is associated with increased risk of malignancy. METHODS This is a retrospective study performed at two high volume tertiary centers. Mean cyst size at baseline (MCSB) and mean growth rate percentage (MGRP) were calculated. Rapid cyst growth was defined as MGRP ≥30%/year. Patient and cyst related characteristics were studied. RESULTS 160 patients were followed for a median of 27.4 (12-114.5) months. MCSB was 15.1 ± 8.0 mm. During follow-up, 73 (45.6%) showed any cyst size increase, of which 15 cysts (9.4%) exhibited MGRP ≥30%/year. Rapid cyst growth was not associated with patient or cyst characteristics. Cyst fluid molecular analysis from 101 cysts showed KRAS mutation in 26. Compared to KRAS-negative cysts, neither MCSB (16.0 mm vs. 17.7 mm; p = 0.3) nor MGRP (3.9%/year vs. 5.8%/year; p = 0.7) was significantly different. Eighteen patients underwent surgery; 15 (83%) had LGD, and 3 had advanced neoplasia. Two cysts with LGD and one cyst with advanced neoplasia had MGRP ≥30%/year. CONCLUSION Increase in BD-IPMNs size was not associated with the known high risk patient or cyst-related characteristics. Rapid growth of BD-IPMNs was not associated with advanced neoplasia on surgical pathology.
Collapse
Affiliation(s)
- Abdul El Chafic
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA; Division of Gastroenterology, Thomas Jefferson University, Philadelphia, PA, USA; Division of Gastroenterology, Ochsner Health System, New Orleans, LA, USA
| | - Ihab I El Hajj
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA; Division of Gastroenterology, Saint George Hospital University Medical Center, Balamand University, Beirut, Lebanon
| | - John DeWitt
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Christian M Schmidt
- Department of Surgery, Indiana University Pancreatic Cyst and Cancer Early Detection Center, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ali Siddiqui
- Division of Gastroenterology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stuart Sherman
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Mohammad Al-Haddad
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA.
| |
Collapse
|
20
|
Elta GH, Enestvedt BK, Sauer BG, Lennon AM. ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts. Am J Gastroenterol 2018; 113:464-479. [PMID: 29485131 DOI: 10.1038/ajg.2018.14] [Citation(s) in RCA: 376] [Impact Index Per Article: 62.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 01/05/2018] [Indexed: 02/07/2023]
Abstract
Pancreatic cysts are very common with the majority incidentally identified. There are several types of pancreatic cysts; some types can contain cancer or have malignant potential, whereas others are benign. However, even the types of cysts with malignant potential rarely progress to cancer. At the present time, the only viable treatment for pancreatic cysts is surgical excision, which is associated with a high morbidity and occasional mortality. The small risk of malignant transformation, the high risks of surgical treatment, and the lack of high-quality prospective studies have led to contradictory recommendations for their immediate management and for their surveillance. This guideline will provide a practical approach to pancreatic cyst management and recommendations for cyst surveillance for the general gastroenterologist.
Collapse
Affiliation(s)
- Grace H Elta
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Brintha K Enestvedt
- Division of Gastroenterology, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Bryan G Sauer
- Division of Gastroenterology, University of Virginia, Charlottesville, Virginia, USA
| | - Anne Marie Lennon
- Division of Gastroenterology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| |
Collapse
|
21
|
Are pancreatic IPMN volumes measured on MRI images more reproducible than diameters? An assessment in a large single-institution cohort. Eur Radiol 2018; 28:2790-2800. [DOI: 10.1007/s00330-017-5268-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/09/2017] [Accepted: 12/20/2017] [Indexed: 12/15/2022]
|
22
|
Du C, Chai NL, Linghu EQ, Li HK, Sun LH, Jiang L, Wang XD, Tang P, Yang J. Comparison of endoscopic ultrasound, computed tomography and magnetic resonance imaging in assessment of detailed structures of pancreatic cystic neoplasms. World J Gastroenterol 2017; 23:3184-3192. [PMID: 28533675 PMCID: PMC5423055 DOI: 10.3748/wjg.v23.i17.3184] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/20/2017] [Accepted: 03/15/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the advantages of endoscopic ultrasound (EUS) in the assessment of detailed structures of pancreatic cystic neoplasms (PCNs) compared to computed tomography (CT) and magnetic resonance imaging (MRI).
METHODS All patients with indeterminate PCNs underwent CT, MRI, and EUS. The detailed information, including size, number, the presence of a papilla/nodule, the presence of a septum, and the morphology of the pancreatic duct of PCNs were compared among the three imaging modalities. The size of each PCN was determined using the largest diameter measured. A cyst consisting of several small cysts was referred to as a mother-daughter cyst. Disagreement among the three imaging modalities regarding the total number of mother cysts resulted in the assumption that the correct number was the one in which the majority of imaging modalities indicated.
RESULTS A total of 52 females and 16 males were evaluated. The median size of the cysts was 42.5 mm by EUS, 42.0 mm by CT and 38.0 mm by MRI; there was no significant difference in size as assessed among the three imaging techniques. The diagnostic sensitivity and ability of EUS to classify PCNs were 98.5% (67/68) and 92.6% (63/68), respectively. These percentages were higher than those of CT (73.1%, P < 0.001; 17.1%, P < 0.001) and MRI (81.3%, P = 0.001; 20.3%, P < 0.001). EUS was also able to better assess the number of daughter cysts in mother cysts than CT (P = 0.003); however, there was no significant difference between EUS and MRI in assessing mother-daughter cysts (P = 0.254). The papilla/nodule detection rate by EUS was 35.3% (24/68), much higher than those by CT (5.8%, 3/52) and MRI (6.3%, 4/64). The detection rate of the septum by EUS was 60.3% (41/68), which was higher than those by CT (34.6%, 18/52) and by MRI (46.9%, 30/64); the difference between EUS and CT was significant (P = 0.02). The rate of visualizing the pancreatic duct using EUS was 100%, whereas using CT and MRI it was less than 10%.
CONCLUSION EUS helps visualize the detailed structures of PCNs and has many advantages over CT and MRI. EUS is valuable in the diagnosis and assessment of PCNs.
Collapse
|
23
|
Boos J, Brook A, Chingkoe CM, Morrison T, Mortele K, Raptopoulos V, Pedrosa I, Brook OR. MDCT vs. MRI for incidental pancreatic cysts: measurement variability and impact on clinical management. Abdom Radiol (NY) 2017; 42:521-530. [PMID: 27581431 DOI: 10.1007/s00261-016-0883-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To investigate incidental pancreatic cysts (IPCs) size discrepancy in a cohort of patients receiving both computed tomography (CT) and magnetic resonance imaging (MRI) and its impact on clinical management based on the 2010 American College of Radiology (ACR) guidelines. METHODS This was a HIPAA-compliant, retrospective, IRB-approved study. Informed consent was waived. Patients with known IPCs and at least one case-pair, consisting of an abdominal CT and MRI examination within 180 days between 05/1999 and 12/2011, were included. Maximum diameter of cysts was measured in both the CT and MR examinations. A subset of 30 patients was measured by three radiologists independently to assess inter-observer variability. Absolute difference in diameter measurements between CT and MRI was calculated. Influence of cyst size, cyst location, and patient characteristics such as weight, height, and body mass index (BMI) on variability of size measurements were evaluated. Clinical impact in terms of current ACR guidelines was assessed. RESULTS Overall, 267 case-pairs of cysts in 113 patients were included in this study. 59/267 cysts were visualized on MRI but not on CT (22.1%, 95% CI 17.1%-27.1%; 32 patients, 64.6 ± 11.7 years, BMI 28.5 ± 4.8 kg/m2), with a median MRI cyst size of 7.8 mm, IQR 6.0-9.0 mm, range 2-17.8 mm. 208 case-pairs in 113 patients with a mean BMI of 26.9 ± 5.1 kg/m2 (range 16.9-39.5 kg/m2) and mean cysts size of 13.4 ± 8.1 mm (range 3-49 mm) were seen in both CT and MRI. The mean absolute size difference for IPCs measured on MRI and CT was 2.1 ± 1.8 mm (median 1.5 mm, IQR 0.9-2.9 mm, range 0-9 mm). Absolute size difference between CT and MRI measurements increased with size of the cyst (r = 0.31, p < 0.001), whereas location of the cyst did not influence the absolute difference between CT and MRI measurements (p = 0.44). Patient weight and BMI had a negative correlation with the difference in cyst size between CT and MRI (weight r = -0.17, p = 0.023; BMI r = -0.17, p = 0.027), with cyst measurements being larger on MRI in thin patients and on CT in obese patients. Inter-reader variability was excellent (ICC = 0.99). In 12/208 (5.7%, 95% CI 2.7%-9.1%), variability between CT and MRI would have changed ACR-based follow-up recommendation. CONCLUSION There was a median difference of 1.5 mm between measurements of IPCs on CT vs. MRI. If imaging modality was switched during follow-up, variability of measurements may lead to inappropriate change of follow-up regimen in 6% of all cases. A single follow-up CT for incidental IPCs does not seem sufficient due to a high number (22%) of missed IPCs on CT.
Collapse
Affiliation(s)
- Johannes Boos
- Division of Abdominal Imaging, Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Alexander Brook
- Division of Abdominal Imaging, Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Christina M Chingkoe
- Division of Abdominal Imaging, Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Trevor Morrison
- Division of Abdominal Imaging, Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Koenraad Mortele
- Division of Abdominal Imaging, Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Vassilios Raptopoulos
- Division of Abdominal Imaging, Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, USA
| | - Ivan Pedrosa
- Department of Radiology, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA
| | - Olga R Brook
- Division of Abdominal Imaging, Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA.
- Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
24
|
Cancer Measurement at Ultrasound: State of the Art. Ultrasound Q 2016; 33:116-124. [PMID: 27984513 DOI: 10.1097/ruq.0000000000000266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Reliable and reproducible tumor measurement is fundamental in the oncologic decision making. In this article, we first highlight the importance of a precise tumor measurement, reviewing the correct modality of measuring tumor lesions at ultrasound. Then we analyze the measurement discrepancies between ultrasound and pathology as well as the discrepancies reported between ultrasound and other imaging modalities. Thereafter, basing on the existent literature and on our experience, we discuss the factors influencing the tumor size measurements at ultrasound. Finally, we illustrate the current strategies to improve the effectiveness of cancer lesions measurement.
Collapse
|
25
|
Dunn DP, Brook OR, Brook A, Revah G, Jawadi S, Sun M, Lee KS, Mortele KJ. Measurement of pancreatic cystic lesions on magnetic resonance imaging: efficacy of standards in reducing inter-observer variability. Abdom Radiol (NY) 2016; 41:500-7. [PMID: 27039321 DOI: 10.1007/s00261-015-0588-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The purpose of this study is to assess inter-observer variability in the measurement of pancreatic cystic lesions with MRI and to determine the impact of measurement standards. MATERIALS AND METHODS In this IRB-approved, HIPAA-compliant study with waiver of informed consent, 144 MRI examinations, containing pancreatic cystic lesions measuring between 5 and 35 mm, were reviewed independently by two radiology attendings and two abdominal imaging fellows. Measurements were repeated by the same reviewers 12 weeks later after the introduction of measurement standards. Results were analyzed using within-subject standard deviation, intraclass correlation coefficient, and kappa. RESULTS Prior to standardization, the within-subject standard deviation, showing measurement variability in each cyst, was 4.0 mm, which was reduced to 3.3 mm after introduction of measurement standards (p < 0.01). Overall inter-observer agreement, kappa, improved from 0.59 to 0.65 (p = 0.04). The frequency of all four reviewers agreeing on size category increased from 51% to 60%. The intraclass correlation coefficient increased from 0.81 to 0.86. CONCLUSIONS There is significant and frequent inter-observer variability in the measurement of pancreatic cystic lesions with MRI which could affect clinical management. Implementation of measurement standards reduces measurement variability and aids in preventing erroneous reporting of growth and potentially unwarranted changes in management.
Collapse
Affiliation(s)
- Dell P Dunn
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Ansin 224, Boston, MA, 02115, USA.
- Department of Radiology, David Grant Medical Center, Travis AFB, CA, USA.
| | - Olga R Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Ansin 224, Boston, MA, 02115, USA
| | - Alexander Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Ansin 224, Boston, MA, 02115, USA
| | - Giselle Revah
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Ansin 224, Boston, MA, 02115, USA
- Medical Imaging Department, Ottawa Hospital, Ottawa, ON, Canada
| | - Sumayya Jawadi
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Ansin 224, Boston, MA, 02115, USA
- Department of Radiology, St. Vincents Hospital, Worcester, MA, USA
| | - Maryellen Sun
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Ansin 224, Boston, MA, 02115, USA
| | - Karen S Lee
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Ansin 224, Boston, MA, 02115, USA
| | - Koenraad J Mortele
- Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Ansin 224, Boston, MA, 02115, USA
| |
Collapse
|
26
|
Chiang AL, Lee LS. Clinical approach to incidental pancreatic cysts. World J Gastroenterol 2016; 22:1236-1245. [PMID: 26811661 PMCID: PMC4716034 DOI: 10.3748/wjg.v22.i3.1236] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Revised: 08/08/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
The approach to incidentally noted pancreatic cysts is constantly evolving. While surgical resection is indicated for malignant or higher risk cysts, correctly identifying these highest risk pancreatic cystic lesions remains difficult. Using parameters including cyst size, presence of solid components, and pancreatic duct involvement, the 2012 International Association of Pancreatology (IAP) and the 2015 American Gastroenterological Association (AGA) guidelines have sought to identify the higher risk patients who would benefit from further evaluation using endoscopic ultrasound (EUS). Not only can EUS help further assess the presence of solid component and nodules, but also fine needle aspiration of cyst fluid aids in diagnosis by obtaining cellular, molecular, and genetic data. The impact of new endoscopic innovations with novel methods of direct visualization including confocal endomicroscopy require further validation. This review also highlights the differences between the 2012 IAP and 2015 AGA guidelines, which include the thresholds for sending patients for EUS and surgery and methods, interval, and duration of surveillance for unresected cysts.
Collapse
MESH Headings
- Cholangiopancreatography, Magnetic Resonance
- Diagnosis, Differential
- Endoscopic Ultrasound-Guided Fine Needle Aspiration
- Endosonography
- Humans
- Incidental Findings
- Microscopy, Confocal
- Neoplasms, Cystic, Mucinous, and Serous/diagnosis
- Neoplasms, Cystic, Mucinous, and Serous/surgery
- Pancreatectomy/adverse effects
- Pancreatic Cyst/diagnosis
- Pancreatic Cyst/surgery
- Pancreatic Neoplasms/diagnosis
- Pancreatic Neoplasms/surgery
- Practice Guidelines as Topic
- Predictive Value of Tests
- Risk Factors
- Tomography, X-Ray Computed
- Treatment Outcome
Collapse
|
27
|
Lee YS, Paik KH, Kim HW, Lee JC, Kim J, Hwang JH. Comparison of Endoscopic Ultrasonography, Computed Tomography, and Magnetic Resonance Imaging for Pancreas Cystic Lesions. Medicine (Baltimore) 2015; 94:e1666. [PMID: 26469901 PMCID: PMC4616797 DOI: 10.1097/md.0000000000001666] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Consensus regarding which modality is optimal for the measurement of pancreas cystic lesions (PCLs) was not achieved although cyst size is important for clinical decisions. This study aimed to evaluate the properties of endoscopic ultrasonography (EUS) compared with computed tomography (CT) and magnetic resonance imaging (MRI) in measuring the size of PCL.A total of 34 patients who underwent all 3 imaging modalities within 3 months before surgery were evaluated retrospectively. The size measured by each modality was compared with the pathologic size as a reference standard using Bland-Altman analysis and intraclass correlation coefficients (ICCs).The mean size difference was 1.76 mm (ICC 0.86), 7.35 mm (ICC 0.95), and 8.65 mm (ICC 0.93) in EUS, CT, and MRI. EUS had the widest range of 95% limits of agreement (LOA) (-17.54 to +21.07), compared with CT (-6.21 to +20.91), and MRI (-6.82 to +24.12). The size by EUS tended to be read smaller in tail portion, while those by CT and MRI did not. When the size was more than 4 cm, the size on EUS was estimated to be smaller than on pathology (r = 0.492; P = 0.003).Although 3 modalities showed very good reliability for the size measurement on PCL compared with corresponding pathologic size, EUS had the lowest level of agreement, while CT showed the highest level among the 3 modalities. Therefore, the size estimated by EUS has to be interpreted with caution, especially when it is located in tail and relevantly large.
Collapse
Affiliation(s)
- Yoon Suk Lee
- From the Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gyeonggi-do (YSL, K-HP, HWK, J-CL, JK, J-HH); and Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Republic of Korea (YSL)
| | | | | | | | | | | |
Collapse
|
28
|
Kwong WT, Lawson RD, Hunt G, Fehmi SM, Proudfoot JA, Xu R, Giap A, Tang RS, Gonzalez I, Krinsky ML, Savides TJ. Rapid Growth Rates of Suspected Pancreatic Cyst Branch Duct Intraductal Papillary Mucinous Neoplasms Predict Malignancy. Dig Dis Sci 2015; 60:2800-6. [PMID: 25924899 DOI: 10.1007/s10620-015-3679-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 04/17/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The majority of branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) are recommended for surveillance imaging based on consensus guidelines. However, growth rates that should prompt concern for malignant transformation of BD-IPMN are unknown. AIMS To determine whether BD-IPMN growth can predict an increased risk of malignancy and define growth rates concerning for malignant BD-IPMN. METHODS The study is a retrospective, multicenter study of suspected BD-IPMN patients undergoing imaging surveillance. All patients underwent EUS evaluation followed by surveillance imaging. RESULTS Two hundred and eighty-four patients with suspected BD-IPMN without worrisome features or high-risk stigmata were followed for a median 56 months and underwent a median of four imaging studies. Nine patients (3.2 %) developed malignant BD-IPMN. Malignant BD-IPMN grew at a faster rate (18.6 vs. 0.8 mm/year; P = 0.05) compared to benign BD-IPMN. BD-IPMN growth rate between 2 and 5 mm/year was associated with an increased risk of malignancy with hazard ratio (HR) of 11.4 (95 % CI 2.2-58.6) when compared to subjects with BD-IPMN growth rate <2 mm/year (P = 0.004). BD-IPMN growth rate ≥5 mm/year had a hazard ratio of 19.5 (95 % CI 2.4-157.8) (P = 0.005). BD-IPMN growth rate of 2 mm/year had a sensitivity of 78 %, specificity of 90 %, and accuracy of 88 % to identify malignancy. Total BD-IPMN growth was also associated with increased risk of malignancy (P = 0.003) with all malignant IPMNs growing at least 10 mm prior to cancer diagnosis. CONCLUSIONS BD-IPMN growth rates ≥2 mm/year and total growth of ≥10 mm should be considered worrisome features for BD-IPMN at increased risk of malignancy.
Collapse
Affiliation(s)
- Wilson T Kwong
- Division of Gastroenterology, University of California San Diego Health Sciences, 9500 Gilman Drive (MC 0956), La Jolla, CA, 92093-0956, USA,
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Abstract
PURPOSE OF REVIEW Diagnosis of pancreatic cysts remains challenging due to limitations of currently available radiologic and endoscopic tools. The diagnostic approach should focus on identifying mucinous and malignant cysts. Mucinous cysts require further differentiation to allow appropriate management. RECENT FINDINGS Although the overall rate of malignant pancreatic cysts is low, it remains higher than the general population. MRI with magnetic resonance cholangiopancreatography is the preferred imaging modality for pancreatic cysts. Attempts to improve diagnostic yield of endoscopic ultrasound-guided fine needle aspiration include performing cyst wall cytology and DNA analysis. The 2012 international consensus guidelines for mucinous cystic neoplasm and intraductal papillary mucinous neoplasm are superior to the original 2006 guidelines, although issues include the relatively poor ability to diagnose malignant cysts leading to unnecessary surgeries and the de-emphasis of cyst size. Cyst size remains an important predictor of malignancy. Translational research involving genomics, microRNA, proteomics, and metabolomics holds promise for improved biomarkers. Endoscopic innovations may safely aid in cyst diagnosis. SUMMARY Incremental improvements in pancreatic cyst diagnosis have occurred with new biomarkers and endoscopic tools requiring validation in large-scale studies.
Collapse
|
30
|
Lee LS. Incidental Cystic Lesions in the Pancreas: Resect? EUS? Follow? CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2014; 12:333-49. [PMID: 24903582 DOI: 10.1007/s11938-014-0019-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pancreatic cysts challenge clinicians due to their increased incidental identification on radiology imaging, the limitations of currently available diagnostic tools, and potential for malignancy. Following initial identification of an incidental pancreatic cyst, a dedicated pancreatic protocol abdominal CT scan or MRI pancreas with MRCP should be performed. Surgical resection is recommended for all surgical candidates with MD-IPMN, mixed or combined type IPMN, mucinous cystic neoplasm, and solid pseudopapillary neoplasm. Serous cystadenoma may be followed with serial imaging unless the patient develops symptoms, the cyst is larger than 4 cm or rapidly growing, or diagnostic uncertainty remains despite thorough evaluation. Surveillance is also recommended for BD-IPMN without the following features concerning malignancy: obstructive jaundice with a cyst in the head of the pancreas; solid component; nodule; main pancreatic duct ≥10 mm; or cytology suspected or positive for malignancy. BD-IPMN ≥3 cm without concerning features may also be followed carefully, although surgical resection should be considered in surgically fit patients. EUS-FNA for cyst wall cytology, CEA, amylase, and occasionally k-ras mutation are also likely aids in the diagnosis of pancreatic cysts beyond radiologic imaging. This author typically recommends EUS-FNA to further evaluate cysts larger than 1 cm without definitive indication for resection. EUS is also appropriate in patients with solid component, nodule, or size ≥3 cm to aid in decision making, especially in older patients who may be less suitable surgical candidates. A multidisciplinary approach with a team of dedicated gastrointestinal radiologists, pancreatic surgeons, gastrointestinal pathologists, and gastroenterologists is essential for managing patients with pancreatic cysts.
Collapse
Affiliation(s)
- Linda S Lee
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA,
| |
Collapse
|
31
|
Yoon WJ, Brugge WR. Endoscopic ultrasound and pancreatic cystic lesions-diagnostic and therapeutic applications. Endosc Ultrasound 2014; 1:75-9. [PMID: 24949341 PMCID: PMC4062214 DOI: 10.7178/eus.02.004] [Citation(s) in RCA: 13] [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: 02/27/2012] [Accepted: 04/26/2012] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cystic lesions are being detected with an increasing frequency. Endoscopic ultrasound (EUS) provides both diagnostic and therapeutic means for pancreatic cystic lesions. Detailed imaging and EUS-guided fine-needle aspiration provide additional information on pancreatic cystic lesions. EUS-guided pseudocyst drainage has advantages over conventional drainage modalities. EUS-guided cyst ablation is a promising therapeutic modality.
Collapse
Affiliation(s)
- Won Jae Yoon
- Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - William R Brugge
- Harvard Medical School; Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| |
Collapse
|
32
|
Kim YI, Woo SM, Lee WJ, Han SS, Park SJ, Kim TH, Koh YH, Hong EK. Appropriate indications of initial endoscopic ultrasound evaluation for detecting mural nodules in branch duct intraductal papillary mucinous neoplasms of the pancreas. Scand J Gastroenterol 2013; 48:610-6. [PMID: 23597152 DOI: 10.3109/00365521.2013.782065] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The presence of mural nodules is a strong predictor of malignancy in patients with branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs). Endoscopic ultrasound (EUS) is the most sensitive imaging for the detection of mural nodules. The aim was to evaluate whether initial EUS evaluation is necessary to detect mural nodules in all patients with BD-IPMNs. MATERIAL AND METHODS We reviewed retrospectively the medical records of all 104 patients with BD-IPMNs diagnosed by EUS from January 2008 to December 2011. Of the 104 patients, 13 (12.5%) had mural nodules (MN-positive group) and 91 (87.5%) did not (MN-negative group). RESULTS Patients in the MN-positive group were significantly older (69 years vs. 61 years, p = 0.013), had larger-sized cysts on EUS (24.1 ± 8.3 mm vs. 16.2 ± 8.0 mm, p = 0.001), a higher rate of main pancreatic duct dilatation (30.8% vs. 3.3%, p = 0.004), and higher serum CA 19-9 concentrations (67.8 ± 109.4 U/mL vs. 17.5 ± 27.0 U/mL, p = 0.012), than patients in the MN-negative group. Cyst sizes measured by EUS, CT, and MRCP did not differ significantly. Multivariate logistic regression analysis showed that cysts ≥16 mm in size on CT (odds ratio [OR], 9.84; 95% confidential interval [CI], 1.08-89.93; p = 0.043) and main pancreatic duct dilatation (OR, 12.65; 95% CI, 1.62-98.99; p = 0.016) were independent predictors of mural nodules. CONCLUSIONS Patients with BD-IPMNs, cyst size ≥16 mm, and main pancreatic duct dilatation should be further evaluated by EUS for the presence of mural nodules.
Collapse
Affiliation(s)
- Young-Il Kim
- Center for Liver Cancer, National Cancer Center, Goyang, Republic of Korea
| | | | | | | | | | | | | | | |
Collapse
|
33
|
Leeds JS, Nayar MN, Dawwas M, Scott J, Anderson K, Haugk B, Oppong KW. Comparison of endoscopic ultrasound and computed tomography in the assessment of pancreatic cyst size using pathology as the gold standard. Pancreatology 2013; 13:263-6. [PMID: 23719598 DOI: 10.1016/j.pan.2013.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 02/03/2013] [Accepted: 02/23/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Accurate assessment of whether a cyst is greater than 3 cm is an essential component when considering resection especially for mucinous lesions. The most accurate method of assessing cyst size is uncertain with many patients undergoing several complimentary imaging modalities. This study aimed to compare the accuracy of endoscopic ultrasound (EUS) with CT scanning in assessing pancreatic cyst size compared to histology. METHODS Patients referred for EUS of a pancreatic cystic lesion from April 2003 to August 2011. Patient age and gender, lesion size and site were recorded and compared using cyst size at histology compared to EUS and CT recorded within 3 months of surgery. Subgroup analysis was performed with respect to cyst site and proven mucinous lesions. RESULTS 357 patients were included of which 70 (mean age 60.6 years, 24 males) had undergone surgical resection. The resected cysts were located 30/17/23 in the head/body/tail of the pancreas. Median size at histology was 32 mm compared to 35 mm at EUS (p = 0.47) and 35 mm at CT (p = 0.52). For mucinous lesions alone, median size at histology was 32 mm compared to 33 mm at EUS (p = 0.46) and 35 mm at CT (p = 0.39). EUS and CT had comparable sensitivity, specificity, negative predictive value, positive predictive value and accuracy for all cyst types and locations. CONCLUSIONS CT and EUS measurements are not significantly different to pathological size following resection of pancreatic cystic lesions. CT and EUS are interchangeable investigations for determining cyst size pre-operatively although EUS has the additional advantage of fluid sampling.
Collapse
Affiliation(s)
- J S Leeds
- HPB Unit, Royal Victoria Infirmary, Newcastle Upon Tyne, UK.
| | | | | | | | | | | | | |
Collapse
|
34
|
Fusaroli P, Kypraios D, Caletti G, Eloubeidi MA. Pancreatico-biliary endoscopic ultrasound: A systematic review of the levels of evidence, performance and outcomes. World J Gastroenterol 2012; 18:4243-56. [PMID: 22969187 PMCID: PMC3436039 DOI: 10.3748/wjg.v18.i32.4243] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 08/01/2012] [Accepted: 08/03/2012] [Indexed: 02/06/2023] Open
Abstract
Our aim was to record pancreaticobiliary endoscopic ultrasound (EUS) literature of the past 3 decades and evaluate its role based on a critical appraisal of published studies according to levels of evidence (LE). Original research articles (randomized controlled trials, prospective and retrospective studies), meta-analyses, reviews and surveys pertinent to gastrointestinal EUS were included. All articles published until September 2011 were retrieved from PubMed and classified according to specific disease entities, anatomical subdivisions and therapeutic applications of EUS. The North of England evidence-based guidelines were used to determine LE. A total of 1089 pertinent articles were reviewed. Published research focused primarily on solid pancreatic neoplasms, followed by disorders of the extrahepatic biliary tree, pancreatic cystic lesions, therapeutic-interventional EUS, chronic and acute pancreatitis. A uniform observation in all six categories of articles was the predominance of LE III studies followed by LE IV, IIb, IIa, Ib and Ia, in descending order. EUS remains the most accurate method for detecting small (< 3 cm) pancreatic tumors, ampullary neoplasms and small (< 4 mm) bile duct stones, and the best test to define vascular invasion in pancreatic and peri-ampullary neoplasms. Detailed EUS imaging, along with biochemical and molecular cyst fluid analysis, improve the differentiation of pancreatic cysts and help predict their malignant potential. Early diagnosis of chronic pancreatitis appears feasible and reliable. Novel imaging techniques (contrast-enhanced EUS, elastography) seem promising for the evaluation of pancreatic cancer and autoimmune pancreatitis. Therapeutic applications currently involve pancreaticobiliary drainage and targeted fine needle injection-guided antitumor therapy. Despite the ongoing development of extra-corporeal imaging modalities, such as computed tomography, magnetic resonance imaging, and positron emission tomography, EUS still holds a leading role in the investigation of the pancreaticobiliary area. The major challenge of EUS evolution is its expanding therapeutic potential towards an effective and minimally invasive management of complex pancreaticobiliary disorders.
Collapse
|
35
|
Onishi M, Tominaga K, Sugimori S, Machida H, Okazaki H, Yamagami H, Tanigawa T, Watanabe K, Watanabe T, Fujiwara Y, Arakawa T. Internal hypoechoic feature by EUS as a possible predictive marker for the enlargement potential of gastric GI stromal tumors. Gastrointest Endosc 2012; 75:731-8. [PMID: 22281109 DOI: 10.1016/j.gie.2011.10.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 10/25/2011] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is no clinical predictor for the enlargement potential of gastric GI stromal tumors (GISTs) during the follow-up observation period. OBJECTIVE The aim of our study was to identify predictive markers for the enlargement potential of gastric GISTs on the basis of various endosonographic features determined at the initial examination. DESIGN Single-center retrospective analysis. SETTING Academic university hospital in Japan. PATIENTS All patients (n = 74) with histologically diagnosed GISTs in the stomach underwent EUS. INTERVENTION EUS. MAIN OUTCOME MEASUREMENTS We analyzed the following endoscopic and EUS features: mucosal ulceration, irregular shape, irregular border, heterogeneity, internal hyperechoic spot, hypoechoic area, and anechoic area of gastric GISTs in 3 groups according to tumor size. Furthermore, we compared the characteristics between increased growth and unchanged growth of GISTs, that were defined on the basis of the novel tumor growth index: changes in tumor volume/follow-up interval (days between initial EUS and second EUS) (mm(3)/day). RESULTS The presence of heterogeneity (P = .016) and anechoic area (P = .003) was significantly highest in the group with the largest tumor size. The increased growth group had a higher presence of hypoechoic area than did the unchanged growth group (84.2% vs 51.9%, P = .023). Multivariate analysis showed that the presence of a hypoechoic area was an enlargement-associated factor (odds ratio 5.38; 95% confidence interval 1.19-24.39; P = .029). LIMITATIONS Retrospective design of the study. CONCLUSIONS The internal hypoechoic area determined by EUS may be a predictor for the enlargement potential of gastric GISTs.
Collapse
Affiliation(s)
- Miho Onishi
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Lim LG, Itoi T, Lim WC, Mesenas SJ, Seo DW, Tan J, Wang HP, Akaraviputh T, Lakhtakia S, Omar S, Rantachu T, Sachitanandan S, Yasuda K, Varadarajulu S, Wong J, Dhir V, Ho KY. Current status on the diagnosis and management of pancreatic cysts in the Asia-Pacific region: role of endoscopic ultrasound. J Gastroenterol Hepatol 2011; 26:1702-8. [PMID: 21871024 DOI: 10.1111/j.1440-1746.2011.06884.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) play increasingly prominent roles in the diagnosis and management of pancreatic cysts. The Asian Consortium of Endoscopic Ultrasound was recently formed to conduct collaborative research in this area. This is a review of literature on true pancreatic cysts. Due to the lack of systematic studies, there are no robust data on the true incidence of pancreatic cystic lesions in Asia and any change in over the recent decades. Certain EUS morphological features have been used to predict particular types of pancreatic cysts. Pancreatic cyst fluid viscosity, cytology, pancreatic enzymes, and tumor markers, in particular carcinoembryonic antigen, can aid in the diagnosis of pancreatic cysts. Hemorrhage and infection are the most common complications of EUS-FNA of pancreatic cysts. Pancreatic cysts can either be observed or resected depending on the benign or malignant nature, or malignant potential of the lesions. Guidelines from an international consensus did not require positive cytological findings to be present in their recommendation for resection, which included all mucinous cystic neoplasms, all main-duct intraductal papillary mucinous neoplasms (IPMN), all mixed IPMN, symptomatic side-branch IPMN, and side-branch IPMN larger than 3 cm. In patients with poor surgical risks, EUS-guided cyst ablation of mucinous pancreatic cysts is an alternative. As long-term prospective data on pancreatic cysts are still not available in Asia, management strategies are largely based on risk stratification by surgical risk and malignant potential. Gene expression profiling of pancreatic cyst fluid and confocal laser endomicroscopic examination of pancreatic cysts are novel techniques currently being studied.
Collapse
Affiliation(s)
- Lee Guan Lim
- Department of Gastroenterology and Hepatology, National University Health System, Singapore
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Abstract
The advent of computed tomographic scan with its wide use in the evaluation of acute pancreatitis has opened up a new topic in pancreatology i.e. fluid collections. Fluid collections in and around the pancreas occur often in acute pancreatitis and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992. Two decades since the Atlanta Conference additional experience has brought to light the inadequacy and poor understanding of the terms used by different specialists involved in the care of patients with acute pancreatitis when interpreting imaging modalities and the need for a uniformly used classification system. The deficiencies of the Atlanta definitions and advances in medicine have led to a proposed revision of the Atlanta classification promulgated by the Acute Pancreatitis Classification Working Group. The newly used terms "acute peripancreatic fluid collections," "pancreatic pseudocyst," "postnecrotic pancreatic/peripancreatic fluid collections," and "walled-off pancreatic necrosis" are to be clearly understood in the interpretation of imaging studies. The current treatment methods for fluid collections are diverse and depend on accurate interpretations of radiologic tests. Management options include conservative treatment, percutaneous catheter drainage, open and laparoscopic surgery, and endoscopic drainage. The choice of treatment depends on a correct diagnosis of the type of fluid collection. In this study we have attempted to clarify the management and clinical features of different types of fluid collections as they have been initially defined under the 1992 Atlanta Classification and revised by the Working Group's proposed categorization.
Collapse
|
38
|
Kongkam P, Rerknimitr R, Ridtitid W, Pausawasdi N, Akaraviputh T, Ratanachu-ek T, Pisespongsa P, Ovartlarnporn B. EUS-FNA for pancreatic cyst lesion, today and tomorrow in the Kingdom of Thailand. Dig Endosc 2011; 23 Suppl 1:54-7. [PMID: 21535203 DOI: 10.1111/j.1443-1661.2011.01140.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Unlike endoscopic retrograde cholangiopancreatography (ERCP) service, endoscopic ultrasonography (EUS) service in Thailand is at its elementary state. Currently, there are only 11 hospitals in Thailand carrying out EUS whereas there are more than 50 hospitals carrying out ERCP. This is a multicenter questionnaire survey that obtained information on EUS practice for pancreatic cysts. Of those 11 hospitals, only three hospitals provided enough number of patients with pancreatic cysts undergoing EUS. There were many differences in endosonographers opinions regarding specific information in the pancreatic cyst. In addition, the threshold to carry out and not to carry out fine needle aspiration are varies.
Collapse
Affiliation(s)
- Pradermchai Kongkam
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Abstract
The discovery of a pancreatic cyst in an asymptomatic patient presents an immediate challenge to the interpreting radiologist, the clinician who manages the patient, and patients themselves. When a cyst is discovered on imaging in a patient without symptoms directly referable to the pancreas, the following questions are immediately raised: can the lesion be accurately diagnosed or is the appropriate management clear from the examination, is the best management approach to suggest watchful waiting with follow-up imaging, what is the best method for imaging follow-up, and what is the optimal frequency of follow-up? This article recommends an approach to analyzing patients with incidental pancreatic cysts.
Collapse
Affiliation(s)
- Alec J Megibow
- Department of Radiology, New York University Langone Medical Center, New York, NY, USA.
| | | | | | | |
Collapse
|