Current Guideline Controversies in the Management of Pancreatic Cystic Neoplasms

Burden of New Pancreatic Cyst Diagnosis

Pancreatic cysts are an increasingly identified entity with significant health care implications. Although some cysts present with concurrent symptoms that often require operative intervention, the advent of improved cross-sectional imaging has heralded an era of increased incidentally detected pancreatic cysts. Although the rate of malignant progression in pancreatic cysts remains low, the poor prognosis of pancreatic malignancy has driven recommendations for ongoing surveillance. A uniform consensus has not been reached on the management and surveillance of pancreatic cysts leading clinicians to grapple with the burden of how best to approach pancreatic cysts from a health, psychosocial, and cost perspective.

Impact of Antibiotic Prophylaxis on Infection Rate after Endoscopic Ultrasound Through-the-Needle Biopsy of Pancreatic Cysts: A Propensity Score-Matched Study

Background: Despite weak evidence, antibiotic prophylaxis prior to endoscopic ultrasound-guided through-the-needle biopsy (EUS-TTNB) of pancreatic cystic lesions (PCLs) is routinely used in clinical practice. We aim to compare a group of patients treated with antibiotics before EUS-TTNB of PCLs and a group who did not undergo antimicrobial prophylaxis. Methods: Out of 236 patients with pancreatic cystic lesions referred to two high-volume centers between 2016 and 2021, after propensity score matching, two groups were compared: 98 subjects who underwent EUS-TTNB under antibiotic prophylaxis and 49 subjects without prophylaxis. Results: There was no difference in terms of baseline parameters between groups. Final diagnosis was serous cystadenoma in 36.7% of patients in the group not treated with prophylaxis and in 37.7% of patients in the control group, whereas IPMN and mucinous cystadenoma were diagnosed in 3 (6.1%) and 16 (32.6%) versus 6 (6.1%) and 32 (32.6%) patients in the two groups, respectively (p = 0.23). Overall, the adverse event rate was 6.1% in the group not treated with antibiotic prophylaxis and 5.1% in the control group (p = 0.49). Only a single infectious adverse event occurred in each group (p = 0.48). The diagnostic yields were 89.7% and 90.8% in the two groups (p = 0.7), and the diagnostic accuracy rate was 81.6% in both groups (p = 1.0). Conclusions: Prophylactic antibiotics do not seem to influence the risk of infection, and their routine use should be discouraged.

Non-inflammatory pancreatic cysts: from diagnosis to treatment (97 cases series)

OBJECTIVE

to describe the implications of the diagnosis and treatment of non-inflammatory pancreatic cysts in a series of patients.

METHODS

we included patients with pancreatic cysts ≥1.0 cm, excluding those with a presumptive diagnosis of a pseudocyst. Imaging tests, echoendoscopy, and histopathology determined the diagnosis of the type of cyst. We applied the guidelines of the International Association of Pancreatology, with some modifications, in patients with mucinous or indeterminate lesions.

RESULTS

97 adult patients participated in the study. A cystic neoplasm of the pancreas was diagnosed in 82.5% of cases. Diagnosis was mainly made by magnetic resonance (46% of cases). The two most common diagnoses were intraductal papillary mucinous neoplasm (43.3%) and serous cystadenoma (26%). Twenty-nine patients underwent surgery (33.3%). The most common surgical procedure was distal pancreatectomy associated with splenectomy in 19 cases (65.5%). Among the operated patients, 11 were diagnosed with cancer. None of the followed, non-operated patients had a diagnosis of cancer.

CONCLUSIONS

magnetic resonance showed good accuracy, particularly in the diagnosis of intraductal papillary mucinous neoplasm. The guidelines of the International Association of Pancreatology, as applied in this study, showed a negative predictive value for cancer of 100%. A development of better diagnostic tests can reduce the number of unnecessary operations.

Prophylactic Antibiotics Do Not Prevent Infectious Complications of Endoscopic Ultrasound Fine-Needle Aspiration of Pancreatic Cysts: A Systematic Review and Meta-Analysis

Despite limited evidence, endoscopic societies recommend routine use of antibiotic prophylaxis for endoscopic ultrasound fine-needle aspiration of pancreatic cystic lesions. Recent studies suggest lack of benefit in this setting. Our objective is to conduct a systematic review and meta-analysis to assess the efficacy of antibiotics in prevention of infectious complications after ultrasound fine-needle aspiration of pancreatic cystic lesions. A bibliographic search of digital dissertation databases was performed from inception until March 2020. Randomized controlled trials, cohort, and case-control studies that compared prophylactic antibiotics with placebo or no therapy were included in the analysis. The primary outcome was the development of cyst infections. Secondary outcomes were incidence of fever; procedural complications such as bile leak, pancreatitis, or bleeding; and medication-related adverse events. Six studies with a total of 1683 patients were included. The overall incidence of cyst infections was 0.53%. For the primary outcome, there was no significant difference between the 2 groups (odds ratio, 0.54; 95% confidence interval, 0.16-1.82; P = 0.32). No significant difference was noted regarding other complications like fever, pancreatitis, or bile leak. In conclusion, the rate of infectious complications is very low, and antibiotic prophylaxis does not seem to confer any additional benefit in their prevention.

Nomogram for the Prediction of High-Grade Dysplasia and Invasive Carcinoma in Patients With Intraductal Papillary Mucinous Neoplasms of the Pancreas Based on Variables of Noninvasive Examination

Intraductal papillary mucinous neoplasms (IPMNs) are a heterogeneous group of neoplasms and represent the most common identifiable precursor lesions of pancreatic cancer. Clinical decision-making of the risk for malignant disease, including high-grade dysplasia and invasive carcinoma, is challenging. Moreover, discordance on the indication for resection exists between the contemporary guidelines. Furthermore, most of the current nomogram models for predicting malignant disease depend on endoscopic ultrasonography to evaluate the precise size of mural nodules. Thus, this study aimed to propose a model to predict malignant disease using variables from a noninvasive examination. We evaluated patients who underwent resection of pathologically confirmed IPMNs between November 2010 and December 2018 and had preoperative clinical data available for review. Based on binary multivariable logistic regression analysis, we devised a nomogram model to predict malignant IPMNs. The area under the receiver operating characteristics curve (AUC) was used to evaluate the discrimination power of the model. Of the 333 patients who underwent resection of IPMNs, 198 (59.5%) had benign and 135 (40.5%) had malignant IPMNs. Multivariable logistic regression analysis showed that cyst size, cyst location, cyst wall enhancement, multicystic lesion, diameter of main pancreatic duct, neutrophil-to-lymphocyte ratio, serum carbohydrate antigen 19-9, and carcinoembryonic antigen were significantly associated with malignancy. The nomogram, constructed based on these variables, showed excellent discrimination power with an AUC of 0.859 (95% CI: 0.818–0.900, P < 0.001). In conclusion, we have developed a nomogram consisting of a combination of cross-sectional imaging features and blood markers, variables that can readily be obtained by noninvasive examinations during the surveillance period, which can distinguish benign from malignant IPMNs. Nevertheless, external validation is warranted.

The Effect of Cinnamomum burmannii Water Extraction Against Staphylococcus aureus, Enterobacter spp., Pseudomonas aeruginosa, and Candida albicans: In Vitro Study

Indonesian cinnamon (Cinnamomum burmannii) is a native plant of Indonesia that has a lot of potential. The most consumed part is the bark. This study aims to examine the antimicrobial effect of Cinnamomum burmannii bark extract on various types of pathogenic microbes, namely Staphylococcus aureus, Enterobacter spp., Pseudomonas aeruginosa, and Candida albicans. An experimental study using a water extract (infusion) of Cinnamomum burmannii bark and a microbial test obtained from the Faculty of Pharmacy, Widya Mandala Catholic University, Surabaya. The antimicrobial effect test was carried out by the microdilution method in 96-well-microplate to determine the Minimum Inhibitory Level (MIC) and implantation on solid media to determine the Minimum Kill Rate (KBM). The MIC and KBM against Staphylococcus aureus were 625-1,250 ppm and 1,250-2,500 ppm, respectively. MIC and KBM for Enterobacter spp., Pseudomonas aeruginosa, and Candida albicans were not found at the highest concentrations tested at 10,000 ppm. Cinnamomum burmannii extract can be used as a potential ingredient with antimicrobial effects, especially against Gram-positive bacteria. Future studies should pay attention to the quality of simplicia, particle size, and the most effective extraction methods extracting antimicrobial substances from simplicia

Use of antibiotic prophylaxis is not needed for endoscopic ultrasound-guided fine-needle aspiration of pancreatic cysts: a meta-analysis

BACKGROUND

There is limited evidence on the use of antibiotic prophylaxis prior to endoscopic ultrasound-guided fine-needle aspiration of pancreatic cysts. The aim of this meta-analysis was to evaluate the efficacy of antibiotic prophylaxis in this setting.

RESEARCH DESIGN AND METHODS

Bibliographic search was performed through January 2020. The primary outcome was infection rate. Additional endpoints were severe infection rate and overall rates of adverse events.

RESULTS

Six studies, of which one was a randomized controlled trial and five were retrospective, with 1706 patients were included. Most patients were female, and body/tail was the most frequent location of cystic lesions. Overall, eight infectious events were observed in the antibiotic group (0.77%), whereas 12 events were registered in the control group (1.7%), with no difference in terms of infection rate (odds ratio 0.65, 95% confidence interval 0.24-1.78; p = 0.40). Again, no difference was observed between the two study groups in terms of either severe infection (odds ratio 0.88, 0.13-5.82; p = 0.89) and overall adverse event rate (odds ratio 1.09, 0.73-1.65; p = 0.67).

CONCLUSIONS

Prophylactic antibiotics do not seem to substantially reduce the risk of infections after endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions, and routine use of prophylactic antibiotics should be questioned.

Validation of European evidence-based guidelines and American College of Gastroenterology guidelines as predictors of advanced neoplasia in patients with suspected mucinous pancreatic cystic neoplasms

BACKGROUND AND AIM

The European evidence-based guidelines (EEG) and American College of Gastroenterology Guidelines (ACGG) have been published to guide the management of pancreatic cystic lesions. We aim to evaluate the value of both guidelines in predicting advanced pancreatic cystic lesions (A-PCLs) with preoperatively imaging-suspected cystic mucinous pancreatic neoplasms (cMNs).

METHODS

One hundred ninety-eight patients who underwent resections from 2013 to 2019 for suspected cMNs were retrospectively reviewed. Receiver operating characteristic curves were calculated and compared with measure diagnostic value.

RESULTS

Sixty-two patients were diagnosed with A-PCLs pathologically. Cross-imaging modalities had comparable diagnostic accuracy to endoscopic ultrasound in type classification and A-PCLs prediction. Receiver operating characteristic curve comparison analyses showed that EEG absolute + MCN (EEG^AM ) and EEG relative + MCN (EEG^RM ) having at least one indications criteria were comparable to the ACGG (P = 0.21 and P = 0.45). For the criteria having at least two indications, ACGG was superior to EEG^AM (P = 0.001) but comparable to EEG^RM (P = 0.12). EEG^AM ≥ 1 indication criteria was superior to ≥ 2 indications criteria (P = 0.02). EEG^RM ≥ 1 indication criteria had comparable diagnostic performance with ≥ 2 indications criteria (P = 0.86). ACGG ≥ 2 indications criteria was superior to ≥ 1 indication criteria (P = 0.02).

CONCLUSION

On the basis of cross-imaging evaluations, both sets of guidelines were found to be helpful in identifying A-PCLs in suspected cMNs with comparable performance. EEG^AM  ≥ 1 indication criteria was superior to ≥ 2 indications criteria. ACGG ≥ 2 indications criteria was superior to ≥ 1 indication criteria.

Exosomal glypican-1 for risk stratification of pancreatic cystic lesions: A case of pathological progression in the absence of any suspicious imaging finding

The clinical management of patients with pancreatic cystic lesions is of utmost importance to identify those at high risk for pathological progression. Current recommendations are guided by clinical presentation and radiologic criteria, but the results fall short for a disease that the only curative option is surgical resection. There is an urgent need for the introduction of biomarkers that can help in risk assessment of such lesions. We report a case of a pancreatic cystic lesion without imagiological findings suggestive of advanced disease, and high levels of a circulating biomarker, glypican-1 (GPC-1), which parallel those of patients with pancreatic cancer. One year after, the patient revealed malignant progression at follow-up. Our report is unprecedented in the literature. It describes a clinical case in which a biomarker was positive for a patient that only showed progression one year after its detection. This clinical information goes beyond the current knowledge in the field because it shows that the introduction of liquid biopsy and biomarkers is a highly promising clinical tool for the non-invasive assessment of pancreatic cancer precursor lesions, ultimately increasing the rate of patients eligible for surgical resection.

Statins decrease the risk of acute pancreatitis after endoscopic ultrasound fine-needle aspiration of pancreatic cysts

BACKGROUND

Basic and clinical studies suggest that statins may prevent and even ameliorate acute pancreatitis. The present study was to evaluate whether statin decreases the risk of acute pancreatitis in patients undergoing endoscopic ultrasound-guided fine-needle aspiration of pancreatic cysts.

METHODS

Out of 456 patients with pancreatic cysts referred to our center between 2006 and 2018, 365 were finally included in analyses: 86 were treated with statins and 279 were not at the time of endoscopic ultrasound fine-needle aspiration. We compared the acute pancreatitis incidence between the two groups, and we also compared other complications such as bleeding and infections.

RESULTS

Median age was 64 years [interquartile range (IQR) 62-69] and median cyst size was 24 mm (IQR, 21-29). The most frequent histology was intraductal papillary mucinous neoplasm (45.3% and 42.3% in the two groups, respectively; P = 0.98). All 13 patients experiencing post-endoscopic ultrasound acute pancreatitis were from the control group (4.7%), of which 3 were classified as severe pancreatitis. None of statin users developed post-procedural acute pancreatitis (odds ratio: 0.15; 95% confidence interval: 0.03-0.98; P = 0.03). No difference was registered with regard to severe pancreatitis and other complications.

CONCLUSIONS

Statins exert a beneficial role in preventing acute pancreatitis in patients with pancreatic cysts undergoing endoscopic ultrasound-guided fine-needle aspiration. If confirmed in prospective trials, our findings may pave the way to an extensive use of statins as prophylactic agents in pancreatic interventional endoscopy.

Interobserver agreement among expert pathologists on through-the-needle microforceps biopsy samples for evaluation of pancreatic cystic lesions

BACKGROUND AND AIMS

The recent development of microforceps for EUS through-the-needle biopsy (TTNB) sampling of the wall of pancreatic cystic lesions (PCLs) allows the collection of histologic specimens never handled and evaluated before by pathologists. We aimed to estimate the interobserver agreement among pathologists in evaluating such samples.

METHODS

TTNB specimen slides from 40 PCLs with worrisome features were retrieved and independently evaluated for specimen adequacy, presence of lining epithelium, grade of epithelial dysplasia, presence of ovarian type stroma, and specific diagnosis by 6 expert pathologists from 6 different tertiary care centers. The Gwet's AC1 was used to assess interobserver agreement.

RESULTS

An almost perfect agreement was observed for specimen adequacy (AC1, .82; 95% confidence interval [CI], .79-.98), presence of lesional epithelium (AC1, .90; 95% CI, .86-.92), epithelial dysplasia (AC1, .97; 95% CI, .95-.99), and ovarian-like stroma (AC1, .90; 95% CI, .86-.93). When considering all diagnoses separately, a moderate to substantial agreement was observed (AC1, .62; 95% CI, .57-.67), similarly to mucinous cysts versus serous adenoma versus other diagnoses (AC1, .65; 95% CI, .59-.70) and for mucinous cysts versus all other diagnoses (AC1,.74; 95% CI, .68-.84). The agreement for diagnosis of mucinous cystic neoplasm versus intraductal mucinous papillary neoplasm was almost perfect (AC1, .88; 95% CI, .81-.95).

CONCLUSIONS

Interobserver agreement between expert pathologists in the evaluation of TTNB samples from PCLs with worrisome features was close to perfection for all evaluated parameters, except definitive diagnosis. When mucinous cystic lesions were compared versus all other diagnoses, the agreement became substantial, thus indicating that TTNB specimens can provide important information for PCL management decisions.

Antibiotics Do Not Decrease the Rate of Infection After Endoscopic Ultrasound Fine-Needle Aspiration of Pancreatic Cysts

BACKGROUND

In spite of the weak evidence, antibiotic prophylaxis prior to endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions is routinely used in the clinical practice.

AIMS

To compare a group of patients treated with antibiotics before fine-needle aspiration of pancreatic cystic lesions and a group who did not undergo antimicrobial prophylaxis.

METHODS

Out of 335 patients with suspected pancreatic cystic lesions referred to our center between 2006 and 2018, after propensity score matching two groups were compared: 135 subjects who underwent endoscopic ultrasound fine-needle aspiration under antibiotic prophylaxis and 135 treated with no antimicrobial agents. Primary outcome was infection rate; secondary endpoints included other complications or antibiotic-related adverse events.

RESULTS

Median age was 64 (interquartile range 61-68) and median cyst size was 24 mm (22-28), with no difference between groups. Overall, 10 adverse events (7.1%) of which 2 serious (1.4%) were observed in the antibiotic group and 8 (5.8%) of which 1 (0.7%) serious in the non-antibiotic group. Cyst infection was observed in 2 patients (1.4%) in the antibiotic group and 3 patients (2.2%) in the other cohort (p = 0.65).

CONCLUSIONS

Prophylactic antibiotics do not seem to substantially reduce this risk of infection, and their routine use should be abandoned.