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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.
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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.
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Predictors of malignancy in main duct intraductal papillary mucinous neoplasm of the pancreas. Gastrointest Endosc 2022; 95:291-296. [PMID: 34474037 DOI: 10.1016/j.gie.2021.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The International Consensus Guidelines updated in 2017 recommended surgery to all main duct intraductal papillary mucinous neoplasms (MD-IPMNs) with the main pancreatic duct (MPD) of 10 mm or more and those with mural nodules regardless of size. The aim of the present study was to identify predictors of malignancy in MD-IPMN among preoperative factors including MPD and mural nodule size. METHODS Twenty-six benign MD-IPMNs (7 resected and 19 nonresected) and 32 malignant MD-IPMNs (31 resected and 1 nonresected) were included in the study. MRCP, CT, EUS, and cytology were performed using pancreatic juice collected by endoscopic retrograde pancrestography (ERP). Resected IPMNs were classified as benign or malignant by histologic examination and nonresected MD-IPMNs by imaging, cytology, and observation. Cutoff values of candidate parameters were determined by receiver operating characteristic curves. Univariate and multivariate analyses by regression model were performed. RESULTS MPD and mural nodule size and cytology results differed significantly between benign and malignant groups. Cutoff values of MPD and mural nodule sizes were 15 mm and 10 mm with areas under the curve of .66 and .86, respectively. Mural nodules of 10 mm or more (odds ratio, 8.32; 95% confidence interval, 1.13-61.2; P = .038) and positive cytology (odds ratio, 42.5; 95% confidence interval, 4.10-439; P = .002) were shown to be independent predictors of malignancy by multivariate analysis. When MD-IPMNs with either predictor were diagnosed to be malignant, sensitivities, specificities, and overall accuracy for malignancy were 94%, 85%, and 90%, respectively. CONCLUSIONS Mural nodules of 10 mm or more and positive cytology were independent predictors of malignancy in MD-IPMN.
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Yonamine K, Koshita S, Kanno Y, Ogawa T, Kusunose H, Sakai T, Miyamoto K, Kozakai F, Okano H, Okada T, Oikawa M, Tsuchiya T, Sawai T, Noda Y, Ito K. Pancreatic Ductal Adenocarcinoma Concomitant with Main Duct Type Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932565. [PMID: 34473678 PMCID: PMC8422565 DOI: 10.12659/ajcr.932565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 07/28/2021] [Accepted: 07/12/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasm of the pancreas (IPMN) and pancreatic ductal adenocarcinoma (PDAC) often coexist in the same pancreas. Almost all IPMNs involving PDACs concomitant with IPMN have been shown to be branch duct type IPMNs (BD-IPMNs), and their histological subtypes are gastric type. Therefore, PDACs concomitant with main duct type IPMNs (MD-IPMNs) are considered to be rare. We herein report a rare case preoperatively diagnosed as being a PDAC concomitant with MD-IPMN on the basis of imaging findings and histological findings of pancreatic specimens endoscopically obtained from 2 lesions. CASE REPORT A 67-year-old man was referred to our hospital due to an enlarged pancreas. Using imaging studies, a solid mass was found in the pancreatic head and intraductal papillary masses in the dilated main pancreatic duct of the body and tail with a fistula in the duodenum. On the basis of histological results using specimens endoscopically obtained from each of the 2 lesions, total pancreatectomy was planned due to suspected PDAC concomitant with an MD-IPMN. Finally, resected specimens were used to confirm the presence of a rare case of PDAC concomitant with MD-IPMN. CONCLUSIONS We encountered a rare case of a PDAC concomitant with an MD-IPMN which could be preoperatively diagnosed by using imaging studies and histological specimens endoscopically obtained. In addition to invasive cancers derived from IPMNs, PDACs concomitant with IPMNs can rarely develop in the pancreas involving MD-IPMNs.
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Affiliation(s)
- Keisuke Yonamine
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Miyagi, Japan
| | - Shinsuke Koshita
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Miyagi, Japan
| | - Yoshihide Kanno
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Miyagi, Japan
| | - Takahisa Ogawa
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Miyagi, Japan
| | - Hiroaki Kusunose
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Miyagi, Japan
| | - Toshitaka Sakai
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Miyagi, Japan
| | - Kazuaki Miyamoto
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Miyagi, Japan
| | - Fumisato Kozakai
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Miyagi, Japan
| | - Haruka Okano
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Miyagi, Japan
| | - Takaho Okada
- Department of Gastroenterological Surgery, Sendai City Medical Center, Sendai, Miyagi, Japan
| | - Masaya Oikawa
- Department of Gastroenterological Surgery, Sendai City Medical Center, Sendai, Miyagi, Japan
| | - Takashi Tsuchiya
- Department of Gastroenterological Surgery, Sendai City Medical Center, Sendai, Miyagi, Japan
| | - Takashi Sawai
- Department of Pathology, Sendai City Medical Center, Sendai, Miyagi, Japan
| | - Yutaka Noda
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Miyagi, Japan
- Department of Pathology, Sendai City Medical Center, Sendai, Miyagi, Japan
| | - Kei Ito
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Miyagi, Japan
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Wu YA, Oba A, Beaty L, Colborn KL, Rodriguez Franco S, Harnke B, Meguid C, Negrini D, Valente R, Ahrendt S, Schulick RD, Del Chiaro M. Ductal Dilatation of ≥5 mm in Intraductal Papillary Mucinous Neoplasm Should Trigger the Consideration for Pancreatectomy: A Meta-Analysis and Systematic Review of Resected Cases. Cancers (Basel) 2021; 13:cancers13092031. [PMID: 33922344 PMCID: PMC8122854 DOI: 10.3390/cancers13092031] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Intraductal papillary mucinous neoplasms (IPMN) are common but difficult to manage since accurate tools for diagnosing malignancy are unavailable. This study evaluates the diagnostic value of main pancreatic duct (MPD) diameter for detecting IPMN malignancy, using a meta-analysis of published data. The result suggests that malignancy is highly prevalent in IPMN with ductal dilatation of >5 mm. Abstract Intraductal papillary mucinous neoplasms (IPMN) are common but difficult to manage since accurate tools for diagnosing malignancy are unavailable. This study tests the diagnostic value of the main pancreatic duct (MPD) diameter for detecting IPMN malignancy using a meta-analysis of published data of resected IPMNs. Collected from a comprehensive literature search, the articles included in this analysis must report malignancy cases (high-grade dysplasia (HGD) and invasive carcinoma (IC)) and MPD diameter so that two MPD cut-offs could be created. The sensitivity, specificity, and odds ratios of the two cutoffs for predicting malignancy were calculated. A review of 1493 articles yielded 20 retrospective studies with 3982 resected cases. A cutoff of ≥5 mm is more sensitive than the ≥10 mm cutoff and has pooled sensitivity of 72.20% and 75.60% for classification of HGD and IC, respectively. Both MPD cutoffs of ≥5 mm and ≥10 mm were associated with malignancy (OR = 4.36 (95% CI: 2.82, 6.75) vs. OR = 3.18 (95% CI: 2.25, 4.49), respectively). The odds of HGD and IC for patients with MPD ≥5 mm were 5.66 (95% CI: 3.02, 10.62) and 7.40 (95% CI: 4.95, 11.06), respectively. OR of HGD and IC for MPD ≥10 mm cutoff were 4.36 (95% CI: 3.20, 5.93) and 4.75 (95% CI: 2.39, 9.45), respectively. IPMN with MPD of >5 mm could very likely be malignant. In selected IPMN patients, pancreatectomy should be considered when MPD is >5 mm.
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Affiliation(s)
- Y.H. Andrew Wu
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
| | - Atsushi Oba
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan
| | - Laurel Beaty
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Kathryn L. Colborn
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Surgical Outcomes and Applied Research Program, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Salvador Rodriguez Franco
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- The Heart Institute, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Ben Harnke
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA;
| | - Cheryl Meguid
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
| | - Daniel Negrini
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Anesthesiology, Federal University of the State of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Roberto Valente
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Surgery and Perioperative Sciences, Umeå University Hospital, 907 37 Umeå, Sweden
| | - Steven Ahrendt
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- University of Colorado Cancer Center, Aurora, CO 80045, USA
| | - Richard D. Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- University of Colorado Cancer Center, Aurora, CO 80045, USA
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- University of Colorado Cancer Center, Aurora, CO 80045, USA
- Correspondence:
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Geramizadeh B, Marzban M, Shojazadeh A, Kadivar A, Maleki Z. Intraductal papillary mucinous neoplasm of the pancreas: Cytomorphology, imaging, molecular profile, and prognosis. Cytopathology 2021; 32:397-406. [PMID: 33792980 DOI: 10.1111/cyt.12973] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 02/15/2021] [Accepted: 02/24/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasm (IPMN) constitutes up to 20% of all pancreatic resections, and has been increasing in recent years. Histomorphological findings of IPMN are well established; however, there are not many published papers regarding the cytological findings of IPMN on fine needle aspiration (FNA) specimens. We review the cytomorphological features, molecular profile, imaging findings, and prognosis of IPMN. METHODS The English literature was thoroughly searched with key phrases containing IPMN. OBSERVATIONS IPMN is a rare entity, affecting men and women equally and is usually diagnosed at the age of 60-70 years. The characteristic imaging features include a cystic lesion with associated dilatation of the main or branch pancreatic duct, and atrophy of surrounding pancreatic parenchyma. Cytomorphological features of IPMN include papillary fragments of mucinous epithelium in a background of abundant thick extracellular mucin, a hallmark feature. IPMNs should be evaluated for high-grade dysplasia, which manifests with nuclear atypia, nuclear moulding, prominent nucleoli, nuclear irregularity, and cellular crowding. Molecular profiling of IPMN along with carcinoembryonic antigen and amylase levels is useful in predicting malignancy or high-grade dysplasia arising in IPMN. Overall, the prognosis of IPMN is excellent except in those cases with high-grade dysplasia and malignant transformation. Postoperative surveillance is required for resected IPMNs. CONCLUSION IPMN requires a multidisciplinary approach for management. Cytomorphological findings of IPMN on FNA, in conjunction with tumour markers in pancreatic fluid cytology and imaging findings, are of paramount importance in clinical decision-making for IPMN.
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Affiliation(s)
- Bita Geramizadeh
- Department of Pathology, Medical School of Shiraz University, Shiraz University of Medical Sciences, Shiraz, Iran.,Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahsa Marzban
- University of British Columbia, Vancouver, BC, Canada
| | - Alireza Shojazadeh
- Department of Pathology, Medical School of Shiraz University, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ana Kadivar
- University of Maryland, College Park, MD, USA
| | - Zahra Maleki
- Division of Cytopathology, Department of Pathology, The Johns-Hopkins Hospital, Baltimore, MD, USA
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Lara LF, Luthra A, Conwell DL, Krishna SG. Pancreatic Cysts in the Elderly. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:457-469. [PMID: 31707690 DOI: 10.1007/s11938-019-00260-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Incidental pancreatic cysts are common, and management strategies continue to evolve. This review summarizes diagnostic and management recommendations in older patients with these lesions based on guidelines and best clinical evidence. RECENT FINDINGS Diagnosis of cyst type has been enhanced with improved imaging and cyst fluid analysis and visualization. Recent outcome studies indicate that certain cyst types should be followed independent of patient age as long as certain criteria which are reviewed are met. Differentiation of pancreatic cyst type is important as this dictates the need for long-term follow-up. Because most cyst-related neoplasia occurs in older patients, surveillance should continue within certain guidelines.
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Affiliation(s)
- Luis F Lara
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA.
| | - Anjuli Luthra
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA
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Carmicheal J, Patel A, Dalal V, Atri P, Dhaliwal AS, Wittel UA, Malafa MP, Talmon G, Swanson BJ, Singh S, Jain M, Kaur S, Batra SK. Elevating pancreatic cystic lesion stratification: Current and future pancreatic cancer biomarker(s). Biochim Biophys Acta Rev Cancer 2019; 1873:188318. [PMID: 31676330 DOI: 10.1016/j.bbcan.2019.188318] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/25/2019] [Accepted: 10/25/2019] [Indexed: 02/06/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an incredibly deadly disease with a 5-year survival rate of 9%. The presence of pancreatic cystic lesions (PCLs) confers an increased likelihood of future pancreatic cancer in patients placing them in a high-risk category. Discerning concurrent malignancy and risk of future PCL progression to cancer must be carefully and accurately determined to improve survival outcomes and avoid unnecessary morbidity of pancreatic resection. Unfortunately, current image-based guidelines are inadequate to distinguish benign from malignant lesions. There continues to be a need for accurate molecular and imaging biomarker(s) capable of identifying malignant PCLs and predicting the malignant potential of PCLs to enable risk stratification and effective intervention management. This review provides an update on the current status of biomarkers from pancreatic cystic fluid, pancreatic juice, and seromic molecular analyses and discusses the potential of radiomics for differentiating PCLs harboring cancer from those that do not.
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Affiliation(s)
- Joseph Carmicheal
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Asish Patel
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Vipin Dalal
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Pranita Atri
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Amaninder S Dhaliwal
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Uwe A Wittel
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Mokenge P Malafa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Geoffrey Talmon
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Benjamin J Swanson
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Shailender Singh
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Maneesh Jain
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sukhwinder Kaur
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Surinder K Batra
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA; Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA; Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA.
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Should we regard all main duct type intraductal papillary mucinous neoplasms of the pancreas (MD-IPMN) as an indication of surgery? -A retrospective study in 29 patients with MD-IPMN showing mural nodules. Pancreatology 2019; 19:352-359. [PMID: 30679137 DOI: 10.1016/j.pan.2019.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/25/2018] [Accepted: 01/08/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE To elucidate predictive factors for malignant main duct type IPMN (MD-IPMN). METHODS All 29 subjects had mural nodules (MNs) in the main pancreatic duct (MPD) on preoperative endoscopic ultrasonography and underwent surgery (19, malignant; 10, benign). Possible predictive factors for malignancy such as background, imaging, and histological factors including histological subtype (HS), were evaluated. RESULTS Multivariate analysis revealed an MPD diameter of ≥12 mm (p = 0.042) and non-gastric type (p = 0.001) to be the statistically significant predictive factors for malignancy. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy to detect malignancy by using "an MPD diameter of ≥12 mm and/or non-gastric type" were 95%, 70%, 86%, 88%, and 86%, respectively. In 7 subjects in whom HS was preoperatively evaluated using pancreatic specimens obtained before surgery, the agreement rate of the preoperative HS with definitive HS evaluated using resected specimens was 86%. CONCLUSIONS For MD-IPMNs with MNs, "an MPD diameter of ≥12 mm and/or non-gastric type" are indicated for surgery. On the other hand, careful surveillance without immediate pancreatic surgery may be an option for MD-IPMNs showing both an MPD diameter of <12 mm and gastric type.
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Scholten L, van Huijgevoort NCM, Bruno MJ, Fernandez-Del Castillo C, Satoi S, Sauvanet A, Wolfgang C, Fockens P, Chari ST, Del Chiaro M, van Hooft JE, Besselink MG. Surgical management of intraductal papillary mucinous neoplasm with main duct involvement: an international expert survey and case-vignette study. Surgery 2018; 164:S0039-6060(18)30082-5. [PMID: 29778250 DOI: 10.1016/j.surg.2018.01.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 01/24/2018] [Accepted: 01/29/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND The risk of invasive cancer in resected intraductal papillary mucinous neoplasm with main pancreatic duct involvement is 33%-60%. Most guidelines, therefore, advise resection of main duct intraductal papillary mucinous neoplasm and mixed type intraductal papillary mucinous neoplasm in surgically fit patients, although advice on the surgical strategy (partial or total pancreatectomy) differs. We performed a survey amongst international experts to guide the design of future studies and help to prepare for a single international set of guidelines. METHODS An online survey including case vignettes was sent to 221 international experts who had published on main duct/mixed type intraductal papillary mucinous neoplasm in the previous decade and to all surgeon and gastroenterologist members of the pancreatic cyst guideline committees of the European Study Group and the International Association of Pancreatology. RESULTS Overall, 97 experts (67 surgeons, 30 gastroenterologists) from 19 countries replied (44% response rate). Most (93%) worked in an academic hospital, with a median of 15 years' experience with intraductal papillary mucinous neoplasm treatment. In main duct/mixed type intraductal papillary mucinous neoplasm patients with pancreatic duct dilation (>5 mm) in the entire pancreas, 41% (n = 37) advised nonoperative surveillance every 3-6 months, whereas 59% (n = 54) advised operative intervention. Of those who advised operative intervention, 46% (n = 25) would perform a total pancreatectomy and 31% (n = 17) pancreatoduodenectomy with follow-up. No structural differences in advice were seen between surgeons and gastroenterologists, between continents where the respondents lived, and based on years of experience. CONCLUSION This international survey identified a clinically relevant lack of consensus in the treatment strategy in main duct/mixed type intraductal papillary mucinous neoplasm among experts. Studies with long-term follow-up including quality of life after partial and total pancreatectomy for main duct/mixed type intraductal papillary mucinous neoplasm are required.
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Affiliation(s)
- Lianne Scholten
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center Amsterdam, the Netherlands
| | - Nadine C M van Huijgevoort
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Academic Medical Center Amsterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center Rotterdam, the Netherlands
| | | | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Hirakata, Japan
| | | | - Christopher Wolfgang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Academic Medical Center Amsterdam, the Netherlands
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Marco Del Chiaro
- Division of Surgery, Departments of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Academic Medical Center Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center Amsterdam, the Netherlands.
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Abstract
Evidence-based guidelines on the management of pancreatic cystic neoplasms (PCN) are lacking. This guideline is a joint initiative of the European Study Group on Cystic Tumours of the Pancreas, United European Gastroenterology, European Pancreatic Club, European-African Hepato-Pancreato-Biliary Association, European Digestive Surgery, and the European Society of Gastrointestinal Endoscopy. It replaces the 2013 European consensus statement guidelines on PCN. European and non-European experts performed systematic reviews and used GRADE methodology to answer relevant clinical questions on nine topics (biomarkers, radiology, endoscopy, intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystic neoplasm, rare cysts, (neo)adjuvant treatment, and pathology). Recommendations include conservative management, relative and absolute indications for surgery. A conservative approach is recommended for asymptomatic MCN and IPMN measuring <40 mm without an enhancing nodule. Relative indications for surgery in IPMN include a main pancreatic duct (MPD) diameter between 5 and 9.9 mm or a cyst diameter ≥40 mm. Absolute indications for surgery in IPMN, due to the high-risk of malignant transformation, include jaundice, an enhancing mural nodule >5 mm, and MPD diameter >10 mm. Lifelong follow-up of IPMN is recommended in patients who are fit for surgery. The European evidence-based guidelines on PCN aim to improve the diagnosis and management of PCN.
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Choi SH, Park SH, Kim KW, Lee JY, Lee SS. Progression of Unresected Intraductal Papillary Mucinous Neoplasms of the Pancreas to Cancer: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2017; 15:1509-1520.e4. [PMID: 28342950 DOI: 10.1016/j.cgh.2017.03.020] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/26/2017] [Accepted: 03/05/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS It is not clear how best to manage patients with low-risk intraductal papillary mucinous neoplasms (IPMNs) of the pancreas because little is known about IPMN progression to cancer. We sought to determine the cumulative incidence of development of pancreatic cancer in persons with unresected IPMNs (particularly low-risk IPMNs). METHODS We performed a systematic search of the MEDLINE and Embase databases through November 30, 2016 for studies reporting the cumulative incidence of pancreatic cancer in patients with unresected IPMNs or studies that provided data in sufficient detail for us to calculate cumulative incidence values. We categorized patient series as studies on low-risk IPMNs (lesions without main pancreatic duct involvement or mural nodules) or non-low-risk IPMNs. We calculated meta-analytic cumulative incidence values for pancreatic cancer at 1, 3, 5, and 10 years of follow-up by using the inverse variance method and random-effects model. RESULTS Among 1514 articles screened, we identified 10 studies of low-risk IPMNs (n = 2411) and 9 studies of non-low-risk IPMNs (n = 825). In studies of low-risk IPMNs, the meta-analytic cumulative incidence values for pancreatic cancer were 0.02% at 1 year (95% confidence interval [CI], 0.0%-0.23%; I2= 0.0%), 1.40% at 3 years (95% CI, 0.58%-2.48%; I2 = 58.5%), 3.12% at 5 years (95% CI, 1.12%-5.90%; I2 = 88.0%), and 7.77% at 10 years (95% CI, 4.09%-12.39%; I2 = 79.8%). These values were much higher in studies of non-low-risk IPMNs; cumulative incidence values for pancreatic cancer were 1.95% at 1 year (95% CI, 0.0%-5.99%; I2 = 84.2%), 5.69% at 3 years (95% CI, 1.10%-12.77%; I2 = 89.9%), 9.77% at 5 years (95% CI, 3.04%-19.27%; I2 = 92.0%), and 24.68% at 10 years (95% CI, 14.87%-35.90%; I2 = 74.3%). The pooled cumulative incidence steadily increased linearly as the follow-up duration increased. CONCLUSIONS In a systematic review and meta-analysis, we found that low-risk IPMNs have almost 8% chance of progressing to pancreatic cancer within 10 years, and higher-risk IPMNs have almost 25% chance of progressing to cancer in 10 years; incidence values increase linearly with time. Continued long-term surveillance is therefore vital for patients with low-risk IPMNs.
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Affiliation(s)
- Sang Hyun Choi
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Seong Ho Park
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.
| | - Kyung Won Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Ja Youn Lee
- National Evidence-based Healthcare Collaborating Agency, Seoul, South Korea
| | - Sang Soo Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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Mukewar S, de Pretis N, Aryal-Khanal A, Ahmed N, Sah R, Enders F, Larson JJ, Levy MJ, Takahashi N, Topazian M, Pearson R, Vege SS, Chari ST. Fukuoka criteria accurately predict risk for adverse outcomes during follow-up of pancreatic cysts presumed to be intraductal papillary mucinous neoplasms. Gut 2017; 66:1811-1817. [PMID: 27390303 PMCID: PMC7597030 DOI: 10.1136/gutjnl-2016-311615] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Fukuoka consensus guidelines classify pancreatic cystic lesions (PCLs) presumed to be intraductal papillary mucinous neoplasms (IPMNs) into Fukuoka positive (FP) (subgroups of high-risk (HR) and worrisome features (WFs)) and Fukuoka negative (FN) (non-HR feature/WF cysts). We retrospectively estimated 5-year risk of pancreatic cancer (PC) in FN, WF and HR cysts of patients with PCL-IPMN. DESIGN From Mayo Clinic databases, we randomly selected 2000 patients reported to have a PCL; we excluded inflammatory or suspected non-IPMN cysts and those without imaging follow-up. We re-reviewed cross-sectional imaging and abstracted clinical and follow-up data on PCL-IPMNs. The study contained 802 patients with FN cysts and 358 with FP cysts. RESULTS Patients with PCL-IPMN had median (IQR) follow-up of 4.2 (1.8-7.1) years. Among FN cysts, 5-year PC risk was low (2-3%) regardless of cyst size (p=0.67). After excluding events in the first 6 months, 5-year PC risk remained low (0-2%) regardless of cyst size (p=0.61). Among FP cysts, HR cysts (n=66) had greater 5-year PC risk than WF cysts (n=292) (49.7% vs 4.1%; p<0.001). In HR cysts, 3-year PC risk was greatest for obstructive jaundice versus enhancing solid component or main pancreatic duct >10 mm (79.8% vs 37.3% vs 39.4%, respectively; p=0.01). CONCLUSIONS Fukuoka guidelines accurately stratify PCL-IPMNs for PC risk, with FN cysts having lowest and HR cysts having greatest risk. After 6-month follow-up, WF and FN cysts had a low 5-year PC risk. Surveillance strategies should be tailored appropriately.
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Affiliation(s)
- Saurabh Mukewar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicolo de Pretis
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Anupama Aryal-Khanal
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nazir Ahmed
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Raghuwansh Sah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Felicity Enders
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph J Larson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Naoki Takahashi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Randall Pearson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhi S Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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13
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Validation of the 2012 Fukuoka Consensus Guideline for Intraductal Papillary Mucinous Neoplasm of the Pancreas From a Single Institution Experience. Pancreas 2017; 46:936-942. [PMID: 28697135 DOI: 10.1097/mpa.0000000000000874] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The 2012 Fukuoka consensus guideline has stratified the risks of malignant intraductal papillary mucinous neoplasm (IPMN) of the pancreas into "high-risk stigmata" (HRS) and "worrisome feature" (WF). This study aimed to evaluate its clinical validity based on a single institution experience. METHODS Eighty-nine patients who underwent surgical resection with pathological diagnosis of IPMN were retrospectively studied. RESULTS High-risk stigmata was significantly correlated with the prevalence of malignant IPMN as compared with WF. The positive predictive values of HRS and WF were 66.7% and 35.7% for branch duct IPMN and 80% and 38.1% for main duct IPMN, respectively. Univariate analysis indicated that all the factors in HRS and WF had statistical significance. Whereas multivariate analysis revealed only enhanced solid component (odds ratio [OR], 50.01; P = 0.008), presence of mural nodule (OR, 73.83; P < 0.001) and lymphadenopathy (OR, 20.85; P = 0.03) were independent predictors. Scoring HRS and WF by different numbers of positive factors resulted in improved predictive value. The area under the curve of HRS score was significantly lower than that of WF or HRS + WF score (0.680 vs 0.900 or 0.902, respectively; P < 0.001). CONCLUSIONS As supplementary to the 2012 Fukuoka guideline, we suggest that calculating scores of WF and HRS may have superior diagnostic accuracy in predicting malignant IPMN.
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Abstract
Pancreatic cysts, especially incidental asymptomatic ones seen on noninvasive imaging such as CT or MR imaging, remain a clinical challenge. The etiology of such cysts may range from benign cysts without any malignant potential such as pancreatic pseudocysts and serous cystadenomas to premalignant or frankly malignant cysts such as mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, cystic degeneration associated with solid tumors such as pancreatic ductal adenocarcinoma or pancreatic endocrine neoplasms, and solid pseudopapillary neoplasms. The clinical challenge in 2017 is to accurately preoperatively diagnose them and their malignant potential before deciding about surgery, surveillance or doing nothing. This review will focus on the currently available clinical guidelines for doing so.
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Affiliation(s)
- James J Farrell
- Yale Center for Pancreatic Diseases, Interventional Endoscopy, Yale School of Medicine, New Haven, CT, USA. .,Section of Digestive Diseases, Yale University School of Medicine, LMP 1080, 15 York Street, New Haven, CT, 06510-3221, USA.
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15
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Casadei R, Ricci C, Taffurelli G, Pacilio CA, Migliori M, Minni F. Impact of surgery and surveillance in the management of branch duct intraductal papillary mucinous neoplasms of the pancreas according to Fukuoka guidelines: the Bologna experience. Updates Surg 2017; 70:47-55. [PMID: 28593459 DOI: 10.1007/s13304-017-0471-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 05/19/2017] [Indexed: 01/27/2023]
Abstract
The objective of the study was to evaluate the Fukuoka guidelines in indicating the proper management for recognising the risk factors of malignancy. Data of patients with branch duct intraductal papillary mucinous neoplasms who underwent pancreatic resection or surveillance according to the Fukuoka risk parameters were collected in a prospective database. The clinical outcome (development of pancreatic cancer, overall and disease-specific survival) and pathological results were evaluated in all patients and in resected cases, respectively. The data of 197 patients were collected: 23 primarily resected and 174 primarily followed. Of the latter, 16 were secondarily resected. Among the patients resected, 21 (53.9%) showed diagnosis of in situ or invasive carcinoma and only contrast-enhancing mural nodules were significantly related to malignancy (P = 0.002), with a DOR of 3.3 and an LH+ of 2.2. Development of pancreatic cancer was shown in ten (5.7%) of the patients primarily followed. The overall survival and disease-specific survival were similar between patients primarily followed and primarily resected. It seems reasonable to suggest that a branch duct intraductal papillary mucinous neoplasm should be treated as a benign and indolent disease that is rarely malignant. Enhancing mural nodules represent the best indicator for surgery.
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Affiliation(s)
- Riccardo Casadei
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Chirurgia Generale-Minni, Alma Mater Studiorum, Policlinico S.Orsola-Malpighi, Malpighi Hospital, University of Bologna, Via Massarenti n.9, 40138, Bologna, Italy.
| | - Claudio Ricci
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Chirurgia Generale-Minni, Alma Mater Studiorum, Policlinico S.Orsola-Malpighi, Malpighi Hospital, University of Bologna, Via Massarenti n.9, 40138, Bologna, Italy
| | - Giovanni Taffurelli
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Chirurgia Generale-Minni, Alma Mater Studiorum, Policlinico S.Orsola-Malpighi, Malpighi Hospital, University of Bologna, Via Massarenti n.9, 40138, Bologna, Italy
| | - Carlo Alberto Pacilio
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Chirurgia Generale-Minni, Alma Mater Studiorum, Policlinico S.Orsola-Malpighi, Malpighi Hospital, University of Bologna, Via Massarenti n.9, 40138, Bologna, Italy
| | - Marina Migliori
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Chirurgia Generale-Minni, Alma Mater Studiorum, Policlinico S.Orsola-Malpighi, Malpighi Hospital, University of Bologna, Via Massarenti n.9, 40138, Bologna, Italy
| | - Francesco Minni
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Chirurgia Generale-Minni, Alma Mater Studiorum, Policlinico S.Orsola-Malpighi, Malpighi Hospital, University of Bologna, Via Massarenti n.9, 40138, Bologna, Italy
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16
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Lekkerkerker SJ, Besselink MG, Busch OR, Verheij J, Engelbrecht MR, Rauws EA, Fockens P, van Hooft JE. Comparing 3 guidelines on the management of surgically removed pancreatic cysts with regard to pathological outcome. Gastrointest Endosc 2017; 85:1025-1031. [PMID: 27693645 DOI: 10.1016/j.gie.2016.09.027] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 09/19/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Currently, 3 guidelines are available for the management of pancreatic cysts. These guidelines vary in their indication for resection of high-risk cysts. We retrospectively compared the final pathologic outcome of surgically removed pancreatic cysts with the indications for resection according to 3 different guidelines. METHODS Patients who underwent pancreatic resection were extracted from our prospective pancreatic cyst database (2006-present). The final histopathologic diagnosis was compared with the initial indication for surgery stated by the guidelines of the International Association of Pancreatology (IAP), European Study Group on Cystic tumors of the Pancreas and American Gastroenterological Association (AGA). We considered surgery in retrospect justified for malignancy, high-grade dysplasia, solid pseudopapillary neoplasms, neuroendocrine tumors or symptom improvement. Furthermore, we evaluated the patients with suspected intraductal papillary mucinous neoplasm (IPMN) separately. RESULTS Overall, 115 patients underwent pancreatic resection. The preoperative diagnosis was correct in 83 of 115 patients (72%) and differentiation between benign and premalignant in 99 of 115 patients (86%). In retrospect, surgery was justified according to the aforementioned criteria in 52 of 115 patients (45%). For patients with suspected IPMN (n = 75) resection was justified in 36 of 67 (54%), 36 of 68 (53%), and 32 of 54 (59%) of patients who would have had surgery based on the IAP, European, or AGA guidelines, respectively. The AGA guideline would have avoided resection in 21 of 75 (28%) patients, versus 8 of 75 (11%) and 7 of 75 (9%) when the IAP or European guideline would have been applied strictly. Nevertheless, 4 of 33 patients (12%) with high-grade dysplasia or malignancy would have been missed with the AGA guidelines, compared with none with the IAP or European guidelines. CONCLUSION Although fewer patients undergo unnecessary surgery based on the AGA guidelines, the risk of missing malignancy or high-grade dysplasia with this guideline seems considerably high.
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Affiliation(s)
- Selma J Lekkerkerker
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Joanne Verheij
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marc R Engelbrecht
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Erik A Rauws
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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17
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Risk Factors for Malignancy of Branch-Duct Intraductal Papillary Mucinous Neoplasms: A Critical Evaluation of the Fukuoka Guidelines With a Systematic Review and Meta-analysis. Pancreas 2016; 45:1243-1254. [PMID: 27776043 DOI: 10.1097/mpa.0000000000000642] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES This study aimed to evaluate the accuracy of the risk factors proposed by Fukuoka guidelines in detecting malignancy of branch-duct intraductal papillary mucinous neoplasms. METHOD Diagnostic meta-analysis of cohort studies. A systematic literature search was conducted using MEDLINE, the Cochrane Library, Scopus, and the ISI-Web of Science databases to identify all studies published up to 2014. RESULTS Twenty-five studies (2025 patients) were suitable for the meta-analysis. The "high risk stigmata" showed the highest pooled diagnostic odds ratio (jaundice, 6.3; positive citology, 5.5; mural nodules, 4.8) together with 2 "worrisome features" (thickened/enhancing walls, 4.2; duct dilatation, 4.0) and 1 "other parameters" (carbohydrate antigen 19-9 serum levels, 4.6). CONCLUSIONS An "ideal risk factor" capable of recognizing all malignant branch-duct intraductal papillary mucinous neoplasms was not identified and some "dismal areas" remain. However, "high risk stigmata" were strongly related to malignancy, mainly enhancing mural nodules. Among the "worrisome features," duct dilatation and thickened/enhancing walls were underestimated, and their diagnostic performance was similar to those of "high risk stigmata." The carbohydrate antigen 19-9 serum level should be added to the Fukuoka algorithm because this value could help in carrying out correct management.
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18
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Risk Factors for Progression or Malignancy in Main-Duct and Mixed-Type Intraductal Papillary Mucinous Neoplasm of the Pancreas. Pancreas 2016; 45:1027-31. [PMID: 26692447 DOI: 10.1097/mpa.0000000000000592] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The 2012 international guidelines state that surgery should be considered for all surgically fit patients with pancreatic main-duct (MD)/mixed intraductal papillary mucinous neoplasms (IPMNs). This study evaluated the follow-up results of MD/mixed IPMNs and risk factors for progression or malignancy. METHODS Patients with MD/mixed IPMNs were retrospectively enrolled and divided into surgical and nonsurgical groups. These 2 groups were compared and further categorized as progression/malignancy or not. In the nonsurgical group, disease progression was defined as radiologic tumor growth or adjacent organ invasion. RESULTS Data from 101 patients (73 males; mean [SD] age, 66.3 [9.1] years), including 27 and 74 in the nonsurgical and surgical groups, respectively, were analyzed. Mural nodules were more frequently detected in the surgical group (7.4% vs 31.1%, P = 0.018), whereas more multifocal cysts were observed in the nonsurgical group (40.7% vs 20.3%, P = 0.037). Forty-one patients (40.6%) showed progression or malignancy. Multivariate analysis showed that main pancreatic duct of 10 mm or greater (odds ratio, 4.368; P = 0.024) and pre-existing diabetes (odds ratio, 3.077; P = 0.046) were independent risk factors for progression or malignancy. CONCLUSIONS A watchful waiting strategy could be feasible for some patients with MD/mixed IPMNs, particularly those with a main pancreatic duct of less than 10 mm and without diabetes.
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Validation of the 2012 International Consensus Guidelines Using Computed Tomography and Magnetic Resonance Imaging: Branch Duct and Main Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas. Ann Surg 2016; 263:557-64. [PMID: 25822687 DOI: 10.1097/sla.0000000000001217] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To validate the 2012 guidelines for intraductal papillary mucinous neoplasm (IPMN) of the pancreas and to compare diagnostic performances of computed tomography (CT) and magnetic resonance imaging (MRI) for differentiating malignant from benign IPMN. BACKGROUND As IPMN has variable risks of malignancy and management of this entity is closely related to its malignant potential, it is important to predict risks of IPMN malignancy. METHODS This retrospective study included 158 patients with surgically confirmed IPMN of the pancreas who underwent both preoperative CT and MRI. Two radiologists evaluated the "high-risk stigmata" and "worrisome features" of the 2012 guidelines for branch duct (BD)-IPMN and main duct (MD)-IPMN. Univariate and multivariable analyses were used to identify significant predictors of malignancy in IPMN. The diagnostic performance was compared between CT and MRI. RESULTS Malignant IPMN was seen in 8 of 60 patients (13.3%) with BD-IPMN and 44 of 98 patients (44.9%) with MD-IPMN. Presence of mural nodule was the most important predictor in BD-IPMN and MD-IPMN (odds ratios, 9.2 and 7.6, respectively, P = 0.01 on CT; and odds ratios, 5.7 and 13.3, respectively, P ≤ 0.04 on MRI), whereas mural nodule size and lymphadenopathy were significant only in MD-IPMN (P < 0.05). The diagnostic performance of CT and MRI for significant findings was not statistically different in both types of IPMN (P > 0.34). CONCLUSIONS The presence of mural nodule was the most important predictor of malignancy in both types of IPMN. Mural nodule size and lymphadenopathy were also significant predictors in MD-IPMN. Computed tomography and MRI showed similar diagnostic performances for differentiating malignant from benign IPMN.
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20
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Seo N, Byun JH. Evaluation of malignant intraductal papillary mucinous neoplasms of the pancreas on computed tomography and magnetic resonance imaging. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Nieun Seo
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Ho Byun
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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21
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Ceppa EP, Roch AM, Cioffi JL, Sharma N, Easler JJ, DeWitt JM, House MG, Zyromski NJ, Nakeeb A, Schmidt CM. Invasive, mixed-type intraductal papillary mucinous neoplasm: Superior prognosis compared to invasive main-duct intraductal papillary mucinous neoplasm. Surgery 2015; 158:937-44; discussion 944-5. [DOI: 10.1016/j.surg.2015.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 05/01/2015] [Accepted: 06/03/2015] [Indexed: 01/27/2023]
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Effects of Comorbidities on Outcomes of Patients With Intraductal Papillary Mucinous Neoplasms. Clin Gastroenterol Hepatol 2015; 13:1816-23. [PMID: 25956837 DOI: 10.1016/j.cgh.2015.04.177] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 04/20/2015] [Accepted: 04/22/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas occur mostly in older individuals. Individual life expectancy and risk of death from other factors must be carefully considered in analyzing the risks that IPMNs pose. We investigated whether there is a subset of patients with IPMNs and a high risk of dying from other causes who would not benefit from pancreatic surgery. METHODS We collected data from 725 patients at Massachusetts General Hospital who underwent resection or have been under observation for IPMNs from 1992 through 2012. Comorbidities were classified according to the age-adjusted Charlson comorbidity index (CACI). Causes of death were recorded, and survival data were analyzed by the Kaplan-Meier method. RESULTS The patients' median CACI score was 3; 10% of patients had CACI of 7 or more. Of the entire cohort, 55% underwent resection, and the remaining 45% have been under observation. After a median follow-up period of 5 years, 177 patients died (24%, 55% of deaths within 5 years of diagnosis); 78% of deaths were not related to IPMNs. The median survival time for all patients with CACI score of 7 or more was 43 months. Multivariate regression analysis revealed that the chance of non-IPMN-related death within 3 years of diagnosis is 11-fold higher for patients with CACI score of 7 or more than for patients with lower scores. CONCLUSIONS The CACI can be used to identify patients with a high risk of death from factors other than IPMNs within a few years after diagnosis. These patients are therefore not likely to benefit from further IPMN observation or pancreatic resection.
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Jana T, Shroff J, Bhutani MS. Pancreatic cystic neoplasms: Review of current knowledge, diagnostic challenges, and management options. J Carcinog 2015; 14:3. [PMID: 25821410 PMCID: PMC4374202 DOI: 10.4103/1477-3163.153285] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 02/01/2015] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cystic lesions are being detected with increasing frequency, largely due to advances in cross-sectional imaging. The most common neoplasms include serous cystadenomas, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, solid pseudopapillary neoplasms, and cystic pancreatic endocrine neoplasms. Computed tomography (CT), magnetic resonance imaging (MRI), and endoscopic ultrasound (EUS) are currently used as imaging modalities. EUS-guided fine needle aspiration has proved to be a useful diagnostic tool, and enables an assessment of tumor markers, cytology, chemistries, and DNA analysis. Here, we review the current literature on pancreatic cystic neoplasms, including classification, diagnosis, treatment, and recommendations for surveillance. Data for this manuscript was acquired via searching the literature from inception to December 2014 on PubMed and Ovid MEDLINE.
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Affiliation(s)
- Tanima Jana
- Department of Internal Medicine, University of Texas Medical School at Houston, Houston, TX, USA
| | - Jennifer Shroff
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Texas Medical School at Houston, Houston, TX, USA
| | - Manoop S Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Should all branch-duct intraductal papillary mucinous neoplasms be resected? Am J Surg 2015; 209:478-82. [DOI: 10.1016/j.amjsurg.2014.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/28/2014] [Accepted: 10/31/2014] [Indexed: 01/04/2023]
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