Chronic immunosuppression does not potentiate the malignant progression of mucinous pancreatic cystic lesions

Premalignant Lesions in the Kidney Transplant Candidate

End-stage kidney disease patients who are referred for transplant undergo an extensive evaluation process to ensure their health prior to transplant due in part to the shortage of available organs. Although management and surveillance guidelines exist for malignancies identified in the transplant and waitlist populations, less is written about the management of premalignant lesions in this population. This review covers the less common premalignant lesions (intraductal papillary mucinous neoplasm, gastrointestinal stromal tumor, thymoma, and pancreatic neuroendocrine tumor) that can be found in the transplant candidate population. High-level evidence for the management of these rarer premalignant lesions in the transplant population is lacking, and this review extrapolates evidence from the general population and should not be a substitute for a multidisciplinary discussion with medical and surgical oncologists.

Prevalence and progression of intraductal papillary mucinous neoplasms of the pancreas in solid organ transplant recipients: A systematic review

Solid organ transplantation (SOT) recipients are known to carry an increased risk of malignancy because of long-term immunosuppression. However, the progression of intraductal papillary mucinous neoplasm of the pancreas (IPMN) in this population remains unclear. We performed a systematic review by searching PubMed, Embase, Scopus, and Google Scholar. All studies containing IPMNs in solid organ transplantation recipients were screened. We included 11 studies in our final analysis, totaling 274 patients with IPMNs of the 8213 SOT recipients. The prevalence from 8 studies was 4.7% (95% CI 2.4%-7.7%) in a random-effects model with median study periods of 24 to 220 months. The median rate for all progressions from 10 studies was 20% (range, 0%-88%) within 13 to 41 months of the median follow-up time. By utilizing the results of 3 case-control studies, the relative risk from a random-effects model for progression (worrisome features and high-risk stigmata) of IPMNs was 0.39 (95% CI 0.12-1.31). No adenocarcinoma derived from IPMN was reported in the included studies. Overall, this study indicates that the progression of pretransplant IPMN does not increase drastically compared with the general nontransplant population. However, considering the limited literature, further studies are required for confirmation.

The Natural History of Pancreatic Cystic Lesions in Liver Transplant Recipients: A Systematic Review and Meta-analysis

OBJECTIVES

The management of incidentally discovered pancreatic cystic lesions (PCLs) with surveillance or resection often requires shared decision-making. Patients with cirrhosis are more likely to have PCLs discovered due to increased imaging, and those undergoing liver transplantations (LTs) may be at increased risk of carcinogenesis due to immunosuppressive medications. Our study aimed to characterize the outcomes and risk of malignant progression of PCLs in post-LT patients.

METHODS

Multiple databases were searched for studies looking at PCLs in post-LT patients from inception until February 2022. Primary outcomes were the incidence of PCLs in LT recipients and progression to malignancy. Secondary outcomes included development of worrisome features, outcomes of surgical resection for progression, and change in size.

RESULTS

A total of 12 studies with 17,862 patients with 1411 PCLs were included. The pooled proportion of new PCL development in post-LT patients was 68% (95% confidence interval [CI], 42-86; I2 = 94%) over the follow-up of 3.7 (standard deviation, 1.5) years. The pooled progression of malignancy and worrisome features was 1% (95% CI, 0-2; I2 = 0%) and 4% (95% CI, 1-11; I2 = 89%), respectively.

CONCLUSIONS

Compared with nontransplant patients, incidental PCLs do not carry a higher risk of malignancy.

The Natural Course of Pancreatic Cysts in Inflammatory Bowel Disease: Results of a Long-term Follow-up

OBJECTIVES

The natural course of pancreatic cysts in inflammatory bowel disease (IBD) is unknown. We aim to describe the natural course of pancreatic cysts in IBD and evaluate long-term outcomes.

METHODS

A database of patients with abdominal imaging diagnosis of pancreatic cysts (2008-2019) was reviewed. Patients with IBD and pancreatic cysts (study group) and pancreatic cysts without IBD (controls) were selected. Outcomes were measured at 1, 3, 5, and 10 years. Several logistic regression models were used for analysis.

RESULTS

Of the 1789 patients evaluated, 1690 had pancreatic cysts without IBD, and 78 had IBD and pancreatic cysts. Majority of cysts were intraductal papillary mucinous neoplasms. Patients with IBD and pancreatic cysts were more likely to be diagnosed with pancreatic cysts at a younger age (P < 0.001) and were more likely to undergo surgical intervention at a younger age (P < 0.001).

CONCLUSIONS

This is the first study to evaluate the natural course of pancreatic cysts in IBD patients. Patients with IBD were more likely to have pancreatic cysts detected at a younger age. Despite the early presentation, there were no differences in long-term outcomes. Patients with IBD with pancreatic cysts should be managed similarly to those without IBD.

Current Evidence in the Management of Premalignant Cystic Lesions of the Pancreas in Patients Undergoing Liver Transplantation

ABSTRACT

Incidental premalignant pancreatic cystic lesions (pPCLs) are increasingly being detected in patients undergoing orthotopic liver transplantation (OLT). The impact of chronic immunosuppression upon pPCLs may elevate risk of progression to pancreatic cancer. This systematic review assesses prevalence, outcome, and management of pPCLs in patients undergoing OLT. Systematic literature searches were performed in accordance with Cochrane review guidelines. Data on 658 patients were identified from 13 articles. Median age was 59 years with a prevalence of 6.2%. Most studies focused on branch-duct intraductal papillary mucinous neoplasms. Average cyst size at diagnosis was 10.3 mm. Six patients (0.9%) underwent pancreatic resection, post-OLT, for suspected "worrisome features" on imaging. One death was due to pancreatic-related cancer, post-OLT. Based on the review, the authors suggest the following: (1) patients with pPCLs undergoing OLT, without "worrisome features," should be followed conservatively; (2) presence of pPCLs alone should not preclude eligibility for OLT, nor should chronic immunosuppression be altered; (3) follow-up should parallel standard approach applied in immunocompetent patients, as development of "worrisome features" of cancer is rare and does not appear to be hastened by immunosuppression; (4) resection is recommended for surgically fit patients without portal hypertension that develop "worrisome features."

A 3-Decade Analysis of Pancreatic Adenocarcinoma After Solid Organ Transplant

OBJECTIVE

Solid organ transplant (SOT) recipients have moderately increased risk of pancreatic adenocarcinoma (PAC). We evaluated the incidence and survival of PAC in 2 cohorts and aimed to identify potential risk factors.

METHODS

This study performed a retrospective cohort analysis. Cohort A was extracted from the United Network of Organ Sharing data set and cohort B from SOT recipients evaluated at 3 Mayo Clinic transplant centers. The primary outcome was age-adjusted annual incidence of PAC. Descriptive statistics, hazard ratios, and survival rates were compared.

RESULTS

Cohort A and cohort B included 617,042 and 29,472 SOT recipients, respectively. In cohort A, the annual incidence rate was 12.78 per 100,000 in kidney-pancreas, 13.34 in liver, and 21.87 in heart-lung transplant recipients. Receiving heart-lung transplant, 50 years or older, and history of cancer (in either recipient or donor) were independent factors associated with PAC. Fifty-two patients developed PAC in cohort B. Despite earlier diagnosis (21.15% with stage I-II), survival rates were similar to those reported for sporadic (non-SOT) patients.

CONCLUSIONS

We report demographic and clinical risk factors for PAC after SOT, many of which were present before transplant and are common to sporadic pancreatic cancer. Despite the diagnosis at earlier stages, PAC in SOT portends a very poor survival.

European evidence-based guidelines on pancreatic cystic neoplasms

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.