1
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Zamir E, Zelnik Yovel D, Scapa E, Shnell M, Bar N, Bar Yishay I, Ziv-Baran T, Younis F, Phillips A, Lubezky N, Shibolet O, Ben-Ami Shor D. Pancreatic cyst fluid glucose: a rapid on-site diagnostic test for mucinous cysts. Therap Adv Gastroenterol 2022; 15:17562848221133581. [PMID: 36353735 PMCID: PMC9638530 DOI: 10.1177/17562848221133581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Pancreatic cystic fluid (PCF) analysis is frequently used for cyst diagnosis with carcinoembryonic antigen (CEA) being the most accepted biomarker. Low glucose levels in PCF were previously suggested as a marker for mucinous cysts. A bed-side glucometer is a point-of care, immediate, simple, and cheap method which requires a small volume of PCF. OBJECTIVES The aim of our study was to identify the optimal glucose cut-off level for identifying mucinous cysts, evaluate the diagnostic accuracy of glucose compared to CEA, and validate glucometry against reference laboratory biochemical analysis. DESIGN A single-center prospective cohort study. METHODS Consecutive patients aged 18 and older, who underwent pancreatic cyst evaluation, at the Tel Aviv Medical Center between 2016 and 2021 were analyzed. Cyst type was defined based on clinical, laboratory, and radiologic findings. Glucose was measured using laboratory biochemical analysis and two glucometers. Receiver operating characteristic analysis derived sensitivity, specificity, and accuracy were calculated and McNemar test was used to compare between methods. RESULTS One hundred and one PCF samples were evaluated. The areas under the receiver operating characteristics curve for identifying mucinous cysts using glucometer, glucose laboratory, and their combination were 0.88 (p < 0.001), 0.92 (p < 0.001), and 0.93 (p < 0.001), respectively. A glucose level of 87 mg/dL was identified as the optimal laboratory glucose threshold value to detect mucinous cyst with a sensitivity of 90.9%, specificity of 83.3%, and accuracy of 89.3, higher in comparison to cyst fluid CEA. Furthermore, PCF glucose levels had the strongest association with mucinous cysts. CONCLUSION Our findings suggest that PCF glucose level is more accurate than CEA for the diagnosis of mucinous cysts. Glucometry glucose level assessment demonstrated an excellent correlation with laboratory glucose measurements and may become a useful diagnostic test.
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Affiliation(s)
| | - Dana Zelnik Yovel
- Sackler Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel,The Kamila Gonczarowski Institute of
Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center,
Zerifin, Israel
| | - Erez Scapa
- Sackler Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel,Gastroenterology and Liver Disease, Tel Aviv
Sourasky Medical Center, Tel Aviv, Israel
| | - Mati Shnell
- Sackler Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel,Gastroenterology and Liver Disease, Tel Aviv
Sourasky Medical Center, Tel Aviv, Israel
| | - Nir Bar
- Sackler Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel,Gastroenterology and Liver Disease, Tel Aviv
Sourasky Medical Center, Tel Aviv, Israel
| | - Iddo Bar Yishay
- Sackler Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel,Gastroenterology and Liver Disease, Tel Aviv
Sourasky Medical Center, Tel Aviv, Israel
| | - Tomer Ziv-Baran
- School of Public Health, Sackler Faculty of
Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Fadi Younis
- Sackler Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel,Gastroenterology and Liver Disease, Tel Aviv
Sourasky Medical Center, Tel Aviv, Israel
| | - Adam Phillips
- Sackler Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel,Gastroenterology and Liver Disease, Tel Aviv
Sourasky Medical Center, Tel Aviv, Israel
| | - Nir Lubezky
- Sackler Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel,Unit of Liver Surgery, Department of Surgery,
Tel Aviv Medical Center, Tel Aviv, Israel
| | - Oren Shibolet
- Sackler Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel,Gastroenterology and Liver Disease, Tel Aviv
Sourasky Medical Center, Tel Aviv, Israel
| | - Dana Ben-Ami Shor
- Sackler Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel,Gastroenterology and Liver Disease, Tel Aviv
Sourasky Medical Center, Tel Aviv, Israel
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2
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Hu F, Hu Y, Wang D, Ma X, Yue Y, Tang W, Liu W, Wu P, Peng W, Tong T. Cystic Neoplasms of the Pancreas: Differential Diagnosis and Radiology Correlation. Front Oncol 2022; 12:860740. [PMID: 35299739 PMCID: PMC8921498 DOI: 10.3389/fonc.2022.860740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/04/2022] [Indexed: 12/18/2022] Open
Abstract
Although the probability of pancreatic cystic neoplasms (PCNs) being detected is raising year by year, their differential diagnosis and individualized treatment are still a challenge in clinical work. PCNs are tumors containing cystic components with different biological behaviors, and their clinical manifestations, epidemiology, imaging features, and malignant risks are different. Some are benign [e.g., serous cystic neoplasms (SCNs)], with a barely possible that turning into malignant, while others display a low or higher malignant risk [e.g., solid pseudopapillary neoplasms (SPNs), intraductal papillary mucinous neoplasms (IPMNs), and mucinous cystic neoplasms (MCNs)]. PCN management should concentrate on preventing the progression of malignant tumors while preventing complications caused by unnecessary surgical intervention. Clinically, various advanced imaging equipment are usually combined to obtain a more reliable preoperative diagnosis. The challenge for clinicians and radiologists is how to accurately diagnose PCNs before surgery so that corresponding surgical methods and follow-up strategies can be developed or not, as appropriate. The objective of this review is to sum up the clinical features, imaging findings and management of the most common PCNs according to the classic literature and latest guidelines.
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Affiliation(s)
- Feixiang Hu
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yue Hu
- Hefei Cancer Hospital, Chinese Academy of Sciences (CAS), Hefei, China
| | - Dan Wang
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai, China
| | - Xiaowen Ma
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yali Yue
- Children's Hospital, Fudan University, Shanghai, China
| | - Wei Tang
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wei Liu
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Puye Wu
- General Electric (GE) Healthcare, Shanghai, China
| | - Weijun Peng
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Tong Tong
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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3
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Duvvuri A, Bandla H, Thoguluva VC, Dasari C, Desai M, Nutalapati V, Moole V, Anvesh N, Harsh P, Gress F, Sharma P, Kohli DR. Comparing accuracy of high-risk features for detecting advanced neoplasia in pancreatic cystic lesions: a systematic review and meta-analysis. Ann Gastroenterol 2021; 34:743-750. [PMID: 34475747 PMCID: PMC8375658 DOI: 10.20524/aog.2021.0630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 02/24/2021] [Indexed: 11/11/2022] Open
Abstract
Background The American Gastroenterological Association recommends endoscopic ultrasound (EUS) for evaluating pancreatic cystic lesions (PCL) with ≥2 high-risk features (HRF), whereas the American College of Gastroenterology recommends EUS for ≥1 HRF. This systematic review and meta-analysis compared the diagnostic accuracy of using ≥1 vs. ≥2 HRF for assessing the risk of advanced neoplasia (AN) and performing EUS in PCL. Methods An electronic database search was performed for eligible studies. AN was defined as pancreatic adenocarcinoma, intraductal papillary mucinous neoplasm or mucinous cystadenoma with high-grade dysplasia, pancreatic intraepithelial neoplasia and pancreatic neuroendocrine tumors. HRF included cyst size ≥3 cm, solid component, and dilated pancreatic duct ≥5 mm. The primary outcome was the sensitivity and specificity of using ≥1 vs. ≥2 HRF as an indication for EUS to detect AN in PCL. Results Of 38 studies initially screened, 8 were included in the final analysis. Seven studies assessed the accuracy of ≥2 HRF and 4 studies assessed ≥1 HRF. The pooled sensitivity, specificity, positive and negative predictive values of EUS for detecting AN were 41.7% (95% confidence interval 19.5-67.8%), 90.8% (81.9-95.5%), 30.4% (19.4-44.2%) and 94.3% (89.6-97.0%) with ≥2HRFs, and 77.1% (66.1-85.3%), 72.7% (50.4-87.5%), 17.95% (10.3-29.4%), 98.1% (90.8-99.6%), respectively, with ≥1 HRF. Conclusion Performing EUS for PCL with ≥1 HRF could offer greater sensitivity in detecting AN compared to ≥2 HRF, with a similar negative predictive value.
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Affiliation(s)
- Abhiram Duvvuri
- Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, MO (Abhiram Duvvuri, Vivek Chandrasekar Thoguluva, Chandra Dasari, Madhav Desai, Venkat Nutalapati, Prateek Sharma, Divyanshoo Rai Kohli).,Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS (Abhiram Duvvuri, Vivek Chandrasekar Thoguluva, Madhav Desai, Venkat Nutalapati, Patel Harsh)
| | - Harikrishna Bandla
- Saint Peter's University Hospitals, New Brunswick, NJ (Harikrishna Bandla)
| | - Vivek Chandrasekar Thoguluva
- Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, MO (Abhiram Duvvuri, Vivek Chandrasekar Thoguluva, Chandra Dasari, Madhav Desai, Venkat Nutalapati, Prateek Sharma, Divyanshoo Rai Kohli).,Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS (Abhiram Duvvuri, Vivek Chandrasekar Thoguluva, Madhav Desai, Venkat Nutalapati, Patel Harsh)
| | - Chandra Dasari
- Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, MO (Abhiram Duvvuri, Vivek Chandrasekar Thoguluva, Chandra Dasari, Madhav Desai, Venkat Nutalapati, Prateek Sharma, Divyanshoo Rai Kohli)
| | - Madhav Desai
- Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, MO (Abhiram Duvvuri, Vivek Chandrasekar Thoguluva, Chandra Dasari, Madhav Desai, Venkat Nutalapati, Prateek Sharma, Divyanshoo Rai Kohli).,Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS (Abhiram Duvvuri, Vivek Chandrasekar Thoguluva, Madhav Desai, Venkat Nutalapati, Patel Harsh)
| | - Venkat Nutalapati
- Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, MO (Abhiram Duvvuri, Vivek Chandrasekar Thoguluva, Chandra Dasari, Madhav Desai, Venkat Nutalapati, Prateek Sharma, Divyanshoo Rai Kohli).,Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS (Abhiram Duvvuri, Vivek Chandrasekar Thoguluva, Madhav Desai, Venkat Nutalapati, Patel Harsh)
| | - Vishnu Moole
- University of Illinois College of Medicine, Peoria, IL (Vishnu Moole)
| | - Narimiti Anvesh
- Saint Vincent Hospital, Worcester, MA (Narimiti Anvesh), USA
| | - Patel Harsh
- Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, KS (Abhiram Duvvuri, Vivek Chandrasekar Thoguluva, Madhav Desai, Venkat Nutalapati, Patel Harsh)
| | - Frank Gress
- Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY (Frank Gress)
| | - Prateek Sharma
- Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, MO (Abhiram Duvvuri, Vivek Chandrasekar Thoguluva, Chandra Dasari, Madhav Desai, Venkat Nutalapati, Prateek Sharma, Divyanshoo Rai Kohli)
| | - Divyanshoo Rai Kohli
- Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, MO (Abhiram Duvvuri, Vivek Chandrasekar Thoguluva, Chandra Dasari, Madhav Desai, Venkat Nutalapati, Prateek Sharma, Divyanshoo Rai Kohli)
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4
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Pan S, Brand RE, Lai LA, Dawson DW, Donahue TR, Kim S, Khalaf NI, Othman MO, Fisher WE, Bronner MP, Simeone DM, Brentnall TA, Chen R. Proteome heterogeneity and malignancy detection in pancreatic cyst fluids. Clin Transl Med 2021; 11:e506. [PMID: 34459141 PMCID: PMC8382978 DOI: 10.1002/ctm2.506] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/08/2021] [Accepted: 07/12/2021] [Indexed: 01/12/2023] Open
Affiliation(s)
- Sheng Pan
- The Brown Foundation Institute of Molecular MedicineUniversity of Texas Health Science Center at HoustonHoustonTexasUSA,Department of Integrative Biology and PharmacologyMcGovern Medical SchoolUniversity of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Randall E. Brand
- Department of MedicineUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Lisa A. Lai
- Division of GastroenterologyDepartment of Medicinethe University of WashingtonSeattleWashingtonUSA
| | - David W. Dawson
- Department of Pathology and Laboratory MedicineDavid Geffen School of Medicine, UCLALos AngelesCaliforniaUSA,Jonsson Comprehensive Cancer CenterDavid Geffen School of Medicine, UCLALos AngelesCaliforniaUSA
| | - Timothy R. Donahue
- Jonsson Comprehensive Cancer CenterDavid Geffen School of Medicine, UCLALos AngelesCaliforniaUSA,Department of SurgeryDavid Geffen School of Medicine, UCLALos AngelesCaliforniaUSA
| | - Stephen Kim
- Division of Digestive DiseasesDavid Geffen School of Medicine, UCLALos AngelesCaliforniaUSA
| | - Natalia I. Khalaf
- Section of Gastroenterology and HepatologyDepartment of MedicineBaylor College of MedicineHoustonTexasUSA
| | - Mohamed O. Othman
- Section of Gastroenterology and HepatologyDepartment of MedicineBaylor College of MedicineHoustonTexasUSA
| | | | - Mary P. Bronner
- Department of PathologyUniversity of UtahSalt Lake CityUtahUSA
| | - Diane M. Simeone
- Department of SurgeryNew York UniversityNew YorkNew YorkUSA,Perlmutter Cancer CenterNew York UniversityNew YorkNew YorkUSA
| | - Teresa A. Brentnall
- Division of GastroenterologyDepartment of Medicinethe University of WashingtonSeattleWashingtonUSA
| | - Ru Chen
- Section of Gastroenterology and HepatologyDepartment of MedicineBaylor College of MedicineHoustonTexasUSA
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5
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Sidhu H, Maher S, Bleszynski MS, Chen L, Farnell D, Gan I, Segedi M. Determining when endoscopic ultrasound changes management for patients with pancreatic cystic neoplasms. Am J Surg 2020; 221:813-818. [PMID: 32334802 DOI: 10.1016/j.amjsurg.2020.03.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Pancreatic cystic neoplasms (PCNs) are being incidentally detected at an increased rate due to increased CT and MRI usage. EUS is an emerging tool that can differentiate between benign and malignant features of pancreatic cysts. We hoped to identify the specific cross-sectional imaging findings and patient characteristics that warrant EUS referral. METHODS We conducted a retrospective case-control chart review, evaluating patients, who were diagnosed with pancreatic cysts and underwent EUS between January 1, 2010 and December 31, 2017. RESULTS EUS was found to change management when CT imaging found cyst size > 4 cm (OR = 4.07, p < 0.01), cyst size > 3 cm (OR = 3.79, p < 0.001) and associated solid component to the cyst (OR = 5.95, p < 0.01). Additionally, patient characteristics, including age less than 50 years, male sex and 10-pack year smoking history were significantly associated with EUS change in management. DISCUSSION Our findings suggest that EUS referral should be coordinated based on the findings of specific HRFs, with support from high risk patient characteristics, rather than the accumulation of multiple HRFs, as suggested by existing guidelines.
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Affiliation(s)
- Hasrit Sidhu
- University of British Columbia, 2329, West Mall, Vancouver, BC, V6T 1Z4, Canada.
| | - Safia Maher
- University of British Columbia, 2329, West Mall, Vancouver, BC, V6T 1Z4, Canada.
| | - Michael S Bleszynski
- University of British Columbia, 2329, West Mall, Vancouver, BC, V6T 1Z4, Canada.
| | - Leo Chen
- University of British Columbia, 2329, West Mall, Vancouver, BC, V6T 1Z4, Canada.
| | - Dave Farnell
- University of British Columbia, 2329, West Mall, Vancouver, BC, V6T 1Z4, Canada.
| | - Ian Gan
- University of British Columbia, 2329, West Mall, Vancouver, BC, V6T 1Z4, Canada.
| | - Maja Segedi
- University of British Columbia, 2329, West Mall, Vancouver, BC, V6T 1Z4, Canada.
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6
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New guidelines for use of endoscopic ultrasound for evaluation and risk stratification of pancreatic cystic lesions may be too conservative. Surg Endosc 2017; 32:2420-2426. [PMID: 29288277 DOI: 10.1007/s00464-017-5941-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/17/2017] [Indexed: 12/11/2022]
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7
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Basar O, Brugge WR. My Treatment Approach: Pancreatic Cysts. Mayo Clin Proc 2017; 92:1519-1531. [PMID: 28890216 DOI: 10.1016/j.mayocp.2017.06.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/21/2017] [Accepted: 06/06/2017] [Indexed: 12/12/2022]
Abstract
Our treatment approach for either symptomatic or incidentally found pancreatic cysts continues to improve. The true incidence of pancreatic cysts is not known, and pancreatic cystic neoplasms, especially intraductal papillary mucinous neoplasms, are currently most commonly diagnosed and resected. This is a result of increasing awareness, widespread availability of imaging, and better understanding of the nature of pancreatic cysts as well. Recent studies on molecular analysis and devices such as microbiopsy forceps help us better define and select the treatment approach to alleviate symptoms and to prevent malignant tumors while avoiding unnecessary surgery.
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Affiliation(s)
- Omer Basar
- Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA.
| | - William R Brugge
- Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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8
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Best LMJ, Rawji V, Pereira SP, Davidson BR, Gurusamy KS. Imaging modalities for characterising focal pancreatic lesions. Cochrane Database Syst Rev 2017; 4:CD010213. [PMID: 28415140 PMCID: PMC6478242 DOI: 10.1002/14651858.cd010213.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Increasing numbers of incidental pancreatic lesions are being detected each year. Accurate characterisation of pancreatic lesions into benign, precancerous, and cancer masses is crucial in deciding whether to use treatment or surveillance. Distinguishing benign lesions from precancerous and cancerous lesions can prevent patients from undergoing unnecessary major surgery. Despite the importance of accurately classifying pancreatic lesions, there is no clear algorithm for management of focal pancreatic lesions. OBJECTIVES To determine and compare the diagnostic accuracy of various imaging modalities in detecting cancerous and precancerous lesions in people with focal pancreatic lesions. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase, and Science Citation Index until 19 July 2016. We searched the references of included studies to identify further studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. SELECTION CRITERIA We planned to include studies reporting cross-sectional information on the index test (CT (computed tomography), MRI (magnetic resonance imaging), PET (positron emission tomography), EUS (endoscopic ultrasound), EUS elastography, and EUS-guided biopsy or FNA (fine-needle aspiration)) and reference standard (confirmation of the nature of the lesion was obtained by histopathological examination of the entire lesion by surgical excision, or histopathological examination for confirmation of precancer or cancer by biopsy and clinical follow-up of at least six months in people with negative index tests) in people with pancreatic lesions irrespective of language or publication status or whether the data were collected prospectively or retrospectively. DATA COLLECTION AND ANALYSIS Two review authors independently searched the references to identify relevant studies and extracted the data. We planned to use the bivariate analysis to calculate the summary sensitivity and specificity with their 95% confidence intervals and the hierarchical summary receiver operating characteristic (HSROC) to compare the tests and assess heterogeneity, but used simpler models (such as univariate random-effects model and univariate fixed-effect model) for combining studies when appropriate because of the sparse data. We were unable to compare the diagnostic performance of the tests using formal statistical methods because of sparse data. MAIN RESULTS We included 54 studies involving a total of 3,196 participants evaluating the diagnostic accuracy of various index tests. In these 54 studies, eight different target conditions were identified with different final diagnoses constituting benign, precancerous, and cancerous lesions. None of the studies was of high methodological quality. None of the comparisons in which single studies were included was of sufficiently high methodological quality to warrant highlighting of the results. For differentiation of cancerous lesions from benign or precancerous lesions, we identified only one study per index test. The second analysis, of studies differentiating cancerous versus benign lesions, provided three tests in which meta-analysis could be performed. The sensitivities and specificities for diagnosing cancer were: EUS-FNA: sensitivity 0.79 (95% confidence interval (CI) 0.07 to 1.00), specificity 1.00 (95% CI 0.91 to 1.00); EUS: sensitivity 0.95 (95% CI 0.84 to 0.99), specificity 0.53 (95% CI 0.31 to 0.74); PET: sensitivity 0.92 (95% CI 0.80 to 0.97), specificity 0.65 (95% CI 0.39 to 0.84). The third analysis, of studies differentiating precancerous or cancerous lesions from benign lesions, only provided one test (EUS-FNA) in which meta-analysis was performed. EUS-FNA had moderate sensitivity for diagnosing precancerous or cancerous lesions (sensitivity 0.73 (95% CI 0.01 to 1.00) and high specificity 0.94 (95% CI 0.15 to 1.00), the extremely wide confidence intervals reflecting the heterogeneity between the studies). The fourth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (dysplasia) provided three tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing invasive carcinoma were: CT: sensitivity 0.72 (95% CI 0.50 to 0.87), specificity 0.92 (95% CI 0.81 to 0.97); EUS: sensitivity 0.78 (95% CI 0.44 to 0.94), specificity 0.91 (95% CI 0.61 to 0.98); EUS-FNA: sensitivity 0.66 (95% CI 0.03 to 0.99), specificity 0.92 (95% CI 0.73 to 0.98). The fifth analysis, of studies differentiating cancerous (high-grade dysplasia or invasive carcinoma) versus precancerous (low- or intermediate-grade dysplasia) provided six tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing cancer (high-grade dysplasia or invasive carcinoma) were: CT: sensitivity 0.87 (95% CI 0.00 to 1.00), specificity 0.96 (95% CI 0.00 to 1.00); EUS: sensitivity 0.86 (95% CI 0.74 to 0.92), specificity 0.91 (95% CI 0.83 to 0.96); EUS-FNA: sensitivity 0.47 (95% CI 0.24 to 0.70), specificity 0.91 (95% CI 0.32 to 1.00); EUS-FNA carcinoembryonic antigen 200 ng/mL: sensitivity 0.58 (95% CI 0.28 to 0.83), specificity 0.51 (95% CI 0.19 to 0.81); MRI: sensitivity 0.69 (95% CI 0.44 to 0.86), specificity 0.93 (95% CI 0.43 to 1.00); PET: sensitivity 0.90 (95% CI 0.79 to 0.96), specificity 0.94 (95% CI 0.81 to 0.99). The sixth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (low-grade dysplasia) provided no tests in which meta-analysis was performed. The seventh analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) provided two tests in which meta-analysis was performed. The sensitivity and specificity for diagnosing cancer were: CT: sensitivity 0.83 (95% CI 0.68 to 0.92), specificity 0.83 (95% CI 0.64 to 0.93) and MRI: sensitivity 0.80 (95% CI 0.58 to 0.92), specificity 0.81 (95% CI 0.53 to 0.95), respectively. The eighth analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) or benign lesions provided no test in which meta-analysis was performed.There were no major alterations in the subgroup analysis of cystic pancreatic focal lesions (42 studies; 2086 participants). None of the included studies evaluated EUS elastography or sequential testing. AUTHORS' CONCLUSIONS We were unable to arrive at any firm conclusions because of the differences in the way that study authors classified focal pancreatic lesions into cancerous, precancerous, and benign lesions; the inclusion of few studies with wide confidence intervals for each comparison; poor methodological quality in the studies; and heterogeneity in the estimates within comparisons.
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Affiliation(s)
- Lawrence MJ Best
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRowland Hill StreetLondonUKNW32PF
| | - Vishal Rawji
- University College London Medical SchoolLondonUK
| | - Stephen P Pereira
- Royal Free Hospital CampusUCL Institute for Liver and Digestive HealthUpper 3rd FloorLondonUKNW3 2PF
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRowland Hill StreetLondonUKNW32PF
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9
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Ali S, Bashir A. Giant mucinous cystadenoma: case report with review of literature. Gland Surg 2014; 3:207-10. [PMID: 25207214 DOI: 10.3978/j.issn.2227-684x.2014.03.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 03/04/2014] [Indexed: 11/14/2022]
Abstract
Cystic tumors of the pancreas are rare and can be confused with hydatid cyst especially in endemic areas like ours. We present a 30-year-old woman with a huge mucinous cystadenoma of the pancreas initially diagnosed and prepared on table as hydatid cyst. After incising the cyst the diagnosis of cystic tumor was considered and underwent total excision with spleen and healthy pancreatic margin. Histologically and biochemistry of fluid confirmed potentially benign mucinous cystic tumor of pancreas tumor excision after histological diagnosis. Sensitivity of radiological imaging values in differentiating between cystic pancreatic tumors and other limited. Cyst wall histology is diagnostic and biopsy of cyst wall should be done in cases with inconclusive preoperative diagnosis or questionable operative findings.
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Affiliation(s)
- Sadaf Ali
- Department of Surgical GE, SKIMS, Soura, Srinagar, Jammu and Kashmir, India
| | - Atthar Bashir
- Department of Surgical GE, SKIMS, Soura, Srinagar, Jammu and Kashmir, India
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10
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Boot C. A review of pancreatic cyst fluid analysis in the differential diagnosis of pancreatic cyst lesions. Ann Clin Biochem 2013; 51:151-66. [PMID: 24097809 DOI: 10.1177/0004563213503819] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diagnosis and management of pancreatic cyst lesions is challenging as there is currently no investigation that offers both high diagnostic sensitivity and high specificity for the identification of potentially malignant lesions. Accurate classification of these lesions is vital in order to avoid unnecessary treatment of benign lesions and missed opportunities for early treatment of lesions that are malignant/pre-malignant. Pancreatic cyst fluid analysis has an important role in diagnosis, although all currently available investigations based on fluid analysis have significant limitations. Cytological analysis can reveal features that are specific for a certain class of cyst, but offers limited sensitivity in detecting malignant/pre-malignant cysts. Measurement of tumour markers, particularly carcinoembryonic antigen can also be informative. Concentrations of cyst fluid carcinoembryonic antigen tend to be higher in malignant/pre-malignant cysts, although there is a wide overlap between the various classes of cyst. A number of studies have suggested that diagnostic carcinoembryonic antigen cut-offs can be chosen that provide a high degree of specificity but limited sensitivity. Studies of the analytical validity of tumour marker assays in pancreatic cyst fluid analysis have highlighted discrepancies in some fluid specimens, which require further investigation. DNA analysis also has a role. In particular, K-Ras-2 mutational analysis appears to provide high specificity for detection of malignant/pre-malignant lesions. A number of diagnostic algorithms have been published, integrating use of available investigations in order to achieve the optimum discrimination of benign and potentially malignant cysts. Research into new biochemical markers and optimal use of available pancreatic cyst fluid analyses is ongoing.
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Affiliation(s)
- Christopher Boot
- Clinical Laboratory Services, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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11
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Abstract
BACKGROUND The management of asymptomatic pancreatic cysts is controversial and indications for excision are based on pathology and natural history. OBJECTIVES This study aimed to examine outcomes of asymptomatic lesions using a protocol based on size and cyst fluid analysis. METHODS Asymptomatic cysts were identified from a prospectively maintained database. Sequential cross-sectional imaging studies were assessed, and results of endoscopic ultrasound-guided aspiration were co-analysed. RESULTS A total of 338 asymptomatic patients underwent evaluation. Overall, 84 cysts were <1.5 cm and 254 were ≥1.5 cm in diameter. Median patient follow-up was 5.1 years [interquartile range (IQR): 4.1-6.9 years]. In the group in which cysts measured <1.5 cm in diameter, median cyst size was 1.0 cm (IQR: 0.6-1.2 cm) at presentation and increased to 1.2 cm (IQR: 0.7-1.6 cm) during follow-up. Five (6.0%) patients underwent resection, all within 2 months of presentation. In the group in which cysts measured ≥1.5 cm in diameter, median cyst size was 2.5 cm (IQR: 2.0-3.4 cm) at presentation and increased to 2.7 cm (IQR: 3.0-4.2 cm). A total of 63 (24.8%) patients underwent resection. Surgery was performed with 2 months in 53 (84.1%) patients, within 12 months in four (6.3%) patients and at >12 months post-presentation in six (9.5%) patients. A total of 70.6% of resected specimens were identified as malignancies or mucinous lesions. CONCLUSIONS Asymptomatic cysts of <1.5 cm in diameter can safely be followed by imaging and are expected to undergo little change. A quarter of all asymptomatic cysts measuring ≥1.5 cm are appropriately resected based on imaging and cyst fluid analysis.
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Affiliation(s)
- Gareth Morris-Stiff
- Department of General Surgery, Section of Surgical Oncology and Hepatopancreatobiliary Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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12
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Samarasena JB, Nakai Y, Chang KJ. Endoscopic ultrasonography-guided fine-needle aspiration of pancreatic cystic lesions: a practical approach to diagnosis and management. Gastrointest Endosc Clin N Am 2012; 22:169-85, vii. [PMID: 22632942 DOI: 10.1016/j.giec.2012.04.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The diagnosis and management of pancreatic cystic lesions remains a challenging area in gastroenterology. Differentiating benign from premalignant or premalignant from malignant cysts is complicated by the large overlap in morphologic, chemical, and clinical characteristics. Imaging alone is insufficient to accurately characterize these lesions. Cyst aspiration and fluid analysis has therefore become a major research focus through which our ability to characterize pancreatic cystic lesions has improved, although accuracy is often still lacking. Future work with molecular analysis of cyst fluid, direct cystoscopy, and confocal laser endomicroscopy will likely further enhance the diagnostic accuracy of these lesions.
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Affiliation(s)
- Jason B Samarasena
- Division of Gastroenterology and Hepatology, H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine, 101 The City Drive, Orange, CA 92868, USA
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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.
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Affiliation(s)
- Lee Guan Lim
- Department of Gastroenterology and Hepatology, National University Health System, Singapore
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14
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The association of quality-of-life measures with malignancy and survival in patients with pancreatic pathology. Pancreas 2011; 40:1063-9. [PMID: 21785386 DOI: 10.1097/mpa.0b013e31821ad8eb] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES This study assessed whether pretreatment quality-of-life (QoL) scores could predict the presence of pancreatic malignancy and survival. METHODS Patients with pancreatic lesions completed the SF-36, containing 8 domains: physical functioning, role-physical, role-emotional, bodily pain, vitality, mental health, social functioning, and general health. Data obtained included age, sex, resectability, additional antineoplastic therapy, stage, pathology, and survival. Patients were categorized by pathology (benign vs malignant), stage (local, regional, or distant), resectability (resected vs not), survival (<1 vs >1 year), and their pretreatment QoL scores. RESULTS Of the 323 patients assessed, 210 had malignancies. In 6 of the 8 domains, patients with malignancies had lower median QoL scores compared with patients with benign lesions. Of the patients with malignancies, patients surviving at 1 year or less had lower pretreatment scores in all domains. Stage, resection, adjuvant therapy, and vitality score were independent predictors of survival. CONCLUSIONS Patients with pancreatic malignancies had lower QoL scores than patients with benign pancreatic disease. Patients with malignancies surviving at 1 year or less had lower scores, even after controlling for stage. This suggests that pretreatment QoL scores are associated with pancreatic malignancy and survival.
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15
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Barreto SG, Shukla PJ, Shrikhande SV. Tumors of the Pancreatic Body and Tail. World J Oncol 2010; 1:52-65. [PMID: 29147182 PMCID: PMC5649906 DOI: 10.4021/wjon2010.04.200w] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2010] [Indexed: 12/11/2022] Open
Abstract
Tumors of the pancreatic body and tail are uncommon. They have a propensity to present late and often attain a large size with local invasion before they produce any clinical symptoms. The current review aims at comprehensively analysing these tumors with respect to their pathology, presentation, the investigation of these tumors, and finally the latest trends in their surgical and medical management.
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Affiliation(s)
- Savio George Barreto
- Department of General and Digestive Surgery, Flinders Medical Centre, Adelaide - South Australia
| | - Parul J Shukla
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shailesh V Shrikhande
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Hospital, Mumbai, India
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16
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Lee SH. [Clinical approach to incidental pancreatic cystic lesions]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2010; 55:154-61. [PMID: 20357525 DOI: 10.4166/kjg.2010.55.3.154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Cystic lesions of the pancreas are being incidentally recognized with increasing frequency and become a common finding in clinical practice. Despite of recent remarkable advances of radiological and endoscopic assessment and a better understanding of natural history of certain subgroups of cystic lesions, differentiating among lesions and making an optimal management plan is still challenging. A multimodal approach should be performed to evaluate incidentally detected cystic lesions. Emerging evidence supports selective nonoperative management for the majority of patients with cystic lesions, but, for those in whom a suspicion of malignancy remains, surgery is indicated. Concerning long-term follow-up, there is limited data to support the ideal modality, intensity, and duration. Therefore, evidence-based guidelines for the diagnosis, management, and follow-up of cystic lesions of the pancreas should be established.
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Affiliation(s)
- Sang Hyub Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Bundang-gu, Seongnam, Korea.
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17
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Das A, Ngamruengphong S, Nagendra S, Chak A. Asymptomatic pancreatic cystic neoplasm: a cost-effectiveness analysis of different strategies of management. Gastrointest Endosc 2009; 70:690-699.e6. [PMID: 19647240 DOI: 10.1016/j.gie.2009.02.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 02/07/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Optimal management of asymptomatic pancreatic cystic neoplasm is not known. OBJECTIVE In a decision analysis, the cost-effectiveness of different strategies for managing solitary, asymptomatic pancreatic cystic neoplasm were compared. INTERVENTION Three strategies were examined in a Markov model with a third-party-payer perspective. In strategy I, the natural history of the lesion was followed without any specific intervention. In strategy II, an aggressive surgical approach was considered in that all patients were considered for resection. In strategy III, an initial EUS-guided FNA with cyst fluid analysis was performed for risk stratification, and patients with mucinous cysts were considered for resection. Transitional probabilities, discounted cost, and utility values to estimate quality-adjusted life years were obtained from published information. An operability risk score based on patient age, comorbidity, and size and location of the cyst was developed to estimate the probability of surgical resection. RESULTS In the baseline analysis, strategy III yielded the highest quality-adjusted life years with an acceptable incremental cost-effectiveness ratio. In a Monte Carlo analysis, the relative risk of patients developing unresectable pancreatic cancer was decreased in strategy III compared to the other strategies. Although threshold analyses identified few important parameters influencing the conclusion of the analysis, operability risk score was the critical determinant of the optimal management strategy. LIMITATIONS Indirect costs were not considered in this analysis. CONCLUSION For asymptomatic patients with incidental solitary pancreatic cystic neoplasm, a blanket policy of surgical resection for all patients cannot be justified. A strategy based on risk stratification of malignant potential by EUS-guided FNA and cyst fluid analysis is the most cost-effective strategy.
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Affiliation(s)
- Ananya Das
- Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, AZ 85259, USA.
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18
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Kim E, Telford JJ. Endoscopic ultrasound advances, part 1: diagnosis. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 23:594-601. [PMID: 19816621 PMCID: PMC2776547 DOI: 10.1155/2009/876057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2009] [Accepted: 07/27/2009] [Indexed: 12/17/2022]
Affiliation(s)
- Edward Kim
- Division of Internal Medicine, University of British Columbia
| | - Jennifer J Telford
- Division of Gastroenterology, St Paul’s Hospital, Vancouver, British Columbia
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19
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Stutchfield BM, Joseph S, Duckworth AD, Garden OJ, Parks RW. Distal pancreatectomy: what is the standard for laparoscopic surgery? HPB (Oxford) 2009; 11:210-4. [PMID: 19590649 PMCID: PMC2697890 DOI: 10.1111/j.1477-2574.2009.00008.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2008] [Accepted: 09/11/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIMS Distal pancreatectomy (DP) is performed for a range of benign and malignant lesions. Accurate pre-operative diagnosis can be unreliable and morbidity remains high. This study evaluates a 12-year, single-centre experience with open DP to review indications, diagnoses and associated morbidity. METHODS Retrospective review of patients who underwent DP at a UK-based tertiary referral centre between 1994 and 2006. RESULTS Sixty-five patients (mean age 49.9 years) had final diagnoses of chronic pancreatitis +/- pseudocyst (n= 22), benign cystadenoma (n= 15), neuroendocrine tumour (n= 8), primary pancreatic carcinoma (n= 6) and 14 other conditions. DP performed for presumed cystic neoplasm (n= 24) revealed a correct pre-operative diagnosis in 71% of patients. Histological examination confirmed that 59% of resected cystic tumours were either malignant or had malignant potential. When DP was undertaken for presumed pseudocyst (n= 12), 83% of cases were correctly diagnosed pre-operatively. Overall mortality and morbidity rates were 3% and 39%, respectively, with five patients (8%) developing a clinically significant pancreatic fistula. Ten (17%) patients developed diabetes mellitus and nine (14%) required long-term pancreatic exocrine supplementation. CONCLUSIONS Open DP can be performed with acceptable morbidity, low mortality and preservation of pancreatic function in the majority of cases, setting the standard for laparoscopic techniques.
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Affiliation(s)
- Benjamin M Stutchfield
- Department of Clinical and Surgical Sciences (Surgery), Royal Infirmary of Edinburgh, Edinburgh, UK.
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20
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Choi JY, Lee JM, Lee MW, Kim SJ, Choi SY, Kim JY, Han JK, Choi BI. Magnetic resonance pancreatography: comparison of two- and three-dimensional sequences for assessment of intraductal papillary mucinous neoplasm of the pancreas. Eur Radiol 2009; 19:2163-70. [PMID: 19381643 DOI: 10.1007/s00330-009-1391-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2008] [Revised: 12/17/2008] [Accepted: 01/24/2009] [Indexed: 12/17/2022]
Abstract
The purpose was to compare two-dimensional (2D) magnetic resonance pancreatography (MRP) with 3D MRP to evaluate intraductal papillary mucinous neoplasm (IPMN). Thirty-four patients (22 men, 12 women; age range, 45-80 years) with IPMN (n = 40) were examined with MRP on 2D and 3D sequences. Two readers independently reviewed the images to assess the overall image quality, artifacts, lesion location, communication with main pancreatic duct, and potential for malignancy. The readers assigned their confidence level (1-5) for predicting ductal communication of the lesion. The results of MRP were compared with endoscopic retrograde pancreatography and surgical and histopathologic findings. Studies obtained with 3D MRP were of significantly higher technical quality than those obtained with 2D MRP. Although 3D MRP showed higher area under the ROC curve (Az) values for predicting ductal communication of the lesion, there was no statistical significance between Az values of 2D and 3D MRP (Az for 2D = 0.821, 0.864 for readers 1 and 2, respectively, and Az for 3D= 0.964, 0.921). Accuracies for discriminating benign from malignant lesions were 70 and 67.5% (reader 1 and 2, respectively, for 2D) and 62.5 and 80.1% (3D). 3D MRP showed superior image quality to that of 2D MRP but did not increase the diagnostic accuracy for predicting ductal communication of the lesion.
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Affiliation(s)
- Jin-Young Choi
- Department of Radiology, Research Institute of Radiological Science, Yonsei University Health System, Seodaemun-ku Shinchon-dong 134, Seoul 120-752, Korea
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21
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22
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Brugge WR. Management and outcomes of pancreatic cystic lesions. Dig Liver Dis 2008; 40:854-9. [PMID: 18502709 DOI: 10.1016/j.dld.2008.03.023] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2008] [Accepted: 03/31/2008] [Indexed: 12/11/2022]
Abstract
The management of pancreatic cystic lesions offers a challenge to clinicians. Mucinous cystic lesions pose a low risk of the development of neoplasia that must be taken into account in long-term management. Although the natural history has not been well defined, it is likely that malignant change in the mucinous epithelium takes place over years, very similar to what is observed with Barrett's esophagus. The traditional therapy of mucinous cystic lesions has been surgical resection. Lesions in the head of the pancreas will require a Whipple resection whereas tail lesions are managed with a distal pancreatectomy and splenectomy. In patients at high risk for surgical resection, the risk/benefit ratio may be excessively high, not supporting the use of resection therapy. Ethanol ablation therapy has been thoroughly studied in hepatic, renal, and thyroid cysts. Epithelial ablation with ethanol appears to be highly effective and relatively safe. Recently, ethanol ablation has been evaluated in pancreatic cystic neoplasms. In macrocystic lesions between 1 and 5 cm, ethanol lavage will result in epithelial ablation and cyst resolution in a high percentage of patients. Pancreatitis is rarely observed clinically and is not present in resection specimens. A randomised prospective clinical trial is currently underway.
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Affiliation(s)
- W R Brugge
- GI Unit Blake 4, Massachusetts General Hospital, Boston, MA, United States.
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23
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Navarro S, Amador J, Argüello L, Ayuso C, Boadas J, de Las Heras G, Farré A, Fernández-Cruz L, Ginés A, Guarner L, López Serrano A, Llach J, Lluis F, de Madaria E, Martínez J, Mato R, Molero X, Oms L, Pérez-Mateo M, Vaquero E. [Recommendations of the Spanish Biliopancreatic Club for the Treatment of Acute Pancreatitis. Consensus development conference]. GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:366-87. [PMID: 18570814 DOI: 10.1157/13123605] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Salvador Navarro
- Servicio de Gastroenterología, Institut de Malalties Digestives i Metabóliques, Hospital Clínic, Barcelona, Spain.
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Das A, Wells CD, Nguyen CC. Incidental cystic neoplasms of pancreas: what is the optimal interval of imaging surveillance? Am J Gastroenterol 2008; 103:1657-62. [PMID: 18564119 DOI: 10.1111/j.1572-0241.2008.01893.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The optimal interval of imaging studies for surveillance of incidental pancreatic cystic neoplasms is not known. OBJECTIVE A retrospective analysis of longitudinal medical records of patients with pancreatic cystic neoplasms was performed to examine the natural history of incidentally detected cystic pancreatic neoplasms with respect to the development of significant growth and to identify predictors of such growth. RESULTS After excluding patients with small (<10 mm) cysts (N = 144) and inadequate clinical follow-up of less than 6 months (N = 79) and those with a clinical diagnosis of pancreatic pseudocysts, serous cystadenoma, main duct intraductal papillary mucinous neoplasm (N = 29), and neuroendocrine tumor (N = 3), in total, 166 cysts in 150 patients were available for analysis. The working diagnoses on these cysts (based on clinical, radiological features, aspiration cytology, cyst fluid analysis, and surgical pathology data when available) were mucinous cystic neoplasm in 117 and branch-type intraductal papillary mucinous neoplasm in 49. The mean standard error (SE) initial size of these cysts was 2 (0.1) cm. Over a median period of follow-up of 32 (IQR [inter-quartile range] 19-48) months, 89% of all the cysts did not show significant growth during the follow-up. In a multivariate Cox proportional hazards model, the initial size of the cystic lesion was an independent predictor of significant growth during follow-up (relative risk 1.28, 95% confidence interval [CI] 1.08-1.61, P= 0.01); the only other significant variable was the presence of intracystic or mural nodule (relative risk 38.6, 95% CI 2.3-654, P= 0.01). CONCLUSION Most incidentally detected cystic neoplasms of the pancreas did not have significant growth during follow-up. Such growth is unlikely to occur before 2 yr of the baseline evaluation, and we suggest that the optimal imaging interval during follow-up of these patients should be at 2 yr from the baseline evaluation, particularly in cystic lesions 3.0 cm or less in size and without intracystic or mural nodules.
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Affiliation(s)
- Ananya Das
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona 85259, USA
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25
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Garcea G, Ong SL, Rajesh A, Neal CP, Pollard CA, Berry DP, Dennison AR. Cystic lesions of the pancreas. A diagnostic and management dilemma. Pancreatology 2008; 8:236-51. [PMID: 18497542 DOI: 10.1159/000134279] [Citation(s) in RCA: 143] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Due to enhanced imaging modalities, pancreatic cysts are being increasingly detected, often as an incidental finding. They comprise a wide range of differing underlying pathologies from completely benign through premalignant to frankly malignant. The exact diagnostic and management pathway of these cysts remains problematic and this review attempts to provide an overview of the pathology underlying pancreatic cystic lesions and suggests appropriate methods of management. METHODS A search was undertaken with a Pubmed database to identify all English articles using the keywords 'pancreatic cysts', 'serous cystadenoma', 'intraductal papillary mucinous tumour', 'pseudocysts', 'mucinous cystic neoplasm' and 'solid pseudopapillary tumour'. RESULTS The mainstay of assessment of pancreatic cysts is cross-sectional imaging incorporating CT and MRI. Fine-needle aspiration (FNA) (often with endoscopic ultrasound) may provide valuable additional information but can lack sensitivity. Symptomatic cysts, increasing age and multilocular cysts (with a solid component and thick walls) are predictors of malignancy. A raised cyst aspirate CEA, CA 19-9 and mucin content (including abnormal cytology), if present, can accurately distinguish premalignant and malignant cysts from benign ones. CONCLUSION In summary, all patients with pancreatic cystic lesions, whether asymptomatic or symptomatic, must be thoroughly investigated to ascertain the underlying nature of the cyst. Small asymptomatic cysts (<3 cm) with no suspicious features on imaging or FNA may be safely followed up. Follow-up should continue for at least 4 years, with a repeat FNA if needed. An algorithm for the management of pancreatic cystic tumours is also suggested. and IAP.
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Affiliation(s)
- G Garcea
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK.
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Abstract
The diagnosis and management of pancreatic cystic lesions is a common problem. At least 1% of hospitalized patients at major medical centers will have a pancreatic cystic lesion on cross sectional imaging. Up to a quarter of all pancreata examined in an autopsy series contained a pancreatic cyst, 16% of which were lined by an "atypical" epithelium and 3% of which had progressed to carcinoma-in-situ (high grade dysplasia). in the past, it was thought these cystic lesions were benign, but increasing evidence points to the cystic lesions as being the origin of some pancreatic malignancies. The most important clinical tools in the diagnosis and management of pancreatic cystic lesions are cross sectional imaging, endoscopic ultrasound, and cyst fluid analysis. The most important differential diagnosis is distinguishing mucinous (pre-malignant) and non-mucinous cystic lesions. The findings of a macrocystic lesion containing viscous fluid rich in CEA are supportive of a diagnosis of a mucinous lesion. Serous lesion are the most common non-mucinous cyst and are characterized by a microcystic morphology, non-viscous fluid and a low concentration of CEA in the cyst fluid. The following document includes a description of neoplastic pancreatic cysts, a critical review of relevant diagnostic tests, and a discussion of treatment options. We have proposed a set of guidelines for the diagnosis and management of patients with neoplastic pancreatic cysts. The guidelines are based on published data backed by an analysis of the quality of the data and are designed to address the most frequent and important clinical scenarios. In addition to providing a summary of the diagnostic data, we offer diagnostic and management suggestions based on 13 common clinical problems. Although the field is rapidly evolving, a set of core principles is provided based on a balance between the risk of malignancy and the benefit of pancreatic resection.
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Affiliation(s)
- Asif Khalid
- VA Pittsburgh Health Care System & Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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27
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Abstract
OBJECTIVES Pancreatic cysts are being found with increasing frequency. Although symptomatic cysts should be resected, what to do about asymptomatic cysts is less clear. The purpose of this study was to determine threshold values to choose resection over observation for a patient with an asymptomatic pancreatic cyst. METHODS Decision analysis assesses the consequences of a decision based on occurrence probabilities. This decision analysis assessed 1 decision, to resect or observe a patient with an asymptomatic pancreatic cyst. The consequences for resection are operative mortality/no operative mortality, short-term morbidity of patients surviving the operation, benign/malignant cyst, and life expectancy after resection of malignant lesions. The probabilities are based on the extant literature. The age-specific life expectancy for benign cysts was considered the same as for the general age-specific population from the 2002 United States Life Table. Because the operative mortality, distribution of benign versus malignant cysts, and life expectancy after resection or observation for malignant cysts vary, sensitivity analysis was done to assess the threshold values of these factors when resection becomes favored over observation. RESULTS The baseline decision analysis is based on the following assumptions: 30% of lesions are malignant, operative mortality rate is 3%, and the 5-year survival rate of resected malignant cysts is 50%. Varying on age, the risk of the cystic lesion being malignant to favor resection is greater than 11.6% to 15.5%, the operative mortality rate has to be less than 7.4% to 13.8%, and the life expectancy gain by resecting, rather than observing a malignant lesion, has to be greater than 3.49 to 5.38 years. CONCLUSIONS The decision to resect must be based on the surgeon's operative mortality rate, the predicted operative mortality for the individual patient, the probability that the lesion is malignant, and the survival difference between resecting and observing malignant cystic lesions. Overall, for resection to be recommended, the physician must believe that the risk that the lesion is malignant is approximately 15% or greater, that the life expectancy gained from resection be approximately 5 years or greater, and that the surgeons' operative mortality rate be approximately 8% or less.
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Affiliation(s)
- Timothy Liao
- Division of General Surgery, Henry Ford Hospital, Detroit, MI 48202, USA
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28
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Katz DS, Friedel DM, Kho D, Georgiou N, Hines JJ. Relative Accuracy of CT and MRI for Characterization of Cystic Pancreatic Masses. AJR Am J Roentgenol 2007; 189:657-61. [PMID: 17715114 DOI: 10.2214/ajr.07.2772] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Douglas S Katz
- Department of Radiology, Winthrop-University Hospital, Mineola, NY 11501, USA
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Goh BKP, Tan YM, Chung YFA, Chow PKH, Cheow PC, Thng CH, Mesenas S, Wong WK, Ooi LLPJ. Pancreatic cysts: a proposed management algorithm based on current evidence. Am J Surg 2007; 193:749-55. [PMID: 17512290 DOI: 10.1016/j.amjsurg.2006.07.019] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2006] [Revised: 07/28/2006] [Accepted: 07/28/2006] [Indexed: 01/07/2023]
Abstract
BACKGROUND Currently, the management strategy of pancreatic cyst (PC) remains controversial because of the inability to diagnose this type of cyst accurately and the limited knowledge of its natural history. Previously, many clinicians have advocated an aggressive resectional policy. This approach is no longer appropriate, and the number of PCs detected incidentally has increased. This study reviews the present literature and attempts to provide a management algorithm of pancreatic cysts based on currently available evidence. METHODS A Medline search was conducted to identify studies investigating PC, with particular emphasis placed on studies addressing its diagnosis and management. Additional articles were obtained from the reference lists of key articles and recent reviews. COMMENTS Based on current evidence, the optimal management of PC remains an art and should be individualized based on the risk-benefit ratio of surgery, which is influenced by multiple factors, such as the patient's potential life expectancy, surgical risk; and malignant potential of the cyst. Our proposed management algorithm is based on an individual's predicted risk-benefit ratio of surgery. Prospective evaluation of the algorithm is needed to determine its integrity.
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Affiliation(s)
- Brian K P Goh
- Department of Surgery, Singapore General Hospital, Outram Road, Singapore 169608.
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30
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Abstract
Pancreatic cystic lesions are detected more frequently as a result of increasing use of high-resolution cross-sectional imaging. The ability of imaging and cyst fluid analysis to predict the biologic behavior of the lesions has aroused much interest recently. A precise diagnosis is critical to help guide further management. The diagnostic criteria and the management principles have evolved dramatically over the past 10 years with the advent of endoscopic ultrasound and fine-needle aspiration. In this review, we summarize the recent publications that have examined the key issues in the diagnosis and management of cystic lesions of the pancreas.
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Affiliation(s)
- Bhavani Moparty
- Massachusetts General Hospital, Blake 452 C, 55 Fruit Street, Boston, MA 02144, USA
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31
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Ruiz-Tovar J, de Oteyza JP, Blanco RR, Guirao MVC, García-Villanueva A. [Two exceptional cases of pancreatic tumor]. Cir Esp 2007; 81:284-7. [PMID: 17498460 DOI: 10.1016/s0009-739x(07)71321-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pancreatic cancer carries a poor prognosis. The only potentially curative treatment is surgical resection. However, this procedure can only be performed in a few cases due to presentation of the tumor in advanced stages. We present 2 exceptional cases of pancreatic cancer presentation. Case 1: A 59-year-old man presented with recurrent melena despite endoscopic sclerosis of a duodenal ulcer. A computed tomography (CT) scan revealed a 7-cm mass in the head of the pancreas infiltrating the second portion of the duodenum. Duodenal biopsy showed a poorly differentiated carcinoma. Palliative pancreatoduodenectomy was performed. Case 2: A 49-year-old man presented with sporadic pain in the right hypochondrium and a familial history of pancreatic cancer in first and second degree relatives. CT and magnetic resonance imaging revealed a 1-cm cystic lesion in the head of the pancreas. Cytology showed mucoid material and atypia. Given a probable diagnosis of mucinous cystoadenoma, pancreatoduodenectomy was performed.
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Affiliation(s)
- Jaime Ruiz-Tovar
- Servicio de Cirugía General y Digestiva (Dr. Fresneda Moreno), Hospital Universitario Ramón y Cajal, Madrid, España.
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Abstract
Pancreatic carcinoma accounts for the most dismal survival among all malignancies with 5-year survival rates approaching 5%. The reason for this, besides the inherent biologic nature of the disease, is the fact that the patients tend to present late in the disease. We present a review of the current published data on cystic neoplasms of the pancreas, which though rare, constitute an important subgroup of pancreatic neoplasms that have a better prognosis and are potentially curable lesions.
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Affiliation(s)
- George Barreto
- Department of Gastrointestinal Surgical Oncology, Tata Memorial HospitalMumbaiIndia
| | - Parul J. Shukla
- Department of Gastrointestinal Surgical Oncology, Tata Memorial HospitalMumbaiIndia
| | - Mukta Ramadwar
- Department of Gastrointestinal Surgical Oncology, Tata Memorial HospitalMumbaiIndia
| | - Supreeta Arya
- Department of Gastrointestinal Surgical Oncology, Tata Memorial HospitalMumbaiIndia
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Brugge WR. The mistletoe and cyst-fluid analysis: a sticky insight. Gastrointest Endosc 2006; 64:703-4. [PMID: 17055860 DOI: 10.1016/j.gie.2006.04.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2006] [Accepted: 04/27/2006] [Indexed: 02/08/2023]
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Abstract
PURPOSE OF REVIEW To highlight publications in the past year in the field of pancreatic surgery. RECENT FINDINGS Novel approaches to the neoadjuvant and adjuvant treatment of surgical candidates with pancreatic cancer have been reported. These new strategies may have significant impact on survival. Many studies detail the refinements of pancreatic surgery, including ways to diminish the complications of these procedures. Specific recommendations about less common pancreatic tumors including cystic tumors, endocrine tumors, and intraductal pancreatic mucinous neoplasms are included. Finally, the operative approaches to chronic pancreatitis have been studied and detailed. SUMMARY The pancreas is a complex organ manifesting many different diseases - some fatal and others chronic. Increased interest in this organ from a growing list of experts has led to a better understanding of these diseases.
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Affiliation(s)
- Oscar J Hines
- Section of Gastrointestinal Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
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Abstract
PURPOSE OF REVIEW This review serves to highlight new technology and novel applications of existing techniques and their role in the management of pancreatic diseases, including acute and chronic pancreatitis, pancreatic cancer, and pancreatic cystic neoplasms. RECENT FINDINGS Contrast-enhanced ultrasound has shown promise in evaluating the severity of acute pancreatitis, staging pancreatic cancer, and predicting malignancy in cystic neoplasms. Optical coherence tomography within the pancreatic duct appears to be able to differentiate malignant and normal pancreatic ducts. Spectroscopy may prove useful in differentiating focal chronic pancreatitis from malignancy. Multidetector-row computed tomography may provide more accurate information regarding cancer respectability and differentiation between ductal type of intraductal papillary mucinous tumors. SUMMARY These new developments will help with the diagnosis and staging of pancreatic diseases.
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Affiliation(s)
- Richard S Kwon
- Division of Gastroenterology, University of Michigan Health System, Ann Arbor, Michigan, USA.
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