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Timmaraju VA, Finkelstein SD, Levine JA. Analytical Validation of Loss of Heterozygosity and Mutation Detection in Pancreatic Fine-Needle Aspirates by Capillary Electrophoresis and Sanger Sequencing. Diagnostics (Basel) 2024; 14:514. [PMID: 38472986 DOI: 10.3390/diagnostics14050514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/15/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
Pancreatic cystic disease, including duct dilation, represents precursor states towards the development of pancreatic cancer, a form of malignancy with relatively low incidence but high mortality. While most of these cysts (>85%) are benign, the remainder can progress over time, leading to malignant transformation, invasion, and metastasis. Cytologic diagnosis is challenging, limited by the paucity or complete absence of cells representative of cystic lesions and fibrosis. Molecular analysis of fluids collected from endoscopic-guided fine-needle aspiration of pancreatic cysts and dilated duct lesions can be used to evaluate the risk of progression to malignancy. The basis for the enhanced diagnostic utility of molecular approaches is the ability to interrogate cell-free nucleic acid of the cyst/duct and/or extracellular fluid. The allelic imbalances at tumor suppressor loci and the selective oncogenic drivers are used clinically to help differentiate benign stable pancreatic cysts from those progressing toward high-grade dysplasia. Methods are discussed and used to determine the efficacy for diagnostic implementation. Here, we report the analytical validation of methods to detect causally associated molecular changes integral to the pathogenesis of pancreatic cancer from pancreatic cyst fluids.
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Lai T, Bull N, Goonawardena J, Bradshaw L, Fox A, Hassen S. Are the screening guidelines for branch duct intraductal papillary mucinous neoplasms cost-effective in an Australian setting? ANZ J Surg 2023; 93:2885-2891. [PMID: 37727043 DOI: 10.1111/ans.18697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUNDS Intraductal papillary mucinous neoplasms (IPMN) are cystic neoplasms of the pancreatic ductal system. These incidental cystic lesions are increasingly found on radiological imaging and screened for malignant transformation. The Fukuoka consensus guidelines recommend screening with computed tomography, magnetic resonance imaging or endoscopic ultrasound. Branch duct IPMN (BD-IPMN) have significantly lower malignancy and mortality rates compared to main duct IPMN. Our aim was to assess the cost-effectiveness of guideline's recommendations for BD-IPMN screening of cysts between 2 and 3 cm in an Australian context. METHODS Markov model decision analysis was used to calculate the incremental cost-effectiveness ratio (ICER) of screening. The ICER was compared to a willingness to pay (WTP) threshold of $50 000. We performed scenario analysis to examine the effect of cyst size and non-linearity of malignancy rate on ICER. Probabilistic sensitivity analyses (PSA) were performed on our input parameters. RESULTS Screening resulted in 586 quality adjusted life years gained and a net present value of $20 379 939, resulting in a base-case ICER of $34 758. After scenario analysis for non-linearity of malignancy rate the ICER increases to $64 555, which is above the WTP threshold. PSA indicates that ICER is most susceptible to the pre-test malignancy rate. CONCLUSION This cost analysis demonstrates that screening of 2-3 cm BD-IPMN according to current guidelines is unlikely to be cost-effective in an Australian context. To determine the true ICER, a cost analysis on real-world data is required.
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Affiliation(s)
- Timothy Lai
- Department of Upper GI and HPB Surgery, Eastern Health, Box Hill, Victoria, Australia
| | - Nicholas Bull
- Department of Upper GI and HPB Surgery, Eastern Health, Box Hill, Victoria, Australia
| | - Janindu Goonawardena
- Department of Upper GI and HPB Surgery, Eastern Health, Box Hill, Victoria, Australia
| | - Luke Bradshaw
- Department of Upper GI and HPB Surgery, Eastern Health, Box Hill, Victoria, Australia
| | - Adrian Fox
- Department of Upper GI and HPB Surgery, Eastern Health, Box Hill, Victoria, Australia
| | - Sayed Hassen
- Department of Upper GI and HPB Surgery, Eastern Health, Box Hill, Victoria, Australia
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Lattimore CM, Kane WJ, Subbarao S, Venitti C, Cramer CL, Turkheimer LM, Bauer TW, Turrentine FE, Zaydfudim VM. Long-term surveillance of branch-duct intraductal papillary mucinous neoplasms without worrisome or high-risk features. J Surg Oncol 2023; 128:1087-1094. [PMID: 37530526 PMCID: PMC10592219 DOI: 10.1002/jso.27414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Long-term data evaluating clinical outcomes in patients with branch-duct Intraductal papillary mucinous neoplasms (BD-IPMN) without high-risk stigmata (HRS) or worrisome features (WF) remain limited. METHODS This observational cohort study included all patients diagnosed with BD-IPMN without HRS or WF between 2003 and 2019 who were enrolled in a prospective surveillance program. Time-to-progression analysis was performed using a cumulative incidence function plot and survival analysis was conducted using Kaplan-Meier. RESULTS The median follow-up time for the 267 patient cohort was 44.5 months (interquartile range [IQR]: 24.1-72.2). Radiographic cyst growth was observed in 123 (46.1%) patients; 65 (24.3%) patients progressed to WF/HRS. Twenty-six (9.7%) patients were selected for resection during surveillance: 21 (80.8%) WF, 4 (15.4%) HRS; 1 (3.9%) transformed to mixed-duct. Of all the patients who underwent resection, 5 (19.2%) had adenocarcinoma, and 1 (3.8%) had carcinoma-in-situ. The probability of any radiographic progression was 21.3% (5-year) and 51.3% (10-year). For the entire cohort, there was 1.1% mortality secondary to pancreatic adenocarcinoma and 8.2% all-cause mortality. The 5-year overall survival rate was 91.5%, and at 10 years, 81.5%. CONCLUSION Approximately one in four patients with nonworrisome BD-IPMN have progression to WF/HRS stigmata during surveillance. However, the risk of malignant transformation remains low. Surveillance strategy remains prudent in this patient population.
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Affiliation(s)
- Courtney M. Lattimore
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - William J. Kane
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | | | | | - Christopher L. Cramer
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - Lena M. Turkheimer
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | | | - Florence E. Turrentine
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
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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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Papaefthymiou A, Johnson GJ, Maida M, Gkolfakis P, Ramai D, Facciorusso A, Arvanitakis M, Ney A, Fusai GK, Saftoiu A, Tabacelia D, Phillpotts S, Chapman MH, Webster GJ, Pereira SP. Performance and Safety of EUS Ablation Techniques for Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis. Cancers (Basel) 2023; 15:cancers15092627. [PMID: 37174092 PMCID: PMC10177078 DOI: 10.3390/cancers15092627] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/29/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Pancreatic cystic lesions (PCL) represent an increasingly diagnosed condition with significant burden to patients' lives and medical resources. Endoscopic ultrasound (EUS) ablation techniques have been utilized to treat focal pancreatic lesions. This systematic review with meta-analysis aims to assess the efficacy of EUS ablation on PCL in terms of complete or partial response and safety. METHODS A systematic search in Medline, Cochrane and Scopus databases was performed in April 2023 for studies assessing the performance of the various EUS ablation techniques. The primary outcome was complete cyst resolution, defined as cyst disappearance in follow-up imaging. Secondary outcomes included partial resolution (reduction in PCL size), and adverse events rate. A subgroup analysis was planned to evaluate the impact of the available ablation techniques (ethanol, ethanol/paclitaxel, radiofrequency ablation (RFA), and lauromacrogol) on the results. Meta-analyses using a random effects model were conducted and the results were reported as percentages with 95% confidence intervals (95%CI). RESULTS Fifteen studies (840 patients) were eligible for analysis. Complete cyst resolution after EUS ablation was achieved in 44% of cases (95%CI: 31-57; 352/767; I2 = 93.7%), and the respective partial response rate was 30% (95%CI: 20-39; 206/767; I2 = 86.1%). Adverse events were recorded in 14% (95%CI: 8-20; 164/840; I2 = 87.2%) of cases, rated as mild in 10% (95%CI: 5-15; 128/840; I2 = 86.7%), and severe in 4% (95%CI: 3-5; 36/840; I2 = 0%). The subgroup analysis for the primary outcome revealed rates of 70% (95%CI: 64-76; I2 = 42.3%) for ethanol/paclitaxel, 44% (95%CI: 33-54; I2= 0%) for lauromacrogol, 32% (95%CI: 27-36; I2 = 88.4%) for ethanol, and 13% (95%CI: 4-22; I2 = 95.8%) for RFA. Considering adverse events, the ethanol-based subgroup rated the highest percentage (16%; 95%CI: 13-20; I2 = 91.0%). CONCLUSION EUS ablation of pancreatic cysts provides acceptable rates of complete resolution and a low incidence of severe adverse events, with chemoablative agents yielding higher performance rates.
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Affiliation(s)
- Apostolis Papaefthymiou
- Pancreaticobiliary Medicine Unit, University College London Hospitals (UCLH), London NW1 2BU, UK
| | - Gavin J Johnson
- Pancreaticobiliary Medicine Unit, University College London Hospitals (UCLH), London NW1 2BU, UK
| | - Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, 93100 Caltanissetta, Italy
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, General Hospital of Nea Ionia "Konstantopoulio-Patision", 14233 Athens, Greece
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT 84132, USA
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, 37920 Foggia, Italy
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium
| | - Alexander Ney
- Institute for Liver and Digestive Health, University College London, London NW3 2PF, UK
| | - Giuseppe K Fusai
- Department of HPB Surgery and Liver Transplantation, Royal Free Hospital, London NW3 2QG, UK
| | - Adrian Saftoiu
- Research Center of Gastroenterology and Hepatology Craiova, University of Medicine and Pharmacy "Carol Davila", 4192910 Bucharest, Romania
| | - Daniela Tabacelia
- Research Center of Gastroenterology and Hepatology Craiova, University of Medicine and Pharmacy "Carol Davila", 4192910 Bucharest, Romania
| | - Simon Phillpotts
- Pancreaticobiliary Medicine Unit, University College London Hospitals (UCLH), London NW1 2BU, UK
| | - Michael H Chapman
- Pancreaticobiliary Medicine Unit, University College London Hospitals (UCLH), London NW1 2BU, UK
| | - George J Webster
- Pancreaticobiliary Medicine Unit, University College London Hospitals (UCLH), London NW1 2BU, UK
| | - Stephen P Pereira
- Pancreaticobiliary Medicine Unit, University College London Hospitals (UCLH), London NW1 2BU, UK
- Institute for Liver and Digestive Health, University College London, London NW3 2PF, UK
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Dong Z, Chen X, Cheng Z, Luo Y, He M, Chen T, Zhang Z, Qian X, Chen W. Differential diagnosis of pancreatic cystic neoplasms through a radiomics-assisted system. Front Oncol 2022; 12:941744. [PMID: 36591475 PMCID: PMC9802410 DOI: 10.3389/fonc.2022.941744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022] Open
Abstract
Pancreatic cystic neoplasms (PCNs) are a group of heterogeneous diseases with distinct prognosis. Existing differential diagnosis methods require invasive biopsy or prolonged monitoring. We sought to develop an inexpensive, non-invasive differential diagnosis system for PCNs based on radiomics features and clinical characteristics for a higher total PCN screening rate. We retrospectively analyzed computed tomography images and clinical data from 129 patients with PCN, including 47 patients with intraductal papillary mucinous neoplasms (IPMNs), 49 patients with serous cystadenomas (SCNs), and 33 patients with mucinous cystic neoplasms (MCNs). Six clinical characteristics and 944 radiomics features were tested, and nine features were finally selected for model construction using DXScore algorithm. A five-fold cross-validation algorithm and a test group were applied to verify the results. In the five-fold cross-validation section, the AUC value of our model was 0.8687, and the total accuracy rate was 74.23%, wherein the accuracy rates of IPMNs, SCNs, and MCNs were 74.26%, 78.37%, and 68.00%, respectively. In the test group, the AUC value was 0.8462 and the total accuracy rate was 73.61%. In conclusion, our research constructed an end-to-end powerful PCN differential diagnosis system based on radiomics method, which could assist decision-making in clinical practice.
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Affiliation(s)
- Zhenglin Dong
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Department of orthopedics, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiahan Chen
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Zhaorui Cheng
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuanbo Luo
- Department of Otorhinolaryngology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min He
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Tao Chen
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zijie Zhang
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,*Correspondence: Zijie Zhang, ; Xiaohua Qian, ; Wei Chen,
| | - Xiaohua Qian
- School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China,*Correspondence: Zijie Zhang, ; Xiaohua Qian, ; Wei Chen,
| | - Wei Chen
- Department of Biliary-Pancreatic Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China,*Correspondence: Zijie Zhang, ; Xiaohua Qian, ; Wei Chen,
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Keczer B, Benke M, Marjai T, Horváth M, Miheller P, Szücs Á, Harsányi L, Szijártó A, Hritz I. Quantitative Software Analysis of Endoscopic Ultrasound Images of Pancreatic Cystic Lesions. Diagnostics (Basel) 2022; 12:diagnostics12092105. [PMID: 36140506 PMCID: PMC9498186 DOI: 10.3390/diagnostics12092105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/13/2022] [Accepted: 08/26/2022] [Indexed: 11/28/2022] Open
Abstract
Endoscopic ultrasonography (EUS) is the most accurate imaging modality for the evaluation of different types of pancreatic cystic lesions. Our aim was to analyze EUS images of pancreatic cystic lesions using an image processing software. We specified the echogenicity of the lesions by measuring the gray value of pixels inside the selected areas. The images were divided into groups (serous cystic neoplasm /SCN/, intraductal papillary mucinous neoplasms and mucinous cystic neoplasms /Non-SCN/ and Pseudocyst) according to the pathology results of the lesions. Overall, 170 images were processed by the software: 81 in Non-SCN, 30 in SCN and 59 in Pseudocyst group. The mean gray value of the entire lesion in the Non-SCN group was significantly higher than in the SCN group (27.8 vs. 18.8; p < 0.0005). The area ratio in the SCN, Non-SCN and Pseudocyst groups was 57%, 39% and 61%, respectively; significantly lower in the Non-SCN group than in the SCN or Pseudocyst groups (p < 0.0005 and p < 0.0005, respectively). The lesion density was also significantly higher in the Non-SCN group compared to the SCN or Pseudocyst groups (4186.6/mm2 vs. 2833.8/mm2 vs. 2981.6/mm2; p < 0.0005 and p < 0.0005, respectively). The EUS image analysis process may have the potential to be a diagnostic tool for the evaluation and differentiation of pancreatic cystic lesions.
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Anta JA, Martínez-Ballestero I, Eiroa D, García J, Rodríguez-Comas J. Artificial intelligence for the detection of pancreatic lesions. Int J Comput Assist Radiol Surg 2022; 17:1855-1865. [PMID: 35951286 DOI: 10.1007/s11548-022-02706-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 06/17/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Pancreatic cancer is one of the most lethal neoplasms among common cancers worldwide, and PCLs are well-known precursors of this type of cancer. Artificial intelligence (AI) could help to improve and speed up the detection and classification of pancreatic lesions. The aim of this review is to summarize the articles addressing the diagnostic yield of artificial intelligence applied to medical imaging (computed tomography [CT] and/or magnetic resonance [MR]) for the detection of pancreatic cancer and pancreatic cystic lesions. METHODS We performed a comprehensive literature search using PubMed, EMBASE, and Scopus (from January 2010 to April 2021) to identify full articles evaluating the diagnostic accuracy of AI-based methods processing CT or MR images to detect pancreatic ductal adenocarcinoma (PDAC) or pancreatic cystic lesions (PCLs). RESULTS We found 20 studies meeting our inclusion criteria. Most of the AI-based systems used were convolutional neural networks. Ten studies addressed the use of AI to detect PDAC, eight studies aimed to detect and classify PCLs, and 4 aimed to predict the presence of high-grade dysplasia or cancer. CONCLUSION AI techniques have shown to be a promising tool which is expected to be helpful for most radiologists' tasks. However, methodologic concerns must be addressed, and prospective clinical studies should be carried out before implementation in clinical practice.
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Affiliation(s)
- Julia Arribas Anta
- Scientific and Technical Department, Sycai Technologies S.L., Carrer Roc Boronat 117, MediaTIC Building, 08018, Barcelona, Spain.,Department of Gastroenterology, University Hospital, 12 Octubre. Av. de Córdoba, s/n, 28041, Madrid, Spain
| | - Iván Martínez-Ballestero
- Scientific and Technical Department, Sycai Technologies S.L., Carrer Roc Boronat 117, MediaTIC Building, 08018, Barcelona, Spain
| | - Daniel Eiroa
- Scientific and Technical Department, Sycai Technologies S.L., Carrer Roc Boronat 117, MediaTIC Building, 08018, Barcelona, Spain.,Department of Radiology, Institut de Diagnòstic per la Imatge (IDI), Hospital Universitari Vall d'Hebrón, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain
| | - Javier García
- Scientific and Technical Department, Sycai Technologies S.L., Carrer Roc Boronat 117, MediaTIC Building, 08018, Barcelona, Spain
| | - Júlia Rodríguez-Comas
- Scientific and Technical Department, Sycai Technologies S.L., Carrer Roc Boronat 117, MediaTIC Building, 08018, Barcelona, Spain.
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Pancreatic Incidentaloma. J Clin Med 2022; 11:jcm11164648. [PMID: 36012893 PMCID: PMC9409921 DOI: 10.3390/jcm11164648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 11/16/2022] Open
Abstract
Pancreatic incidentalomas (PIs) represent a clinical entity increasingly recognized due to advances in and easier access to imaging techniques. By definition, PIs should be detected during abdominal imaging performed for indications other than a pancreatic disease. They range from small cysts to invasive cancer. The incidental diagnosis of pancreatic cancer can contribute to early diagnosis and treatment. On the other hand, inadequate management of PIs may result in overtreatment and unneeded morbidity. Therefore, there is a strong need to evaluate the nature and clinical features of individual PIs. In this review, we summarize the major characteristics related to PIs and present suggestions for their management.
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10
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Shields MA, Spaulding C, Metropulos AE, Khalafalla MG, Pham TND, Munshi HG. Gα13 loss in Kras/Tp53 mouse model of pancreatic tumorigenesis promotes tumors susceptible to rapamycin. Cell Rep 2022; 38:110441. [PMID: 35235808 PMCID: PMC8989626 DOI: 10.1016/j.celrep.2022.110441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/22/2021] [Accepted: 02/04/2022] [Indexed: 11/20/2022] Open
Abstract
Gα13 transduces signals from G-protein-coupled receptors. While Gα13 functions as a tumor suppressor in lymphomas, it is not known whether Gα13 is pro-tumorigenic or tumor suppressive in genetically engineered mouse (GEM) models of epithelial cancers. Here, we show that loss of Gα13 in the Kras/Tp53 (KPC) GEM model promotes well-differentiated tumors and reduces survival. Mechanistically, tumors developing in KPC mice with Gα13 loss exhibit increased E-cadherin expression and mTOR signaling. Importantly, human pancreatic ductal adenocarcinoma (PDAC) tumors with low Gα13 expression also exhibit increased E-cadherin expression and mTOR signaling. Treatment with the mTOR inhibitor rapamycin decreases the growth of syngeneic KPC tumors with Gα13 loss by promoting cell death. This work establishes a tumor-suppressive role of Gα13 in pancreatic tumorigenesis in the KPC GEM model and suggests targeting mTOR in human PDAC tumors with Gα13 loss.
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Affiliation(s)
- Mario A Shields
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 303 E. Superior Avenue, Lurie 3-220 or Lurie 3-117, Chicago, IL 60611, USA; The Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA.
| | - Christina Spaulding
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 303 E. Superior Avenue, Lurie 3-220 or Lurie 3-117, Chicago, IL 60611, USA; Jesse Brown VA Medical Center, Chicago, IL, USA
| | - Anastasia E Metropulos
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 303 E. Superior Avenue, Lurie 3-220 or Lurie 3-117, Chicago, IL 60611, USA
| | - Mahmoud G Khalafalla
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 303 E. Superior Avenue, Lurie 3-220 or Lurie 3-117, Chicago, IL 60611, USA
| | - Thao N D Pham
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 303 E. Superior Avenue, Lurie 3-220 or Lurie 3-117, Chicago, IL 60611, USA
| | - Hidayatullah G Munshi
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 303 E. Superior Avenue, Lurie 3-220 or Lurie 3-117, Chicago, IL 60611, USA; The Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA; Jesse Brown VA Medical Center, Chicago, IL, USA.
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11
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Schweber AB, Agarunov E, Brooks C, Hur C, Gonda TA. Prevalence, Incidence, and Risk of Progression of Asymptomatic Pancreatic Cysts in Large Sample Real-world Data. Pancreas 2021; 50:1287-1292. [PMID: 34860813 DOI: 10.1097/mpa.0000000000001918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Using large-sample, real-world administrative claims data, we evaluated the prevalence of putatively asymptomatic pancreatic cysts, the historical growth in their incident diagnosis, and their risk of malignant progression. METHODS Data were sourced from IBM MarketScan administrative claims databases of more than 200 million patients. Period prevalence was assessed using 700,000 individuals without conditions that predispose to pancreatic cyst. The standardized cumulative incidence was compared with the cross-sectional abdominal imaging rate from 2010-2017. The risk of progression to pancreatic cancer for 14,279 newly diagnosed patients with a cyst was estimated using Kaplan-Meier analysis. RESULTS Standardized prevalence increased exponentially with age and was 1.84% (95% confidence interval, 1.80%-1.87%) for patients older than 45. Standardized incidence nearly doubled from 2010-2017 (6.3 to 11.4 per 10,000), whereas the imaging rate changed from only 8.0% to 9.4%. The cumulative risk of pancreatic cancer at 7 years was 3.0% (95% confidence interval, 2.4%-3.5%), increasing linearly (R2 = 0.991) with an annual progression risk of 0.47%. CONCLUSIONS Using large-sample data, we show a significant burden of asymptomatic pancreatic cysts, with an annual risk of progression to cancer of 0.47% for 7 years. Rapid growth in cyst diagnosis over the last decade far outpaced increases in the imaging rate.
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Affiliation(s)
- Adam B Schweber
- From the Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center
| | - Emil Agarunov
- Division of Gastroenterology and Hepatology, New York University, New York, NY
| | - Christian Brooks
- Larner College of Medicine, University of Vermont, Burlington, VT
| | - Chin Hur
- From the Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center
| | - Tamas A Gonda
- From the Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center
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Association between pancreatic intraductal papillary mucinous neoplasms and extrapancreatic malignancies: A systematic review with meta-analysis. Eur J Surg Oncol 2021; 48:632-639. [PMID: 34620511 DOI: 10.1016/j.ejso.2021.09.018] [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: 06/22/2021] [Revised: 08/05/2021] [Accepted: 09/23/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND It is unclear whether patients with intraductal papillary mucinous neoplasia harbor a higher risk of developing extrapancreatic malignancies. AIMS We performed a pooled estimate of the incidence of extrapancreatic malignancies in patients with intraductal papillary mucinous neoplasia, with a particular focus on the comparison to the general population. METHODS Computerized bibliographic search of main databases was performed through February 2021. The primary endpoint was the pooled incidence of extrapancreatic malignancies in patients with intraductal papillary mucinous neoplasms. Additional outcome was the comparison between intraductal papillary mucinous neoplasia patients and the general population, expressed in terms of standardized incidence ratio along with 95% confidence intervals. RESULTS Eighteen studies with 8709 patients were included. The pooled rate of metachronous extrapancreatic malignancies was 10 (6-13)/1000 persons-year. No difference was observed according to intraductal papillary mucinous neoplasia histology and sex, whereas a significantly superior incidence of extrapancreatic malignancies was observed in patients with main-duct (36.7%, 25.4%-48%) as compared to branch-duct intraductal papillary mucinous neoplasia (26.2%, 17.6%-34.8%; p = 0.03). Pooled standardized incidence ratio comparing expected rates in the general population was 1.01 (0.79-1.29); no difference was observed concerning rates of metachronous gastric cancer (standardized incidence ratio 1.60, 0.72-3.54) and colorectal cancer (1.29, 0.92-1.18), whereas biliary cancer was observed more frequently in intraductal papillary mucinous neoplasia patients (2.29, 1.07-4.93). CONCLUSION Patients with intraductal papillary mucinous neoplasia harbor an overall rate of extrapancreatic malignancies as high as 27.3%. The rate of metachronous extrapancreatic malignancies is not superior to the general population.
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13
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Pancreatic cystic neoplasms: a review of current recommendations for surveillance and management. Abdom Radiol (NY) 2021; 46:3946-3962. [PMID: 33742217 DOI: 10.1007/s00261-021-03030-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/25/2021] [Accepted: 02/27/2021] [Indexed: 12/12/2022]
Abstract
Pancreatic cystic neoplasms (PCN) comprise of a diverse array of pancreatic cysts, including intraductal papillary mucinous neoplasms (IPMN), mucinous cystic neoplasms (MCN), serous cystic neoplasms (SCN), cystic neuroendocrine tumors (cNET), and many others. Increasing use of cross-sectional imaging has resulted in greater numbers of PCNs discovered incidentally. The overall risk of malignancy is low, but can vary considerably between different classes of PCNs. Furthermore, many pancreatic cysts are indeterminate on imaging, and the inability to reliably predict the course of disease remains a challenge for radiologists. Due to the variability in disease course and a lack of high-quality studies on PCNs, there is no universal consensus when it comes to balancing optimal surveillance while avoiding the risk for overtreatment. Currently, there are three widely accepted international guidelines outlining guidelines for surveillance and management of PCNs: the American Gastroenterological Association (AGA) in 2015, the International Association of Pancreatology (IAP) last revised in 2017, and the European Study Group on Cystic Tumours of the Pancreas (European) last revised in 2018. In 2017, the American College of Radiology released its own comprehensive set of recommendations for managing indeterminate pancreatic cysts that are detected incidentally on CT or MRI. The purpose of this paper is to describe the key differences between the ACR recommendations and the aforementioned three sets of guidelines regarding cyst management, imaging surveillance, performance, and cost-effectiveness.
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Reappraisal of a 2-Cm Cut-off Size for the Management of Cystic Pancreatic Neuroendocrine Neoplasms: A Multicenter International Study. Ann Surg 2021; 273:973-981. [PMID: 31348038 DOI: 10.1097/sla.0000000000003508] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of this study was to characterize an international cohort of resected cystic pancreatic neuroendocrine neoplasms (cPanNENs) and identify preoperative predictors of aggressive behavior. BACKGROUND The characteristics of cPanNENs are unknown and their clinical management remains unclear. An observational strategy for asymptomatic cPanNENs ≤2 cm has been proposed by recent guidelines, but evidence is scarce and limited to single-institutional series. METHODS Resected cPanNENs (1995-2017) from 16 institutions worldwide were included. Solid lesions (>50% solid component), functional tumors, and MEN-1 patients were excluded. Aggressiveness was defined as lymph node (LN) involvement, G3 grading, distant metastases, and/or recurrence. RESULTS Overall, 263 resected cPanNENs were included, among which 177 (63.5%) were >2 cm preoperatively. A preoperative diagnosis of cPanNEN was established in 162 cases (61.6%) and was more frequent when patients underwent endoscopic ultrasound [EUS, odds ratio (OR) 2.69, 95% confidence interval (CI) 1.52-4.77] and somatostatin-receptor imaging (OR 3.681, 95% CI 1.809-7.490), and for those managed in specialized institutions (OR 3.12, 95% CI 1.57-6.21). Forty-one cPanNENs (15.6%) were considered aggressive. In the whole cohort, LN involvement on imaging, age >65 years, preoperative size >2 cm, and pancreatic duct dilation were independently associated with aggressive behavior. In asymptomatic patients, older age and a preoperative size >2 cm remained independently associated with aggressiveness. Only 1 of 61 asymptomatic cPanNENs ≤2 cm displayed an aggressive behavior. CONCLUSIONS The diagnostic accuracy of cPanNENs is increased by the use of EUS and somatostatin-receptor imaging and is higher in specialized institutions. Preoperative size >2 cm is independently associated with aggressive behavior. Consequently, a watch-and-wait policy for sporadic asymptomatic cPanNENs ≤2 cm seems justified and safe for most patients.
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15
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Prophylactic Antibiotics Do Not Prevent Infectious Complications of Endoscopic Ultrasound Fine-Needle Aspiration of Pancreatic Cysts: A Systematic Review and Meta-Analysis. Pancreas 2021; 50:667-672. [PMID: 34106575 DOI: 10.1097/mpa.0000000000001816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Despite limited evidence, endoscopic societies recommend routine use of antibiotic prophylaxis for endoscopic ultrasound fine-needle aspiration of pancreatic cystic lesions. Recent studies suggest lack of benefit in this setting. Our objective is to conduct a systematic review and meta-analysis to assess the efficacy of antibiotics in prevention of infectious complications after ultrasound fine-needle aspiration of pancreatic cystic lesions. A bibliographic search of digital dissertation databases was performed from inception until March 2020. Randomized controlled trials, cohort, and case-control studies that compared prophylactic antibiotics with placebo or no therapy were included in the analysis. The primary outcome was the development of cyst infections. Secondary outcomes were incidence of fever; procedural complications such as bile leak, pancreatitis, or bleeding; and medication-related adverse events. Six studies with a total of 1683 patients were included. The overall incidence of cyst infections was 0.53%. For the primary outcome, there was no significant difference between the 2 groups (odds ratio, 0.54; 95% confidence interval, 0.16-1.82; P = 0.32). No significant difference was noted regarding other complications like fever, pancreatitis, or bile leak. In conclusion, the rate of infectious complications is very low, and antibiotic prophylaxis does not seem to confer any additional benefit in their prevention.
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16
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Hsieh MJ, Weng CC, Lin YC, Wu CC, Chen LT, Cheng KH. Inhibition of β-Catenin Activity Abolishes LKB1 Loss-Driven Pancreatic Cystadenoma in Mice. Int J Mol Sci 2021; 22:ijms22094649. [PMID: 33924999 PMCID: PMC8125161 DOI: 10.3390/ijms22094649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 04/16/2021] [Accepted: 04/16/2021] [Indexed: 01/02/2023] Open
Abstract
Pancreatic cancer (PC) is the seventh leading cause of cancer death worldwide, and remains one of our most recalcitrant and dismal diseases. In contrast to many other malignancies, there has not been a significant improvement in patient survival over the past decade. Despite advances in our understanding of the genetic alterations associated with this disease, an incomplete understanding of the underlying biology and lack of suitable animal models have hampered efforts to develop more effective therapies. LKB1 is a tumor suppressor that functions as a primary upstream kinase of adenine monophosphate-activated protein kinase (AMPK), which is an important mediator in the regulation of cell growth and epithelial polarity pathways. LKB1 is mutated in a significant number of Peutz–Jeghers syndrome (PJS) patients and in a small proportion of sporadic cancers, including PC; however, little is known about how LKB1 loss contributes to PC development. Here, we report that a reduction in Wnt/β-catenin activity is associated with LKB1 tumor-suppressive properties in PC. Remarkably, in vivo functional analyses of β-catenin in the Pdx-1-Cre LKB1L/L β-cateninL/L mouse model compared to LKB1 loss-driven cystadenoma demonstrate that the loss of β-catenin impairs cystadenoma development in the pancreas of Pdx-1Cre LKB1L/L mice and dramatically restores the normal development and functions of the pancreas. This study further determined the in vivo and in vitro therapeutic efficacy of the β-catenin inhibitor FH535 in suppressing LKB1 loss-driven cystadenoma and reducing PC progression that delineates the potential roles of Wnt/β-catenin signaling in PC harboring LKB1 deficiency.
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MESH Headings
- AMP-Activated Protein Kinase Kinases
- AMP-Activated Protein Kinases/metabolism
- Animals
- Cell Line, Tumor
- Cystadenoma, Mucinous/etiology
- Cystadenoma, Mucinous/metabolism
- Cystadenoma, Mucinous/prevention & control
- Female
- Humans
- Male
- Mice
- Mice, 129 Strain
- Mice, Inbred C57BL
- Mice, Knockout
- Mice, Transgenic
- Mutation
- Neoplasms, Experimental/genetics
- Neoplasms, Experimental/metabolism
- Pancreas/drug effects
- Pancreas/metabolism
- Pancreas/pathology
- Pancreatic Neoplasms/etiology
- Pancreatic Neoplasms/metabolism
- Pancreatic Neoplasms/prevention & control
- Peutz-Jeghers Syndrome/genetics
- Peutz-Jeghers Syndrome/metabolism
- Protein Serine-Threonine Kinases/deficiency
- Protein Serine-Threonine Kinases/genetics
- Sulfonamides/pharmacology
- Wnt Signaling Pathway/drug effects
- beta Catenin/antagonists & inhibitors
- beta Catenin/genetics
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Affiliation(s)
- Mei-Jen Hsieh
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan; (M.-J.H.); (C.-C.W.); (Y.-C.L.); (C.-C.W.)
- Division of Neurology, Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung 802, Taiwan
| | - Ching-Chieh Weng
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan; (M.-J.H.); (C.-C.W.); (Y.-C.L.); (C.-C.W.)
| | - Yu-Chun Lin
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan; (M.-J.H.); (C.-C.W.); (Y.-C.L.); (C.-C.W.)
| | - Chia-Chen Wu
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan; (M.-J.H.); (C.-C.W.); (Y.-C.L.); (C.-C.W.)
| | - Li-Tzong Chen
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan; (M.-J.H.); (C.-C.W.); (Y.-C.L.); (C.-C.W.)
- National Institute of Cancer Research, National Health Research Institutes, Tainan 704, Taiwan
- Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Oncology, National Cheng Kung University Hospital, National Cheng Kung University, Tainan 704, Taiwan
- Correspondence: (L.-T.C.); (K.-H.C.)
| | - Kuang-Hung Cheng
- Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung 804, Taiwan; (M.-J.H.); (C.-C.W.); (Y.-C.L.); (C.-C.W.)
- National Institute of Cancer Research, National Health Research Institutes, Tainan 704, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Department of Medical Laboratory Science and Biotechnology, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Correspondence: (L.-T.C.); (K.-H.C.)
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17
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Multiparameter Analysis Using 18F-FDG PET/CT in the Differential Diagnosis of Pancreatic Cystic Neoplasms. CONTRAST MEDIA & MOLECULAR IMAGING 2021; 2021:6658644. [PMID: 33880111 PMCID: PMC8046553 DOI: 10.1155/2021/6658644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 03/20/2021] [Accepted: 03/24/2021] [Indexed: 12/18/2022]
Abstract
Purpose To evaluate multiparametric analysis in differential diagnosis between pancreatic serous cystic neoplasms (SCNs) and mucinous cystic neoplasms (MCNs) as well as the differentiation of the benign and malignant MCNs with 18F-FDG (18-fluorodeoxyglucose) PET/CT (positron emission tomography). Methods Forty patients with total of 41 lesions (SCNs: 27/41; MCNs: 14/41), who were preoperatively examined with 18F-FDG PET/CT, were retrospectively analyzed. Multiple quantitative parameters using conventional and texture features were included. The combined model was established with complementary PET/MR parameters. The differential diagnostic efficacy of each independent parameter and the combined model were evaluated with receiver operating characteristic (ROC) analysis. Integrated discriminatory improvement (IDI) and net reclassification improvement (NRI) were used to evaluate improvement of diagnostic efficacy by using combination of multiple parameters. Results Among all independent parameters, the percentile 5th (0.88 ± 0.38 vs 0.47 ± 0.23, P < 0.001) showed the highest discriminative diagnostic value. The combination of multiple parameters can improve the differential diagnostic efficacy of SCNs and MCNs (sensitivity = 71.4%, specificity = 77.8%, and AUC = 0.788), and the addition of texture parameters to the conventional parameters allowed a significant reclassification with IDI = 0.236 (95% CI: 0.095-0.377) and categorical NRI = 0.434 (95% CI: 0.030-0.838). SURmax (tumor to normal pancreas ratio, T/P) and SURmax (tumor to aorta ratio, T/A) both showed the highest discriminative diagnostic value (sensitivity = 100.0%, specificity = 70.0%, AUC = 0.900, and Youden index = 0.700) in the differential diagnosis of benign and malignant MCNs, with the cutoff values of 0.84 and 0.90, respectively. Conclusion Combination of multiple parameters using 18F-FDG PET/CT could further improve differentiation between pancreatic SCNs and MCNs. SURmax (T/P) and SURmax (T/A) could improve differential diagnosis of benign and malignant MCNs.
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18
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Hecht EM, Khatri G, Morgan D, Kang S, Bhosale PR, Francis IR, Gandhi NS, Hough DM, Huang C, Luk L, Megibow A, Ream JM, Sahani D, Yaghmai V, Zaheer A, Kaza R. Intraductal papillary mucinous neoplasm (IPMN) of the pancreas: recommendations for Standardized Imaging and Reporting from the Society of Abdominal Radiology IPMN disease focused panel. Abdom Radiol (NY) 2021; 46:1586-1606. [PMID: 33185741 DOI: 10.1007/s00261-020-02853-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 02/07/2023]
Abstract
There have been many publications detailing imaging features of malignant transformation of intraductal papillary mucinous neoplasms (IPMN), management and recommendations for imaging follow-up of diagnosed or presumed IPMN. However, there is no consensus on several practical aspects of imaging IPMN that could serve as a clinical guide for radiologists and enable future data mining for research. These aspects include how to measure IPMN, define reporting terminology, standardize reporting and unify guidelines for surveillance. The Society of Abdominal Radiology (SAR) created multiple Disease-Focused Panels (DFP) comprised multidisciplinary panel members who focus on a particular disease, with the goal to develop ways for radiologists to improve patient care, education, and research. DFP members met to identify the current controversies and limitations of imaging pancreatic IPMN. This paper aims to provide a practical review of the key imaging characteristics of IPMN for trainees and practicing radiologists, to guide uniformity of performance and interpretation of surveillance imaging studies, and to improve communication with clinicians by providing a lexicon and reporting template based on the experience of the SAR-DFP panel members.
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Affiliation(s)
- Elizabeth M Hecht
- Department of Radiology, New York Presbyterian-Weill Cornell Medicine, New York, NY, USA.
| | - Gaurav Khatri
- Department of Diagnostic Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Desiree Morgan
- Department of Radiology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stella Kang
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Priya R Bhosale
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Isaac R Francis
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Namita S Gandhi
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - David M Hough
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Chenchan Huang
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Lyndon Luk
- Department of Radiology, New York Presbyterian-Columbia University Medical Center, New York, NY, USA
| | - Alec Megibow
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Justin M Ream
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Dushyant Sahani
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Vahid Yaghmai
- Department of Radiological Sciences, University of California, Irvine, Orange, CA, USA
| | - Atif Zaheer
- Department of Radiology, John Hopkins Medicine, Baltimore, MD, USA
| | - Ravi Kaza
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
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19
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Fong ZV, Sekigami Y, Qadan M, Fernandez-Del Castillo C, Warshaw AL, Lillemoe KD, Ferrone CR. Assessment of the Long-Term Impact of Pancreatoduodenectomy on Health-Related Quality of Life Using the EORTC QLQ-PAN26 Module. Ann Surg Oncol 2021; 28:4216-4224. [PMID: 33774773 DOI: 10.1245/s10434-021-09853-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 01/30/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Long-term pancreatoduodenectomy (PD) survivors have previously reported favorable quality of life (QoL). However, there has been a paucity of studies utilizing pancreas-specific modules for QoL assessment, which may uncover disability that general modules cannot detect. METHODS The European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-PAN26 questionnaires were administered to PD survivors who were at least 5 years out of their operations for neoplasms (1998-2011, study cohort) and compared their scores with published preoperative scores of patients with pancreatic cancer (control cohort). The clinical relevance (CR) of differences was scored as small (5-10), moderate (10-20), or large (> 20) based on validated interpretation of clinically important differences. RESULTS Of 1266 patients who underwent PD, there were 305 survivors with valid contact information, of whom 248 responded to the questionnaire (response rate 81.3%) and made up the study cohort. The median follow-up was 9.1 years (range 5.1-21.2 years). When compared with the control cohort, patients in the study cohort reported higher pancreatic pain (41.7 ± 17.6 vs. 18.1 ± 20.5, p < 0.001, CR large), sexuality dissatisfaction (63.0 ± 37.5 vs. 35.1 ± 34.3, p < 0.001, CR large), altered bowel habits (37.6 ± 30.6 vs. 20.0 ± 24.5, p < 0.001, CR moderate), and digestive symptoms (26.3 ± 29.5 vs. 18.7 ± 27.8, p = 0.002, CR small) scores. There was a higher prevalence of bloating, indigestion, and flatulence, but lower prevalence of future health worry (71.7% vs. 89.6%, p < 0.001) and limitation in planning activities (30.1% vs. 48.3%, p < 0.001) at 5 years. CONCLUSION While post-PD patients had better long-term global QoL than healthy controls, a more granular, pancreas-specific questionnaire uncovered digestive abnormalities and sexuality dissatisfaction. These data can better inform clinical decision making and provide potential areas for improvement and patient support.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Yurie Sekigami
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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20
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Han Y, Jang JY, Oh MY, Kim HS, Byun Y, Kang JS, Kim SH, Lee KB, Kim H, Kwon W. Natural history and optimal treatment strategy of intraductal papillary mucinous neoplasm of the pancreas: Analysis using a nomogram and Markov decision model. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 28:131-142. [PMID: 33283481 DOI: 10.1002/jhbp.878] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/06/2020] [Accepted: 11/09/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND/PURPOSE With the increase in detection of intraductal papillary mucinous neoplasms (IPMN), a tailored approach is needed. This study was aimed at exploring the natural history of IPMN and suggest optimal treatment based on malignancy risk using a nomogram and Markov decision model. METHODS Patients with IPMN who underwent surveillance or surgery were included. Changes in worrisome features/high-risk stigmata and malignancy conversion rate were assessed. Life expectancy and quality-adjusted life year (QALY) were compared using a nomogram predicting malignancy. RESULTS Overall, 2006 patients with histologically confirmed or radiologically typical IPMN were enrolled. Of these, 1773 (88.4%), 81 (4.0%), and 152 (7.6%), respectively, had branch duct (BD)-, main duct-, and mixed-type IPMN at initial diagnosis. The cumulative risk of developing worrisome feature or high-risk stigmata was 19.0% and 35.0% at 5- and 10-year follow-up, respectively. The progression of malignancy rate at 10-year follow-up was 79.9% for main and mixed IPMNs and 5.9% for BD-IPMN. Nomogram-based malignancy risk prediction is well correlated with natural history based on pathologic biopsy and shows good stratification of survival. The decision model recommends surgery to maximize survival and QALY especially in those with >35% malignancy risk. CONCLUSIONS Compared with main duct- and mixed-type IPMN, which have a high risk of malignancy (79.9%), BD-IPMN is very indolent (5.9%). The nomogram-based decision model suggests surgery rather than surveillance for patients with a high malignancy risk. The optimal treatment strategy between surgery and surveillance should consider patients' health status, malignancy risk, and centers' experience.
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Affiliation(s)
- Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Moon Young Oh
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeong Seok Kim
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yoonhyeong Byun
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Se Hyung Kim
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung-Bun Lee
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hongbeom Kim
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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21
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Facciorusso A, Mohan BP, Tacelli M, Crinò SF, Antonini F, Fantin A, Barresi L. Use of antibiotic prophylaxis is not needed for endoscopic ultrasound-guided fine-needle aspiration of pancreatic cysts: a meta-analysis. Expert Rev Gastroenterol Hepatol 2020; 14:999-1005. [PMID: 32674699 DOI: 10.1080/17474124.2020.1797486] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is limited evidence on the use of antibiotic prophylaxis prior to endoscopic ultrasound-guided fine-needle aspiration of pancreatic cysts. The aim of this meta-analysis was to evaluate the efficacy of antibiotic prophylaxis in this setting. RESEARCH DESIGN AND METHODS Bibliographic search was performed through January 2020. The primary outcome was infection rate. Additional endpoints were severe infection rate and overall rates of adverse events. RESULTS Six studies, of which one was a randomized controlled trial and five were retrospective, with 1706 patients were included. Most patients were female, and body/tail was the most frequent location of cystic lesions. Overall, eight infectious events were observed in the antibiotic group (0.77%), whereas 12 events were registered in the control group (1.7%), with no difference in terms of infection rate (odds ratio 0.65, 95% confidence interval 0.24-1.78; p = 0.40). Again, no difference was observed between the two study groups in terms of either severe infection (odds ratio 0.88, 0.13-5.82; p = 0.89) and overall adverse event rate (odds ratio 1.09, 0.73-1.65; p = 0.67). CONCLUSIONS Prophylactic antibiotics do not seem to substantially reduce the risk of infections after endoscopic ultrasound-guided fine-needle aspiration of pancreatic cystic lesions, and routine use of prophylactic antibiotics should be questioned.
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Affiliation(s)
- Antonio Facciorusso
- Department of Medical Sciences, Section of Gastroenterology, University of Foggia, Foggia, Italy
| | - Babu P Mohan
- Department of Internal Medicine, University of Arizona Banner University Medical Center, Tucson, AZ, USA
| | - Matteo Tacelli
- Pancreato-biliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Filippo Antonini
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, Augusto Murri Hospital, Fermo, Italy
| | - Alberto Fantin
- Gastroenterology Unit, IRCCS Istituto Oncologico Veneto, Castelfranco, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, Istituto Mediterraneo per I Trapianti E Terapie Ad Alta Specializzazione, Palermo, Italy
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22
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A Quantitative Global Proteomics Approach Identifies Candidate Urinary Biomarkers That Correlate With Intraductal Papillary Mucinous Neoplasm Dysplasia. Pancreas 2020; 49:1044-1051. [PMID: 32769857 DOI: 10.1097/mpa.0000000000001628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES A proteomic discovery study was performed to determine if urine possesses a unique biosignature that could form the basis for a noninvasive test able to predict intraductal papillary mucinous neoplasm (IPMN) dysplasia. METHODS Urine was collected from patients undergoing surgery for IPMN (72 low/moderate, 27 high-grade/invasive). Quantitative mass spectrometry-based proteomics was performed. Proteins of interest were identified by differential expression analysis followed by principal component analysis. RESULTS Proteomics identified greater than 4800 urinary proteins. Low/moderate and high-grade/invasive IPMN were distinguished by 188 proteins (P < 0.05). Following principal component analysis and heatmap visualization, vitamin D binding protein (DBP), apolipoprotein A1 (APOA1), and alpha-1 antitrypsin (A1AT) were selected. The proteomic abundance of DBP (median [interquartile range]) was significantly higher for high-grade/invasive than for low/moderate IPMN (219,735 [128,882-269,943] vs. 112,295 [77,905-180,773] normalized reporter ion intensity units; P = 0.001). Similarly, APOA1 was more abundant in the high-grade/invasive than low/moderate groups (235,420 [144,933-371,247] vs 150,095 [103,419-236,591]; P = 0.0007) as was A1AT (567,514 [358,544-774,801] vs 358,393 [260,850-477,882]; P = 0.0006). CONCLUSIONS Urinary DBP, APOA1, and A1AT represent potential biomarker candidates that may provide a noninvasive means of predicting IPMN dysplastic grade.
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Facciorusso A, Del Prete V, Antonino M, Buccino VR, Wani S. Diagnostic yield of EUS-guided through-the-needle biopsy in pancreatic cysts: a meta-analysis. Gastrointest Endosc 2020; 92:1-8.e3. [PMID: 32014422 DOI: 10.1016/j.gie.2020.01.038] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 01/22/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS There is currently limited evidence supporting the use of EUS-guided through-the-needle biopsy for sampling pancreatic cystic lesions. The aim of this meta-analysis was to provide a pooled estimate of the diagnostic performance of through-the-needle biopsy for sampling of pancreatic cysts. METHODS A bibliographic search on the main databases was performed in September 2019. Pooled effects were calculated using a random-effects model by means of the DerSimonian and Laird test. The primary outcome was sample adequacy. Additional endpoints were diagnostic accuracy, optimal histologic core procurement, mean number of needle passes, pooled specificity, and sensitivity. Adverse event rates were also analyzed. RESULTS Eleven studies enrolling 490 patients were included. Eight articles compared through-the-needle biopsy with cytology/cystic fluid analysis. Most patients were female, and the body/tail was the most frequent location of cystic lesions. Sample adequacy with through-the-needle biopsy was 85.3% (78.2%-92.5%), and subanalysis performed according to cyst morphology, size, and location confirmed the result. Through-the-needle biopsy clearly outperformed FNA both in terms of sample adequacy (odds ratio, 4.83; 95% confidence interval, 1.63-14.31; P =.004) and diagnostic accuracy (odds ratio, 3.44; 95% confidence interval, 1.32-8.96; P =.01). The pooled diagnostic accuracy rate, sensitivity, and specificity of through-the-needle biopsy were 78.8%, 82.2%, and 96.8%, respectively. A mean of 3.121 (2.98-3.25) passes through the cyst was needed to obtain adequate histologic samples. The incidence rates of mild bleeding and pancreatitis were 4% and 2%, respectively. CONCLUSION Our meta-analysis speaks in favor of the use of through-the-needle biopsy as a safe and effective tool in EUS-guided tissue acquisition of pancreatic cysts.
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Affiliation(s)
| | | | | | | | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Surci N, Ramera M, Borin A, Marchegiani G, Salvia R, Bassi C. Implementation of a strategic preoperative surgical meeting to improve the level of care at a high-volume pancreatic center: a before–after analysis of 1000 consecutive cases. Updates Surg 2020; 72:155-161. [DOI: 10.1007/s13304-020-00707-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 01/16/2020] [Indexed: 12/24/2022]
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Yang J, Guo X, Zhang H, Zhang W, Song J, Xu H, Ma X. Differential diagnosis of pancreatic serous cystadenoma and mucinous cystadenoma: utility of textural features in combination with morphological characteristics. BMC Cancer 2019; 19:1223. [PMID: 31842793 PMCID: PMC6915993 DOI: 10.1186/s12885-019-6421-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/02/2019] [Indexed: 02/05/2023] Open
Abstract
Background Texture analysis of medical images has been reported to be a reliable method for differential diagnosis of neoplasms. This study was to investigate the performance of textural features and the combined performance of textural features and morphological characteristics in the differential diagnosis of pancreatic serous and mucinous cystadenomas. Methods We retrospectively reviewed 59 patients with pancreatic serous cystadenoma and 32 patients with pancreatic mucinous cystadenoma at our hospital. A three-dimensional region of interest (ROI) around the margin of the lesion was drawn manually in the CT images of each patient, and textural parameters were retrieved from the ROI. Textural features were extracted using the LifeX software. The least absolute shrinkage and selection operator (LASSO) method was applied to select the textural features. The differential diagnostic capabilities of morphological features, textural features, and their combination were evaluated using receiver operating characteristic (ROC) analysis, and the area under the receiver operating characteristic curve (AUC) was used as the main indicator. The diagnostic accuracy based on the AUC value is defined as follows: 0.9–1.0, excellent; 0.8–0.9, good; 0.7–0.8, moderate; 0.6–0.7, fair; 0.5–0.6, poor. Results In the differential diagnosis of pancreatic serous and mucinous cystadenomas, the combination of morphological characteristics and textural features (AUC 0.893, 95% CI 0.816–0.970) is better than morphological characteristics (AUC 0.783, 95% CI 0.665–0.900) or textural features (AUC 0.777, 95% CI 0.673–0.880) alone. Conclusions In conclusion, our preliminary results highlighted the potential of CT texture analysis in discriminating pancreatic serous cystadenoma from mucinous cystadenoma. Furthermore, the combination of morphological characteristics and textural features can significantly improve the diagnostic performance, which may provide a reliable method for selecting patients with surgical intervention indications in consideration of the different treatment principles of the two diseases.
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Affiliation(s)
- Jing Yang
- Department of Biotherapy, Cancer Center, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, People's Republic of China
| | - Xinli Guo
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Hao Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Weiwei Zhang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jinen Song
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Hui Xu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xuelei Ma
- Department of Biotherapy, Cancer Center, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, People's Republic of China.
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A Prospective Study on Contrast-Enhanced Endoscopic Ultrasound for Differential Diagnosis of Pancreatic Cystic Neoplasms. Dig Dis Sci 2019; 64:3616-3622. [PMID: 31290040 DOI: 10.1007/s10620-019-05718-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 07/02/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIMS To determine the value of contrast-enhanced endoscopic ultrasound (CE-EUS) for differentiation of pancreatic cystic neoplasms (PCNs). METHODS From April 2015 to December 2017, 82 patients were enrolled in this study. All patients were confirmed to have PCNs by surgical pathology. Prior to surgery, all patients underwent fundamental B-mode EUS (FB-EUS) and CE-EUS, 65 of whom underwent computed tomography (CT) and 71 of whom underwent magnetic resonance imaging (MRI). The enhanced mode data of PCNs were recorded. The diagnostic accuracy of CE-EUS in classifying PCNs was compared with that of CT, MRI and FB-EUS. The ability of CE-EUS to identify PCNs was evaluated by comparing the enhanced mode of PCNs. RESULTS There was a significant difference between benign and malignant lesions in enhanced mode (P = 0.017). The enhanced modes of benign lesions were mostly type II and type III, while those of malignant lesions were type 0, type I, and type IV. The sensitivity, specificity, and accuracy of type 0, type I, and type IV enhanced mode as the diagnostic criterion for malignant lesions were 80%, 65.3%, and 67.1%, respectively. CE-EUS demonstrated greater accuracy in identifying PCNs than did CT, MRI, and FB-EUS (CE-EUS vs. CT: 92.3% vs. 76.9%; CE-EUS vs. MRI: 93.0% vs. 78.9%; CE-EUS vs. FB-EUS: 92.7% vs. 84.2%). CONCLUSION Compared with CT, MRI, and FB-EUS, CE-EUS is better at differentiating PCNs. CE-EUS is expected to be another important imaging technique for the diagnosis of PCNs.
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Pancreatic cystic neoplasms: current and future approaches to identify patients at risk. JOURNAL OF PANCREATOLOGY 2019. [DOI: 10.1097/jp9.0000000000000033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Argüello L, Sánchez-Montes C, Mansilla-Vivar R, Artés J, Prieto M, Alonso-Lázaro N, Satorres-Paniagua C, Pons-Beltrán V. Diagnostic yield of endoscopic ultrasound with fine-needle aspiration in pancreatic cystic lesions. GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 43:1-8. [PMID: 31753518 DOI: 10.1016/j.gastrohep.2019.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/14/2019] [Accepted: 07/15/2019] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Despite advances in imaging techniques, in many cases they are insufficient to establish the diagnosis of pancreatic cystic lesions (PCL). There are few publications in our setting that evaluate the combination of several methods obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). The aim of the study was to evaluate the overall utility of EUS-FNA in the diagnosis of PCL. MATERIAL AND METHODS Retrospective study based on a database updated prospectively of a cohort of patients referred for EUS-FNA due to PCL detected in an imaging test. The sensitivity, specificity and diagnostic yield of carcinoembryonic antigen (CEA), cytology and viscosity were studied to detect mucinous lesions. RESULTS From November 2013 to April 2018, 122 EUS were performed for PCL. EUS-FNA was performed in 94/122 (77%) and 21/122 (17.2%) patients were operated on. We included 33/122 patients who had diagnostic confirmation by histology, imaging (serous cyst with typical pattern) or clinical evolution. The study of the ROC curve determined the cutoff point ≥419 ng/ml to differentiate mucinous/non-mucinous cystic lesions. The diagnostic yield of CEA was 87.5% (21/24), cytology 81.8% (27/33) and viscosity 84.4% (27/32). The three parameters in combination obtained the best result (30/33, 90.9%). CONCLUSION The combination of CEA analysis, cytology and viscosity of pancreatic fluid obtained by EUS-FNA increases the performance in the diagnosis of mucinous pancreatic cystic lesions, with it being greater than 90%.
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Affiliation(s)
- Lidia Argüello
- Unidad de Endoscopia Digestiva, Hospital Universitari i Politècnic La Fe, Valencia, España; Grupo de Investigación de Endoscopia Digestiva, IIS La Fe, Valencia, España
| | - Cristina Sánchez-Montes
- Unidad de Endoscopia Digestiva, Hospital Universitari i Politècnic La Fe, Valencia, España; Grupo de Investigación de Endoscopia Digestiva, IIS La Fe, Valencia, España.
| | - Rodrigo Mansilla-Vivar
- Unidad de Endoscopia Digestiva, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - Josefa Artés
- Servicio de Anatomía Patológica, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - Mireya Prieto
- Servicio de Anatomía Patológica, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - Noelia Alonso-Lázaro
- Unidad de Endoscopia Digestiva, Hospital Universitari i Politècnic La Fe, Valencia, España; Grupo de Investigación de Endoscopia Digestiva, IIS La Fe, Valencia, España
| | - Carla Satorres-Paniagua
- Unidad de Endoscopia Digestiva, Hospital Universitari i Politècnic La Fe, Valencia, España; Grupo de Investigación de Endoscopia Digestiva, IIS La Fe, Valencia, España
| | - Vicente Pons-Beltrán
- Unidad de Endoscopia Digestiva, Hospital Universitari i Politècnic La Fe, Valencia, España; Grupo de Investigación de Endoscopia Digestiva, IIS La Fe, Valencia, España
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Laquière A, Lagarde A, Napoléon B, Bourdariat R, Atkinson A, Donatelli G, Pol B, Lecomte L, Curel L, Urena-Campos R, Helbert T, Valantin V, Mithieux F, Buono JP, Grandval P, Olschwang S. Genomic profile concordance between pancreatic cyst fluid and neoplastic tissue. World J Gastroenterol 2019; 25:5530-5542. [PMID: 31576098 PMCID: PMC6767987 DOI: 10.3748/wjg.v25.i36.5530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 07/16/2019] [Accepted: 08/19/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND DNA mutational analysis of pancreatic cystic fluid (CF) is a useful adjunct to the evaluation of pancreatic cysts. KRAS/GNAS or RAF/PTPRD/CTNNB1/RNF43 mutations are highly specific to precancerous or advanced neoplasia. Several studies recently demonstrated the ability of next-generation sequencing (NGS) analysis to detect DNA mutations in pancreatic CF, but few studies have performed a systematic comparative analysis between pancreatic CF and neoplastic surgical tissue (NT). The value of CF-NGS analysis indicators for determining surgical resection necessitates evaluation.
AIM To confirm whether CF genomic profiles are a reliable malignancy predictor by comparing NGS mutational analyses of CF and NT.
METHODS Patients requiring surgery for high-risk pancreatic cysts were included in a multicenter prospective pilot study. DNA from CF (collected by endoscopic ultrasound-guided fine needle aspiration (known as EUS-FNA)) and NT (collected by surgery) were analyzed by NGS. The primary objective was to compare the mutation profiles of paired DNA samples. The secondary objective was to correlate the presence of specific mutations (KRAS/GNAS, RAF/ PTPRD/CTNNB1/RNF43/POLD1/TP53) with a final cancer diagnosis. Sensitivity and specificity were also evaluated.
RESULTS Between December 2016 and October 2017, 20 patients were included in this pilot study. Surgery was delayed for 3 patients. Concordant CF-NT genotypes were found in 15/17 paired DNA, with a higher proportion of mutated alleles in CF than in NT. NGS was possible for all pancreatic CF collected by EUS-FNA. In 2 cases, the presence of a KRAS/GNAS mutation was discordant between CF and NT. No mutations were found in 3 patients with NT or pancreatic cysts with high-grade dysplasia. The sensitivity and specificity of KRAS/GNAS mutations in CF to predict an appropriate indication for surgical resection were 0.78 and 0.62, respectively. The sensitivity and specificity of RAF/PTPRD/CTNNB1 /RNF43/POLD1/TP53 mutations in CF were 0.55 and 1.0, respectively.
CONCLUSION Mutational analyses of CF and NT were highly concordant, confirming the value of NGS analysis of CF in the preoperative malignancy assessment. However, these results need to be confirmed on a larger scale.
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Affiliation(s)
- Arthur Laquière
- Department of Gastroenterology, Saint Joseph Hospital, Marseille 13008, France
| | - Arnaud Lagarde
- Aix-Marseille Univ, INSERM, MMG, Marseille 13385, France
- AP-HM, Conception Hospital, Marseille 13385, France
| | | | | | | | | | - Bernard Pol
- Department of Digestive Surgery, Saint-Joseph Hospital, Marseille 13008, France
| | - Laurence Lecomte
- Department of Gastroenterology, Saint Joseph Hospital, Marseille 13008, France
| | - Laurence Curel
- Department of Clinical Research, Saint Joseph Hospital, Marseille 13008, France
| | - Romina Urena-Campos
- Department of Gastroenterology, Saint Joseph Hospital, Marseille 13008, France
| | | | | | | | | | - Philippe Grandval
- Aix-Marseille Univ, INSERM, MMG, Marseille 13385, France
- AP-HM, Timone Hospital, Marseille 13005, France
| | - Sylviane Olschwang
- Aix-Marseille Univ, INSERM, MMG, Marseille 13385, France
- European Hospital, Marseille 13003, France
- AP-HM, Timone Hospital, Marseille 13005, France
- RGDS, Clairval Hospital, Marseille 13009, France
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Zhong L, Chai N, Linghu E, Li H, Yang J, Tang P. A prospective study on endoscopic ultrasound for the differential diagnosis of serous cystic neoplasms and mucinous cystic neoplasms. BMC Gastroenterol 2019; 19:127. [PMID: 31311499 PMCID: PMC6636106 DOI: 10.1186/s12876-019-1035-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 06/24/2019] [Indexed: 12/21/2022] Open
Abstract
Background To provide criteria for the differential diagnosis of serous cystic neoplasms (SCNs) and mucinous cystic neoplasms (MCNs) by analyzing the imaging features of these two neoplasms by endoscopic ultrasound (EUS). Methods From April 2015 to December 2017, a total of 69 patients were enrolled in this study. All patients were confirmed to have MCNs (31 patients) or SCNs (38 patients) by surgical pathology. All patients underwent EUS examination. The observation and recorded items were size, location, shape, cystic wall thickness, number of septa, and solid components. Results Head/neck location, lobulated shape, thin wall and > 2 septa were the specific imaging features for the diagnosis of SCNs. When any two imaging features were combined, we achieved the highest area under the curve (Az) (0.824), as well as the appropriate sensitivity (84.2%), specificity (80.6%), positive predictive value (PPV) (84.2%), and negative predictive value (NPV) (80.6%). Body/tail location, round shape, thick wall and 0–2 septa were the specific imaging features for the diagnosis of MCNs. When any three imaging features were combined, we obtained the highest Az value (0.808), as well as the appropriate sensitivity (77.4%), specificity (84.2%), PPV (80.0%) and NPV (82.1%). Conclusions Pancreatic cystadenomas that meet any two of the four imaging features of head/neck location, lobulated shape, thin wall and > 2 septa could be diagnosed as SCNs, and those that meet any three of the four imaging features of body/tail location, round shape, thick wall and 0–2 septa could be considered as MCNs. Trial registration The study was registered at the Chinese Clinical Trial Registry. The registration identification number is ChiCTR-OOC-15006118. The date of registration is 2015-03-20.
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Affiliation(s)
- Lisen Zhong
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing, 100853, China
| | - Ningli Chai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing, 100853, China
| | - Enqiang Linghu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing, 100853, China.
| | - Huikai Li
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing, 100853, China
| | - Jing Yang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing, 100853, China
| | - Ping Tang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Fuxing Road 28, Haidian District, Beijing, 100853, China
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Varadarajulu S. Let's Start Looking at the Entire Patient Before Poking at Pancreatic Cysts. Clin Gastroenterol Hepatol 2019; 17:1444-1445. [PMID: 30743009 DOI: 10.1016/j.cgh.2019.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 02/04/2019] [Indexed: 02/07/2023]
Affiliation(s)
- Shyam Varadarajulu
- Center for Interventional Endoscopy, AdventHealth Orlando, Orlando, Florida
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Keegan MJ, Paranandi B. Diagnosis and management of pancreatic cystic neoplasms. Frontline Gastroenterol 2019; 10:300-308. [PMID: 31288258 PMCID: PMC6583589 DOI: 10.1136/flgastro-2018-101122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/18/2019] [Accepted: 01/19/2019] [Indexed: 02/04/2023] Open
Abstract
This review outlines the current classification of pancreatic cystic lesions, with a particular emphasis on pancreatic cystic neoplasms (PCNs). It will describe the diagnostic approach to PCNs, with reference to clinicopathological features, cross-sectional radiology and endoscopic ultrasound. This review will conclude with an evidence-based discussion of the management of PCNs focused on recent clinical guidelines.
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Affiliation(s)
- Mathew James Keegan
- Gastroenterology, Northern Beaches Hospital, Sydney, New South Wales, Australia,Department of Gastroenterology, Peninsula Gastroenterology, Sydney, New South Wales, Australia
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Pancreatic schwannoma, an extremely rare and challenging entity: Report of two cases and review of literature. Pancreatology 2019; 19:729-737. [PMID: 31153779 DOI: 10.1016/j.pan.2019.05.460] [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: 12/19/2018] [Revised: 04/18/2019] [Accepted: 05/17/2019] [Indexed: 02/06/2023]
Abstract
Pancreatic schwannoma is a rare benign tumor, for which the preoperative and intraoperative definitive diagnosis is quite challenging. We present the clinical, radiological and pathologic features of two primary pancreatic schwannomas identified in our pathology database over a period of 30 years at our tertiary care hospital. To better understand the clinico-pathological and radiological features of this entity, we provide a comprehensive review of 73 cases described in the English literature, along with our two cases. This review will especially focus on preoperative and intraoperative diagnosis to assess their accuracy for pancreatic schwannoma. The three most common preoperative diagnoses based on imaging for pancreatic schwannomas were cystic neoplasm (56%), pancreatic neuroendocrine tumor (29%) and mucinous cystic neoplasm (26%). Imaging could not definitely diagnose pancreatic schwannoma in any of the reported cases. To obtain a definite diagnosis before surgery, 25 cases underwent imaging-guided fine-needle aspiration (FNA)/biopsy, of which 60% were correctly reported as benign with definite diagnosis of pancreatic schwannoma in 48%. A higher diagnostic accuracy was observed in biopsies (71%) than FNA (37%). In addition, an intraoperative frozen section was carried out in 15 cases, and 47% were correctly diagnosed. Despite relatively low accuracy, preoperative histological assessment can be helpful in surgical managment. A core tissue specimen is recommended to improve the diagnostic accuracy in this setting.
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Prophylactic Pancreatectomies Carry Prohibitive Mortality at Low-Volume Centers: A California Cancer Registry Study. World J Surg 2019; 43:2290-2299. [PMID: 31062057 DOI: 10.1007/s00268-019-05019-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Pancreatectomy for malignancy is associated with improved outcomes when performed at high-volume centers. The goal of this study was to assess pancreatectomy outcomes for premalignant cystic lesions as a function of hospital volume. METHODS The Healthcare Cost and Utilization Project (HCUP) was queried for all pancreatectomies performed in California from 2003 to 2011. Cases were stratified, separating benign versus malignant disease. Hospitals were categorized as low-volume (≤25 pancreatectomies/year; LV) or high-volume (>25; HV) centers. Perioperative morbidity, mortality, and length of stay were compared in HV vs. LV centers. RESULTS There were 7554 pancreatectomies performed in 201 hospitals during the study period, where 5652 (75%) procedures were performed for malignancy, 338 (4%) for chronic pancreatitis, and 1564 (21%) for benign/premalignant cysts. The majority of pancreatectomies for cystic disease were performed at LV centers (65%). There were no significant differences in length of stay (7 vs. 8 days; p = 0.6) or 90-day readmission rates (12.8% vs. 12.9%; p = 1.0) in HV versus LV centers. However, there were higher surgical (46.2% LV vs. 41.1% HV, p = 0.05) and medical (13.3% LV vs. 9.2% HV; p = 0.017) complications at LV centers. Most importantly, there was a fourfold higher in-hospital mortality at LV centers (2.36% vs. 0.55%; p = 0.007). CONCLUSION Pancreatic resection for benign lesions at HV hospitals is associated with significantly lower morbidity and mortality, suggesting that when feasible, patients should seek care at high-volume centers for these semi-elective surgeries.
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Fernández Del Castillo C. Safe surgery for cystic tumors of the pancreas. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:85-86. [PMID: 30746958 DOI: 10.17235/reed.2019.6042/2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cystic tumors of the pancreas are a common indication for pancreatic surgery, and many of them are incidentally-discovered. Some of these tumors are malignant, and many others are pre-malignant. Less than two generations ago, pancreatic surgery was risky business. Surgical mortality, even in some of the best institutions in the world, was about 25%. Complications were very common and not infrequently patients required reoperations and had to remain in the hospital for weeks or even months. They emerged from this highly debilitated, and often went on to have a very poor quality of life. Not surprisingly, for these reasons, pancreatic resection was used only as a "last resort", and mostly for cancer.
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Kim TH, Woo YS, Chon HK, Hwang JH, Yoo KS, Lee WJ, Lee KH, Lee JK, Dong SH, Park CH, Park ET, Moon JH, Kim HG, Cho KB, Kim HJ, Lee SO, Cheon YK, Lee JM, Park JW, Kim MH. Predictors of Malignancy in "Pure" Branch-Duct Intraductal Papillary Mucinous Neoplasm of the Pancreas without Enhancing Mural Nodules on CT Imaging: A Nationwide Multicenter Study. Gut Liver 2019; 12:583-590. [PMID: 29730906 PMCID: PMC6143451 DOI: 10.5009/gnl17582] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 01/21/2018] [Accepted: 01/30/2018] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Presence of enhanced mural nodules, which can be visualized using computed tomography (CT), is one of high-risk stigmata in branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs). Conversely, the absence of enhanced mural nodules on preoperative imaging does not exclude malignant risk. The present study aimed to investigate other morphological features as predictors of malignancy in "pure" BD-IPMNs without enhanced mural nodules on CT. Methods This retrospective study included 180 patients with surgically confirmed "pure" BD-IPMNs of the pancreas and no enhanced mural nodules on preoperative CT. The study was conducted at 15 tertiary referral centers throughout South Korea. Univariate and multivariate analyses were used to identify significant predictors of malignancy. Results BD-IPMNs with low-grade (n=84) or moderate-grade (n=76) dysplasia were classified as benign; those with high-grade dysplasia (n=8) or invasive carcinoma (n=12) were classified as malignant. The multivariate analysis revealed that cyst size ≥30 mm (odds ratio, 8.6; p=0.001) and main pancreatic duct diameter ≥5 mm (odds ratio, 4.1; p=0.01) were independent risk factors for malignancy in "pure" BD-IPMNs without enhanced mural nodules on CT. Endoscopic ultrasound detected enhanced mural nodules (6/82) that had been missed on CT, and two IPMNs with enhanced mural nodules were malignant. Conclusions In patients with "pure" BD-IPMNs who have no enhanced mural nodules on CT, cyst size ≥30 mm and main pancreatic duct diameter ≥5 mm may be associated with malignancy.
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Affiliation(s)
- Tae-Hyeon Kim
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Young-Sik Woo
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyung-Ku Chon
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University College of Medicine, Seongnam, Korea
| | - Kyo-Sang Yoo
- Department of Internal Medicine, Hanyang University College of Medicine, Guri, Korea
| | - Woo-Jin Lee
- Pancreatobiliary Cancer Clinic, Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Kwang-Hyuck Lee
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Kyun Lee
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok-Ho Dong
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Chang-Hwan Park
- Department of Internal Medicine, Chonnam University College of Medicine, Gwangju, Korea
| | - Eun-Taek Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Jong-Ho Moon
- Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, Korea
| | - Ho-Gak Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Kwang-Bum Cho
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Hong-Ja Kim
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Seung-Ok Lee
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Young-Koog Cheon
- Digestive Disease Center, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jeong-Mi Lee
- Department of Public Health, Wonkwang University Graduate School, Iksan, Korea
| | - Jin-Woo Park
- Department of Internal Medicine, Hepatobiliary and Pancreas Center, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Pancreatic Head Carcinoma-Implications and Correlations in a Romanian Population. CURRENT HEALTH SCIENCES JOURNAL 2019; 44:231-234. [PMID: 30647942 PMCID: PMC6311222 DOI: 10.12865/chsj.44.03.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 09/28/2018] [Indexed: 11/29/2022]
Abstract
Introduction: Pancreatic cancers are often an aggressive type of malignancy,
with a 5-year survival rate estimated at around 5%. The main purpose of our
study was to determine whether or not tumor dimensions influence the presence
of jaundice and the diameters of the CBD and Wirsung duct. Material and methods:
The study group included 32 patients (19 males, 13 females) diagnosed with
various histological types of pancreatic head cancers who were hospitalized
in the Surgery Department of the County Clinical Emergency Hospital of Craiova
during 2016-2018. All 32 patients underwent an initial abdominal ultrasonography
(US), followed by an abdominal computed tomography (CT) scan and an abdominal
magnetic resonance imaging (MRI) with magnetic resonance
cholangiopancreatography (MRCP) sequences. Results: Based on tumor dimensions,
19 (59.38%) were equal to or larger than 30mm, while 13 (40.62%) were smaller
than 30mm. The average age of male patients was 65.15 years, while the average
age of female patients was 60.07 years. Tumor dimensions ranged between 22mm
and 52mm (33.53mm on average). Furthermore, the diameter of the CBD ranged from
5mm to 20mm (13.40mm on average), while the diameter of the Wirsung duct ranged
from 3mm to 12mm (5.75 mm on average). Conclusion: In conclusion, our study
reached its’ initial purpose and revealed a significant association between the
tumor dimensions and the diameter of the Wirsung duct and also between the
diameter of the CBD and the presence of jaundice.
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Wei R, Lin K, Yan W, Guo Y, Wang Y, Li J, Zhu J. Computer-Aided Diagnosis of Pancreas Serous Cystic Neoplasms: A Radiomics Method on Preoperative MDCT Images. Technol Cancer Res Treat 2019; 18:1533033818824339. [PMID: 30803366 PMCID: PMC6374001 DOI: 10.1177/1533033818824339] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 08/07/2018] [Accepted: 09/06/2018] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Our aim was to propose a preoperative computer-aided diagnosis scheme to differentiate pancreatic serous cystic neoplasms from other pancreatic cystic neoplasms, providing supportive opinions for clinicians and avoiding overtreatment. MATERIALS AND METHODS In this retrospective study, 260 patients with pancreatic cystic neoplasm were included. Each patient underwent a multidetector row computed tomography scan and pancreatic resection. In all, 200 patients constituted a cross-validation cohort, and 60 patients formed an independent validation cohort. Demographic information, clinical information, and multidetector row computed tomography images were obtained from Picture Archiving and Communication Systems. The peripheral margin of each neoplasm was manually outlined by experienced radiologists. A radiomics system containing 24 guideline-based features and 385 radiomics high-throughput features was designed. After the feature extraction, least absolute shrinkage selection operator regression was used to select the most important features. A support vector machine classifier with 5-fold cross-validation was applied to build the diagnostic model. The independent validation cohort was used to validate the performance. RESULTS Only 31 of 102 serous cystic neoplasm cases in this study were recognized correctly by clinicians before the surgery. Twenty-two features were selected from the radiomics system after 100 bootstrapping repetitions of the least absolute shrinkage selection operator regression. The diagnostic scheme performed accurately and robustly, showing the area under the receiver operating characteristic curve = 0.767, sensitivity = 0.686, and specificity = 0.709. In the independent validation cohort, we acquired similar results with receiver operating characteristic curve = 0.837, sensitivity = 0.667, and specificity = 0.818. CONCLUSION The proposed radiomics-based computer-aided diagnosis scheme could increase preoperative diagnostic accuracy and assist clinicians in making accurate management decisions.
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Affiliation(s)
- Ran Wei
- Department of Electronic Engineering, Fudan University, Shanghai, China
- Key Laboratory of Medical Imaging, Computing and Computer-Assisted Intervention, Shanghai Medical College, Fudan University, Shanghai, China
| | - Kanru Lin
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wenjun Yan
- Department of Electronic Engineering, Fudan University, Shanghai, China
- Key Laboratory of Medical Imaging, Computing and Computer-Assisted Intervention, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yi Guo
- Department of Electronic Engineering, Fudan University, Shanghai, China
- Key Laboratory of Medical Imaging, Computing and Computer-Assisted Intervention, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yuanyuan Wang
- Department of Electronic Engineering, Fudan University, Shanghai, China
- Key Laboratory of Medical Imaging, Computing and Computer-Assisted Intervention, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ji Li
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jianqing Zhu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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Nguyen AK, Girgis A, Tekeste T, Chang K, Adeyemo M, Eskandari A, Alonso E, Yaramada P, Chaya C, Ko A, Burke E, Roggow I, Butler R, Kawatkar A, Lim BS. Effect of a region-wide incorporation of an algorithm based on the 2012 international consensus guideline on the practice pattern for the management of pancreatic cystic neoplasms in an integrated health system. World J Clin Cases 2018; 6:624-631. [PMID: 30430117 PMCID: PMC6232565 DOI: 10.12998/wjcc.v6.i13.624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 09/16/2018] [Accepted: 10/11/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To examine the practice pattern in Kaiser Permanente Southern California (KPSC), i.e., gastroenterology (GI)/surgery referrals and endoscopic ultrasound (EUS), for pancreatic cystic neoplasms (PCNs) after the region-wide dissemination of the PCN management algorithm.
METHODS Retrospective review was performed; patients with PCN diagnosis given between April 2012 and April 2015 (18 mo before and after the publication of the algorithm) in KPSC (integrated health system with 15 hospitals and 202 medical offices in Southern California) were identified.
RESULTS 2558 (1157 pre- and 1401 post-algorithm) received a new diagnosis of PCN in the study period. There was no difference in the mean cyst size (pre- 19.1 mm vs post- 18.5 mm, P = 0.119). A smaller percentage of PCNs resulted in EUS after the implementation of the algorithm (pre- 45.5% vs post- 34.8%, P < 0.001). A smaller proportion of patients were referred for GI (pre- 65.2% vs post- 53.3%, P < 0.001) and surgery consultations (pre- 24.8% vs post- 16%, P < 0.001) for PCN after the implementation. There was no significant change in operations for PCNs. Cost of diagnostic care was reduced after the implementation by 24%, 18%, and 36% for EUS, GI, and surgery consultations, respectively, with total cost saving of 24%.
CONCLUSION In the current healthcare climate, there is increased need to optimize resource utilization. Dissemination of an algorithm for PCN management in an integrated health system resulted in fewer EUS and GI/surgery referrals, likely by aiding the physicians ordering imaging studies in the decision making for the management of PCNs. This translated to cost saving of 24%, 18%, and 36% for EUS, GI, and surgical consultations, respectively, with total diagnostic cost saving of 24%.
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Affiliation(s)
- Andrew Khoi Nguyen
- School of Medicine, University of California, Riverside, CA 92521, United States
| | - Agathon Girgis
- School of Medicine, University of California, Riverside, CA 92521, United States
| | - Timnit Tekeste
- School of Medicine, University of California, Riverside, CA 92521, United States
| | - Karen Chang
- School of Medicine, University of California, Riverside, CA 92521, United States
| | - Mopelola Adeyemo
- School of Medicine, University of California, Riverside, CA 92521, United States
| | - Armen Eskandari
- School of Medicine, University of California, Riverside, CA 92521, United States
| | - Emilio Alonso
- School of Medicine, University of California, Riverside, CA 92521, United States
| | - Priyanka Yaramada
- School of Medicine, University of California, Riverside, CA 92521, United States
| | - Charles Chaya
- Department of Gastroenterology, Kaiser Permanente Riverside Medical Center, Riverside, CA 92521, United States
| | - Albert Ko
- Department of Surgery, Kaiser Permanente Riverside Medical Center, Riverside, CA 92521, United States
| | - Edmund Burke
- Department of Surgery, Kaiser Permanente Riverside Medical Center, Riverside, CA 92521, United States
| | - Isaiah Roggow
- School of Medicine, University of California, Riverside, CA 92521, United States
| | - Rebecca Butler
- Department of Research and Evaluation, Southern California Permanente Medical Group, Pasadena, CA 92521, United States
| | - Aniket Kawatkar
- Department of Research and Evaluation, Southern California Permanente Medical Group, Pasadena, CA 92521, United States
| | - Brian S Lim
- School of Medicine, University of California, Riverside, CA 92521, United States
- Department of Gastroenterology, Kaiser Permanente Riverside Medical Center, Riverside, CA 92521, United States
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Ideno N, Yamaguchi H, Ghosh B, Gupta S, Okumura T, Steffen DJ, Fisher CG, Wood LD, Singhi AD, Nakamura M, Gutkind JS, Maitra A. GNAS R201C Induces Pancreatic Cystic Neoplasms in Mice That Express Activated KRAS by Inhibiting YAP1 Signaling. Gastroenterology 2018; 155:1593-1607.e12. [PMID: 30142336 PMCID: PMC6219919 DOI: 10.1053/j.gastro.2018.08.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/16/2018] [Accepted: 08/01/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Mutations at hotspots in GNAS, which encodes stimulatory G-protein, α subunits, are detected in approximately 60% of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. We generated mice with KRAS-induced IPMNs that also express a constitutively active form of GNAS in pancreas and studied tumor development. METHODS We generated p48-Cre; LSL-KrasG12D; Rosa26R-LSL-rtTA-TetO-GnasR201C mice (Kras;Gnas mice); pancreatic tissues of these mice express activated KRAS and also express a mutant form of GNAS (GNASR201C) upon doxycycline administration. Mice that were not given doxycycline were used as controls, and survival times were compared by Kaplan-Meier analysis. Pancreata were collected at different time points after doxycycline administration and analyzed by histology. Pancreatic ductal adenocarcinomas (PDACs) were isolated from mice and used to generate cell lines, which were analyzed by reverse transcription polymerase chain reaction, immunoblotting, immunohistochemistry, and colony formation and invasion assays. Full-length and mutant forms of yes-associated protein (YAP) were expressed in PDAC cells. IPMN specimens were obtained from 13 patients with IPMN undergoing surgery and analyzed by immunohistochemistry. RESULTS All Kras;Gnas mice developed pancreatic cystic lesions that resemble human IPMNs; the grade of epithelial dysplasia increased with time. None of the control mice developed cystic lesions. Approximately one third of Kras;Gnas mice developed PDACs at a median of 30 weeks after doxycycline administration, whereas 33% of control mice developed PDACs. Expression of GNASR201C did not accelerate the development of PDACs compared with control mice. However, the neoplasms observed in Kras;Gnas mice were more differentiated, and expressed more genes associated with ductal phenotypes, than in control mice. PDACs isolated from Kras;Gnas mice had activation of the Hippo pathway; in cells from these tumors, phosphorylated YAP1 was sequestered in the cytoplasm, and this was also observed in human IPMNs with GNAS mutations. Sequestration of YAP1 was not observed in PDAC cells from control mice. CONCLUSIONS In mice that express activated KRAS in the pancreas, we found expression of GNASR201C to cause development of more differentiated tumors, with gene expression pattern associated with the ductal phenotype. Expression of mutant GNAS caused phosphorylated YAP1 to be sequestered in the cytoplasm, altering tumor progression.
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Affiliation(s)
- Noboru Ideno
- Department of Translational Molecular Pathology, Sheikh Ahmed Center for Pancreatic Cancer Center, Houston, Texas.
| | - Hiroshi Yamaguchi
- Department of Translational Molecular Pathology, Houston, Texas 77030, USA,Sheikh Ahmed Center for Pancreatic Cancer Center, Houston, Texas 77030, USA
| | - Bidyut Ghosh
- Department of Translational Molecular Pathology, Houston, Texas 77030, USA,Sheikh Ahmed Center for Pancreatic Cancer Center, Houston, Texas 77030, USA
| | - Sonal Gupta
- Department of Translational Molecular Pathology, Houston, Texas 77030, USA,Sheikh Ahmed Center for Pancreatic Cancer Center, Houston, Texas 77030, USA
| | - Takashi Okumura
- Department of Translational Molecular Pathology, Houston, Texas 77030, USA,Sheikh Ahmed Center for Pancreatic Cancer Center, Houston, Texas 77030, USA
| | - Dana J Steffen
- Department of Pharmacology, University of California San Diego, La Jolla, California 92093, USA
| | - Catherine G Fisher
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Baltimore 21287, USA
| | - Laura D Wood
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Baltimore 21287, USA,Department of Oncology, Sol Goldman Pancreatic Cancer Research Center, Baltimore 21287, USA
| | - Aatur D. Singhi
- Department of Anatomic Pathology, University of Pittsburgh, Pittsburgh 15260, USA
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - J Silvio Gutkind
- Department of Pharmacology, University of California San Diego, La Jolla, California 92093, USA
| | - Anirban Maitra
- Department of Translational Molecular Pathology, Houston, Texas 77030, USA,Sheikh Ahmed Center for Pancreatic Cancer Center, Houston, Texas 77030, USA
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Kaplan JH, Gonda TA. The Use of Biomarkers in the Risk Stratification of Cystic Neoplasms. Gastrointest Endosc Clin N Am 2018; 28:549-568. [PMID: 30241643 DOI: 10.1016/j.giec.2018.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Cyst fluid biomarkers may be used to identify pancreatic cyst subtypes. Biomarkers are selected based on their ability to accurately distinguish mucinous from nonmucinous cysts and to risk stratify cysts based on malignant potential. Biomarkers of interest include but are not limited to amylase, oncogenes, DNA analysis, and epigenetic markers. The introduction of next-generation sequencing and molecular panels has aided in improved diagnostic accuracy and risk stratification. This review presents the diagnostic performance of currently available biomarkers and proposes an algorithm to incorporate their use in the diagnosis of pancreatic cysts.
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Affiliation(s)
- Jeremy H Kaplan
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - Tamas A Gonda
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University, 161 Fort Washington Avenue, New York, NY 10032, USA.
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Levink I, Bruno MJ, Cahen DL. Management of Intraductal Papillary Mucinous Neoplasms: Controversies in Guidelines and Future Perspectives. ACTA ACUST UNITED AC 2018; 16:316-332. [PMID: 30196428 PMCID: PMC6153570 DOI: 10.1007/s11938-018-0190-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose of review Management of intraductal papillary mucinous neoplasm (IPMN) is currently based on consensus, in the absence of evidence-based guidelines. In recent years, several consensus guidelines have been published, with distinct management strategies. In this review, we will discuss these discrepancies, in order to guide treating physicians in clinical management. Recent findings The detection rate of pancreatic cysts has increased substantially with the expanded use of high-quality imaging techniques to up to 45%. Of these cysts, 24–82% are IPMNs, which harbour a malignant potential. Timely detection of high-risk lesions is therefore of great importance. Surgical management is based on the presence of clinical and morphological high-risk features, yet the majority of resected specimens appear to be low risk. Summary International collaboration and incentive large-scale prospective registries of individuals undergoing cyst surveillance are needed to accumulate unbiased data and develop evidence-based guidelines. Additionally, development of non-invasive, accurate diagnostic tools (e.g. biomarkers) is needed to differentiate between neoplastic and non-neoplastic pancreatic cysts and detect malignant transformation at an early stage (i.e. high-grade dysplasia).
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Affiliation(s)
- Ijm Levink
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - D L Cahen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
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Lai JH, Lin CC, Liu CY. The endoscopic ultrasound diagnosis of pancreatic ductal adenocarcinoma with cystic degeneration. ADVANCES IN DIGESTIVE MEDICINE 2018. [DOI: 10.1002/aid2.13086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jian-Han Lai
- Division of Gastroenterology, Department of Internal Medicine; MacKay Memorial Hospital; Taipei Taiwan
- MacKay Medicine; Nursing and Management College; Taipei Taiwan
- Department of Medicine, MacKay Medical College; New Taipei Taiwan
| | - Ching-Chung Lin
- Division of Gastroenterology, Department of Internal Medicine; MacKay Memorial Hospital; Taipei Taiwan
- MacKay Medicine; Nursing and Management College; Taipei Taiwan
- Department of Medicine, MacKay Medical College; New Taipei Taiwan
| | - Chia-Yuan Liu
- Division of Gastroenterology, Department of Internal Medicine; MacKay Memorial Hospital; Taipei Taiwan
- MacKay Medicine; Nursing and Management College; Taipei Taiwan
- Department of Medicine, MacKay Medical College; New Taipei Taiwan
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45
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Risk of Pancreatic Cancer in Patients With Pancreatic Cysts and Family History of Pancreatic Cancer. Clin Gastroenterol Hepatol 2018; 16:1123-1130.e1. [PMID: 29425780 DOI: 10.1016/j.cgh.2018.01.049] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 01/26/2018] [Accepted: 01/31/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS A diagnosis of pancreatic cancer in a first-degree relative increases an individuals' risk of this cancer. However, it is not clear whether this cancer risk increases in individuals with pancreatic cystic lesions who have a first-degree relative with pancreatic cancer. The Fukuoka criteria are used to estimate risk of pancreatic cancer for patients with pancreatic cystic lesions: individuals with cysts with high risk or worrisome features (Fukuoka positive) have a higher risk of pancreatic cancer than individuals without these features (Fukuoka negative). We aimed to compare the risk of pancreatic cancer and surgery based on presence or absence of pancreatic cystic lesions and a first-degree relative with pancreatic cancer. METHODS We performed a retrospective study of patients seen at the Mayo Clinic in Rochester, Minnesota, from January 1, 2000, through December 31, 2012. We identified individuals with: pancreatic cystic lesions and first-degree relative with pancreatic cancer (group 1, n = 269), individuals with pancreatic cystic lesions but no first-degree relative with pancreatic cancer (group 2, n = 1195), and individuals without pancreatic cystic lesions but with a first-degree relative with pancreatic cancer (group 3, n = 720). We compared, among groups, as well among patients with cysts classified according to Fukuoka criteria, proportions of individuals who developed pancreatic cancer or underwent pancreatic surgery within a 5-year period. RESULTS A significantly higher proportion of individuals in group 1 developed pancreatic cancer during the 5-year period than in group 3 (6.64% vs 1.69%; P = .03); there was no significant difference between the percentage of individuals in group 1 vs group 2 who developed pancreatic cancer (6.64% vs 4.05%; P = .41). There was no significant difference in pancreatic cancer development among individuals with Fukuoka-positive cysts with vs without a family history of pancreatic cancer (P = .39). There was no significant difference in the proportion of patients in group 1 vs group 2 who underwent pancreatic surgery for their pancreatic cyst over the 5-year period (14.37% vs 11.80%; P = .59). Among patients with Fukuoka-negative cysts, a significantly higher proportion underwent surgery in group 1 than in group 2 (10.90% vs 5.90%; P = .03). However, among patients with Fukuoka-positive cysts, there was no difference in proportions of patients who underwent surgery between groups 1 and 2 (P = .66). CONCLUSIONS In a retrospective study of patients with pancreatic cysts and/or cancer, we found that a family history of pancreatic cancer does not affect 5-year risk of pancreatic cancer in patients with pancreatic cystic lesions. Despite this, among patients with Fukuoka-negative cysts, a higher proportion of those with a family history of pancreatic cancer undergo surgery than patients without family history of pancreatic cancer.
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Patra KC, Kato Y, Mizukami Y, Widholz S, Boukhali M, Revenco I, Grossman EA, Ji F, Sadreyev RI, Liss AS, Screaton RA, Sakamoto K, Ryan DP, Mino-Kenudson M, Castillo CFD, Nomura DK, Haas W, Bardeesy N. Mutant GNAS drives pancreatic tumourigenesis by inducing PKA-mediated SIK suppression and reprogramming lipid metabolism. Nat Cell Biol 2018; 20:811-822. [PMID: 29941929 PMCID: PMC6044476 DOI: 10.1038/s41556-018-0122-3] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 05/15/2018] [Indexed: 12/13/2022]
Abstract
G protein αs (GNAS) mediates receptor-stimulated cAMP signalling, which integrates diverse environmental cues with intracellular responses. GNAS is mutationally activated in multiple tumour types, although its oncogenic mechanisms remain elusive. We explored this question in pancreatic tumourigenesis where concurrent GNAS and KRAS mutations characterize pancreatic ductal adenocarcinomas (PDAs) arising from intraductal papillary mucinous neoplasms (IPMNs). By developing genetically engineered mouse models, we show that GnasR201C cooperates with KrasG12D to promote initiation of IPMN, which progress to invasive PDA following Tp53 loss. Mutant Gnas remains critical for tumour maintenance in vivo. This is driven by protein-kinase-A-mediated suppression of salt-inducible kinases (Sik1-3), associated with induction of lipid remodelling and fatty acid oxidation. Comparison of Kras-mutant pancreatic cancer cells with and without Gnas mutations reveals striking differences in the functions of this network. Thus, we uncover Gnas-driven oncogenic mechanisms, identify Siks as potent tumour suppressors, and demonstrate unanticipated metabolic heterogeneity among Kras-mutant pancreatic neoplasms.
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MESH Headings
- Animals
- Carcinoma, Pancreatic Ductal/enzymology
- Carcinoma, Pancreatic Ductal/genetics
- Carcinoma, Pancreatic Ductal/pathology
- Cell Line, Tumor
- Cell Transformation, Neoplastic/genetics
- Cell Transformation, Neoplastic/metabolism
- Cell Transformation, Neoplastic/pathology
- Cellular Reprogramming/genetics
- Chromogranins/genetics
- Chromogranins/metabolism
- Cyclic AMP-Dependent Protein Kinases/genetics
- Cyclic AMP-Dependent Protein Kinases/metabolism
- Enzyme Repression
- Fatty Acids/metabolism
- Female
- GTP-Binding Protein alpha Subunits, Gs/genetics
- GTP-Binding Protein alpha Subunits, Gs/metabolism
- Gene Expression Regulation, Neoplastic
- Genes, ras
- Genetic Predisposition to Disease
- Humans
- Lipid Metabolism/genetics
- Male
- Mice, 129 Strain
- Mice, Inbred C57BL
- Mice, Inbred NOD
- Mice, Mutant Strains
- Mice, Transgenic
- Mutation
- Oxidation-Reduction
- Pancreatic Neoplasms/enzymology
- Pancreatic Neoplasms/genetics
- Pancreatic Neoplasms/pathology
- Phenotype
- Protein Serine-Threonine Kinases/genetics
- Protein Serine-Threonine Kinases/metabolism
- Signal Transduction
- Time Factors
- Tumor Cells, Cultured
- Tumor Suppressor Protein p53/genetics
- Tumor Suppressor Protein p53/metabolism
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Affiliation(s)
- Krushna C Patra
- Center for Cancer Research, Massachusetts General Hospital, Boston, MA, USA
- Departments of Medicine, Harvard Medical School, Boston, MA, USA
| | - Yasutaka Kato
- Center for Cancer Research, Massachusetts General Hospital, Boston, MA, USA
| | - Yusuke Mizukami
- Center for Cancer Research, Massachusetts General Hospital, Boston, MA, USA
- Institute of Biomedical Research, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
- Asahikawa Medical University, Hokkaido, Japan
| | - Sebastian Widholz
- Center for Cancer Research, Massachusetts General Hospital, Boston, MA, USA
| | - Myriam Boukhali
- Center for Cancer Research, Massachusetts General Hospital, Boston, MA, USA
| | - Iulia Revenco
- Center for Cancer Research, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth A Grossman
- Departments of Nutritional Sciences and Toxicology, Chemistry, and Molecular and Cell Biology, University of California, Berkeley, CA, USA
| | - Fei Ji
- Departments of Molecular Biology, Massachusetts General Hospital, Boston, MA, USA
- Department of Genetics, Harvard Medical School, Boston, MA, USA
| | - Ruslan I Sadreyev
- Center for Cancer Research, Massachusetts General Hospital, Boston, MA, USA
- Departments of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Andrew S Liss
- Center for Cancer Research, Massachusetts General Hospital, Boston, MA, USA
| | - Robert A Screaton
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Biochemistry, University of Toronto, Toronto, Ontario, Canada
| | - Kei Sakamoto
- MRC Protein Phosphorylation and Ubiquitylation Unit, School of Life Sciences, University of Dundee, Scotland, UK
- Nestlé Institute of Health Sciences SA, Lausanne, Switzerland
| | - David P Ryan
- Center for Cancer Research, Massachusetts General Hospital, Boston, MA, USA
- Departments of Medicine, Harvard Medical School, Boston, MA, USA
| | - Mari Mino-Kenudson
- Center for Cancer Research, Massachusetts General Hospital, Boston, MA, USA
- Departments of Pathology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Harvard Medical School, Boston, MA, USA
| | - Carlos Fernandez-Del Castillo
- Center for Cancer Research, Massachusetts General Hospital, Boston, MA, USA
- Departments of Surgery, Massachusetts General Hospital, Boston, MA, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Daniel K Nomura
- Departments of Nutritional Sciences and Toxicology, Chemistry, and Molecular and Cell Biology, University of California, Berkeley, CA, USA
| | - Wilhelm Haas
- Center for Cancer Research, Massachusetts General Hospital, Boston, MA, USA
| | - Nabeel Bardeesy
- Center for Cancer Research, Massachusetts General Hospital, Boston, MA, USA.
- Departments of Medicine, Harvard Medical School, Boston, MA, USA.
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47
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Welinsky S, Lucas AL. Familial Pancreatic Cancer and the Future of Directed Screening. Gut Liver 2018; 11:761-770. [PMID: 28609837 PMCID: PMC5669591 DOI: 10.5009/gnl16414] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 11/01/2016] [Accepted: 11/01/2016] [Indexed: 12/11/2022] Open
Abstract
Pancreatic cancer (PC) is the third most common cause of cancer-related death in the United States and the 12th most common worldwide. Mortality is high, largely due to late stage of presentation and suboptimal treatment regimens. Approximately 10% of PC cases have a familial basis. The major genetic defect has yet to be identified but may be inherited by an autosomal dominant pattern with reduced penetrance. Several known hereditary syndromes or genes are associated with an increased risk of developing PC and account for approximately 2% of PCs. These syndromes include the hereditary breast-ovarian cancer syndrome, Peutz-Jeghers syndrome, familial atypical multiple mole melanoma, Lynch syndrome, familial polyposis, ataxia-telangiectasia, and hereditary pancreatitis. Appropriate screening using methods such as biomarkers or imaging, with endoscopic ultrasound and magnetic resonance imaging, may assist in the early detection of neoplastic lesions in the high-risk population. If these lesions are detected and treated before the development of invasive carcinoma, PC disease morbidity and mortality may be improved. This review will focus on familial PC and other hereditary syndromes implicated in the increased risk of PC; it will also highlight current screening methods and the future of new screening modalities.
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Affiliation(s)
- Sara Welinsky
- Samuel F. Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aimee L Lucas
- Samuel F. Bronfman Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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48
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Petrone MC, Magnoni P, Pergolini I, Capurso G, Traini M, Doglioni C, Mariani A, Crippa S, Arcidiacono PG. Long-term follow-up of low-risk branch-duct IPMNs of the pancreas: is main pancreatic duct dilatation the most worrisome feature? Clin Transl Gastroenterol 2018; 9:158. [PMID: 29895904 PMCID: PMC5997632 DOI: 10.1038/s41424-018-0026-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 03/14/2018] [Accepted: 04/23/2018] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES The management of branch-duct IPMN remains controversial due to the relatively low rate of malignant degeneration and the uncertain predictive role of high-risk stigmata (HRS) and worrisome features (WFs) identified by the 2012 International Consensus Guidelines. Our aim was to evaluate the evolution of originally low-risk (Fukuoka-negative) BD-IPMNs during a long follow-up period in order to determine whether the appearance of any clinical or morphological variables may be independently associated with the development of malignancy over time. METHODS A prospectively collected database of all patients with BD-IPMN referring to our Institute between 2002 and 2016 was retrospectively analyzed. Univariate and multivariate analysis of association between changes during follow-up, including appearance of HRS/WFs, and development of malignancy (high-grade dysplasia/invasive carcinoma) was performed. RESULTS A total of 167 patients were selected for analysis, and seven developed malignant disease (4.2%). During a median follow-up time of 55 months, HRS appeared in only three cases but predicted malignancy with 100% specificity. Worrisome features, on the other hand, appeared in 44 patients (26.3%). Appearance of mural nodules and MPD dilatation >5 mm showed a significant association with malignancy in multivariate analysis (p = 0.004 and p = 0.001, respectively). MPD dilatation in particular proved to be the strongest independent risk factor for development of malignancy (OR = 24.5). CONCLUSIONS The risk of pancreatic malignancy in this population is low but definite. The presence of major WFs, and especially MPD dilatation, should prompt a tighter follow-up with EUS and a valid cytological analysis whenever feasible.
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Affiliation(s)
- Maria Chiara Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Pietro Magnoni
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ilaria Pergolini
- Department of Surgery, Università Politecnica delle Marche, Ancona, Italy
| | - Gabriele Capurso
- Digestive and Liver Disease Unit, S. Andrea University Hospital, Rome, Italy
| | - Mariaemilia Traini
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Claudio Doglioni
- Department of Pathology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Mariani
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Crippa
- Pancreas Translational & Clinical Research Center, Division of Pancreatic Surgery, Università Vita-Salute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy
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49
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Lévy P, Rebours V. The Role of Endoscopic Ultrasound in the Diagnosis of Cystic Lesions of the Pancreas. Visc Med 2018; 34:192-196. [PMID: 30140684 DOI: 10.1159/000489242] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
A precise diagnosis of the nature of pancreatic cystic neoplasm (PCN) is crucial since it determines the patients in need of rapid surgical resection as well as those who can be followed up, and, accordingly, the frequency and modalities of surveillance. Endoscopic ultrasound (EUS) and especially fine needle aspiration (FNA) are invasive methods, with specific adverse events occurring in 2.7-5%. Thus, they should only be used as a third-line tool in the absence of characteristic radiographic features on computed tomography (CT) scan and magnetic resonance imaging (MRI). The most difficult aspects of differential diagnosis are: intraductal papillary mucinous neoplasm (IPMN) versus chronic pancreatitis; unifocal IPMN versus serous cystic neoplasm (SCN); macrocystic SCN versus mucinous cystic neoplasm (MCN); cystic neuroendocrine tumors versus MCN; solid serous cystadenoma versus neuroendocrine tumors versus small solid pseudopapillary tumors; pseudocyst versus MCN; low-grade, high-grade, or invasive IPMN. When classical radiological and EUS features are not conclusive, EUS-FNA may be helpful by analyzing cytological, chemical, and/or molecular data. The addition of EUS-FNA to CT scan and MRI increased the overall accuracy for diagnosing PCN by 36 and 54%, respectively. Analysis of molecular markers in pancreatic cyst fluid might increase the limited accuracy of EUS-FNA by using cytology and chemical and/or tumor marker analysis alone. Current evidence suggests that contrast-enhanced EUS (CH-EUS) is highly accurate for distinguishing non-neoplastic cysts from neoplastic cysts. CH-EUS might also be useful for distinguishing mural epithelial nodules from mucinous clots. Needle-based confocal laser endomicroscopy (nCLE) images a target tissue at a subcellular level of resolution, providing real-time in-vivo optical biopsy. nCLE is feasible during EUS-FNA and allows in-vivo diagnosis of PCN with high accuracy. In conclusion, EUS is a third-line tool in the diagnosis of PCN. Clinical context as well as careful evaluation of CT scan and magnetic resonance cholangiopancreatography images by specialized radiologists are crucial in the diagnosis process. Nowadays it is inconceivable to skip these steps.
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Affiliation(s)
- Philippe Lévy
- Department of Gastroenterology and Pancreatology, Pôle des Maladies de l'Appareil Digestif, DHU Unity, Hôpital Beaujon, Faculté Denis Diderot, AP-HP, Clichy, France.,Centre de référence des maladies rares du pancréas (PAncreatic RAre DISeases), Hôpital Beaujon, Clichy, France.,Centre de référence européen des tumeurs neuroendocrines digestives et pancréatiques, Hôpital Beaujon, Clichy, France
| | - Vinciane Rebours
- Department of Gastroenterology and Pancreatology, Pôle des Maladies de l'Appareil Digestif, DHU Unity, Hôpital Beaujon, Faculté Denis Diderot, AP-HP, Clichy, France.,Centre de référence des maladies rares du pancréas (PAncreatic RAre DISeases), Hôpital Beaujon, Clichy, France.,Centre de référence européen des tumeurs neuroendocrines digestives et pancréatiques, Hôpital Beaujon, Clichy, France
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50
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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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