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Megibow AJ. Pancreatic Cysts: Radiology. Gastrointest Endosc Clin N Am 2023; 33:519-531. [PMID: 37245933 DOI: 10.1016/j.giec.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This article reviews the types of pancreatic cysts encountered in Radiologic practice. It summarizes the malignancy risk of each of the following: serous cystadenoma, mucinous cystic tumor, intraductal papillary mucinous neoplasm main duct and side branch, and some miscellaneous cysts such as neuroendocrine tumor and solid pseudopapillary epithelial neoplasm. Specific reporting recommendations are given. The choice between radiology follow-up versus endoscopic analysis is discussed.
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Affiliation(s)
- Alec J Megibow
- Department of Radiology, NYU-Langone Health, 550 1st Avenue, Room HCC 232, New York, NY 10016, USA.
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2
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Taya M, Hecht EM, Huang C, Lo GC. Pancreatic Cystic Lesions: Imaging Techniques and Diagnostic Features. Gastrointest Endosc Clin N Am 2023; 33:497-518. [PMID: 37245932 DOI: 10.1016/j.giec.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The detection of incidental pancreatic cystic lesions has increased over time. It is crucial to separate benign from potentially malignant or malignant lesions to guide management and reduce morbidity and mortality. The key imaging features used to fully characterize cystic lesions are optimally assessed by contrast-enhanced magnetic resonance imaging/magnetic resonance cholangiopancreatography, with pancreas protocol computed tomography offering a complementary role. While some imaging features have high specificity for a particular diagnosis, overlapping imaging features between diagnoses may require further investigation with follow-up diagnostic imaging or tissue sampling.
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Affiliation(s)
- Michio Taya
- Department of Radiology, New York Presbyterian - Weill Cornell Medicine, 520 East 70th Street, Starr 8a, New York, NY 10021, USA
| | - Elizabeth M Hecht
- Department of Radiology, New York Presbyterian - Weill Cornell Medicine, 520 East 70th Street, Starr 8a, New York, NY 10021, USA
| | - Chenchan Huang
- Department of Radiology, NYU Grossman School of Medicine, 560 1st Avenue, 2F, New York, NY 10016, USA
| | - Grace C Lo
- Department of Radiology, New York Presbyterian - Weill Cornell Medicine, 520 East 70th Street, Starr 8a, New York, NY 10021, USA.
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3
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Quantitative MRI of Pancreatic Cystic Lesions: A New Diagnostic Approach. Healthcare (Basel) 2022; 10:healthcare10061039. [PMID: 35742090 PMCID: PMC9222599 DOI: 10.3390/healthcare10061039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 02/01/2023] Open
Abstract
The commonly used magnetic resonance (MRI) criteria can be insufficient for discriminating mucinous from non-mucinous pancreatic cystic lesions (PCLs). The histological differences between PCLs’ fluid composition may be reflected in MRI images, but cannot be assessed by visual evaluation alone. We investigate whether additional MRI quantitative parameters such as signal intensity measurements (SIMs) and radiomics texture analysis (TA) can aid the differentiation between mucinous and non-mucinous PCLs. Fifty-nine PCLs (mucinous, n = 24; non-mucinous, n = 35) are retrospectively included. The SIMs were performed by two radiologists on T2 and diffusion-weighted images (T2WI and DWI) and apparent diffusion coefficient (ADC) maps. A total of 550 radiomic features were extracted from the T2WI and ADC maps of every lesion. The SIMs and TA features were compared between entities using univariate, receiver-operating, and multivariate analysis. The SIM analysis showed no statistically significant differences between the two groups (p = 0.69, 0.21–0.43, and 0.98 for T2, DWI, and ADC, respectively). Mucinous and non-mucinous PLCs were successfully discriminated by both T2-based (83.2–100% sensitivity and 69.3–96.2% specificity) and ADC-based (40–85% sensitivity and 60–96.67% specificity) radiomic features. SIMs cannot reliably discriminate between PCLs. Radiomics have the potential to augment the common MRI diagnosis of PLCs by providing quantitative and reproducible imaging features, but validation is required by further studies.
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Yadav RK, Jiang X, Chen J. Differentiating benign from malignant pancreatic cysts on computed tomography. Eur J Radiol Open 2020; 7:100278. [PMID: 33163586 PMCID: PMC7607418 DOI: 10.1016/j.ejro.2020.100278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/11/2020] [Accepted: 09/23/2020] [Indexed: 12/19/2022] Open
Abstract
CT can distinguish between benign and premalignant or malignant pancreatic cysts. Solid component and septation were the only CT features that could differentiate benign from malignant cysts. Cyst wall enhancements on CT were more commonly observed in premalignant or malignant cysts than in benign cysts. CT is a necessary diagnostic modality to preoperatively detect and characterize pancreatic lesions.
Purpose It is important to identify features on computed tomography (CT) that can distinguish between benign and premalignant or malignant pancreatic cysts to avoid unnecessary surgeries. This study investigated the preoperative diagnostic evaluation of cystic pancreatic lesions to determine how advanced imaging and clinical factors should guide management. Methods In total, 53 patients with 27 benign and 26 premalignant or malignant cysts were enrolled. CT features of the cysts were compared using univariate and multivariate analyses. Results On univariate analysis, a solid component (p < 0.01), septation (p < 0.01), location (p < 0.01), border (p < 0.01), wall enhancement (p = 0.01), lesion margins (p < 0.01), pancreatic atrophy (p = 0.04), and a cystic wall (p < 0.01) were all significantly different between benign and premalignant or malignant cysts. On multivariate analysis, only a solid component (p < 0.01) and septation (p < 0.01) were significant. Conclusion A thin cystic wall, uniform homogeneity, a clear border, the presence of septation, pancreatic atrophy, and the absence of both wall enhancements and solid components were more frequently seen in benign cysts. A thick wall, lack of homogeneity, the presence of wall enhancements and solid components, absence of septation, only a small degree of pancreatic atrophy, and unclear borders were more frequent among premalignant or malignant cysts. The only CT features to differentiate benign from premalignant or malignant cysts were a solid component and septation.
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Key Words
- CEA, Carcinoembryonic antigen
- CPR, Curved planar reformation
- CTA, CT angiography
- DWI, Diffusion-weighted imaging
- ERCP, Endoscopic retrograde cholangiopancreatography
- FDG PET, Fluorodeoxyglucose PET
- FNA, Fine-needle aspiration
- HASTE, Half-Fourier acquisition single-shot turbo spin-echo
- IPMN, Intraductal papillary mucinous neoplasia
- MCA, Mucinous cystadenoma
- MCB, Mucinous cystic borderline tumor
- MCC, Mucinous cystadenocarcinoma
- MCN, Mucinous cystic neoplasm
- MPD, Main pancreatic duct
- MPR, Multi-planar reformation
- MRA, MR angiography
- MRCP, MR cholangiopancreatography
- MRI, Magnetic resonance imaging
- MSCT, Multi-slice helical computed tomography
- PACS, Picture archiving and communicating system
- PCN, Cystic neoplasms of the pancreas
- PDAC, Pancreatic ductal adenocarcinoma
- PET, Positron emission computed tomography
- Pancreatic cystic lesions
- Pancreatic ductal adenocarcinoma
- Pancreatic neoplasm
- ROI, Region of interest
- SCA, Serous cystadenoma
- SMA, Serous microcystic adenoma
- US, Ultrasonography
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Affiliation(s)
- Rajesh Kumar Yadav
- Second Affiliated Hospital, Department of Radiology, Sun Yat-sen University, Guangzhou 510000, China
- Corresponding author: Current Address: Novus Health Wellness, 4808 Munson St NW, OH 44718 USA.
| | - Xinhua Jiang
- Department of Radiology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Jianyu Chen
- Second Affiliated Hospital, Department of Radiology, Sun Yat-sen University, Guangzhou 510000, China
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Theodorou DJ, Theodorou SJ, Kakitsubata Y, Miyata Y, Shirao K, Marutsuka K. Giant serous cystadenoma of the pancreas appearing sonographically as a remote pararenal mass. JOURNAL OF CLINICAL ULTRASOUND : JCU 2019; 47:304-307. [PMID: 30907433 DOI: 10.1002/jcu.22725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/22/2018] [Accepted: 03/10/2019] [Indexed: 06/09/2023]
Abstract
Macrocystic serous cystadenoma (MSC) of the pancreas is a rare benign neoplasm with varied imaging appearances. We describe an intriguing case of a surgically resected and histologically proven giant MSC, developed in the pararenal space. Ultrasonography (US) revealed a large, oligocystic mass around the lower pole of right kidney. Like US, computed tomography, and magnetic resonance imaging were unable to detect the origin of the lesion, which was only verified at surgical exploration. A bizarre finding was the unusual location of the pancreatic tumor growing seemingly apart from the pancreas itself, with no obvious connection to it.
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Affiliation(s)
| | | | | | - Yuko Miyata
- Department of Radiology, Miyazaki Konan Hospital, Miyazaki, Japan
| | - Kazusada Shirao
- Department of Surgery, Miyazaki Konan Hospital, Miyazaki, Japan
| | - Kousuke Marutsuka
- Department of Pathology, Miyazaki Prefectural Hospital, Miyazaki, Japan
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Megibow AJ, Baker ME, Morgan DE, Kamel IR, Sahani DV, Newman E, Brugge WR, Berland LL, Pandharipande PV. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2017; 14:911-923. [PMID: 28533111 DOI: 10.1016/j.jacr.2017.03.010] [Citation(s) in RCA: 191] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 02/27/2017] [Accepted: 03/13/2017] [Indexed: 12/12/2022]
Abstract
The ACR Incidental Findings Committee (IFC) presents recommendations for managing pancreatic cysts that are incidentally detected on CT or MRI. These recommendations represent an update from the pancreatic component of the JACR 2010 white paper on managing incidental findings in the adrenal glands, kidneys, liver, and pancreas. The Pancreas Subcommittee-which included abdominal radiologists, a gastroenterologist, and a pancreatic surgeon-developed this algorithm. The recommendations draw from published evidence and expert opinion, and were finalized by informal iterative consensus. Algorithm branches successively categorize pancreatic cysts based on patient characteristics and imaging features. They terminate with an ascertainment of benignity and/or indolence (sufficient to discontinue follow-up), or a management recommendation. The algorithm addresses most, but not all, pathologies and clinical scenarios. Our goal is to improve quality of care by providing guidance on how to manage incidentally detected pancreatic cysts.
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Affiliation(s)
- Alec J Megibow
- Department of Radiology, NYU-Langone Medical Center, New York, New York.
| | - Mark E Baker
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio
| | - Desiree E Morgan
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ihab R Kamel
- Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Dushyant V Sahani
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Elliot Newman
- Department of Surgery, NYU-Langone Medical Center, New York, New York
| | - William R Brugge
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lincoln L Berland
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Pari V Pandharipande
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
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7
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de Pretis N, Mukewar S, Aryal-Khanal A, Bi Y, Takahashi N, Chari S. Pancreatic cysts: Diagnostic accuracy and risk of inappropriate resections. Pancreatology 2017; 17:267-272. [PMID: 28117220 DOI: 10.1016/j.pan.2017.01.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 11/18/2016] [Accepted: 01/12/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic cystic neoplasms (PCN) frequently undergo surgery, given malignant potential. Pancreatic cyst surgery is associated with significant rates of morbidity and mortality. It is crucial to accurately characterize these lesions pre-operatively to avoid unnecessary surgery in patients with benign pancreatic cysts. AIM We aimed to assess the correlation between pre-operative (pre-op) diagnosis based on imaging and clinical presentation, and post-operative (post-op) diagnosis based on histopathology in patients undergone pancreatic cyst surgery. METHODS From January 2000 to January 2012, we randomly selected 2000 patients with ICD-9 code 211.6 and 577.2. Amongst these we identified 281 patients undergone pancreas surgery. Patients with no pre-op imaging or non-cyst indication for surgery were excluded (n = 107). Imaging details, demographics, pre-operative physician diagnosis and histopathologic details of pancreatic cysts were recorded in 174 patients. RESULTS There was a discrepancy between the pre- and post-operative pancreatic cyst diagnosis in 54 (31%) patients. There was no difference in the proportion of various imaging studies (CT, EUS or MRI) between patients with a correct and patients with an incorrect pre-op diagnosis. The pre-op diagnosis was confirmed at pathology in 87.5% of the presumed SCNs, in 80% of the presumed pseudocysts, in 73.3% of the presumed BD-IPMNs, in 66.7% of the presumed MD/mixed-IPMNs and in 53.6% of the presumed MCNs. The accuracy of the pre-operative diagnosis of presumed MCN was significantly lower compared to the non-MCN cysts (53.6% vs. 75%; p = 0.037). Fourteen percent of resections were performed for asymptomatic benign cysts, preoperatively suspected to be potentially pre-malignant cysts. CONCLUSION In nearly 1 out of 3 patients undergone pancreas cyst surgery, there is a discrepancy between pre- and post-op diagnosis. Pre-op diagnosis of presumed MCN is more likely to be incorrect, compared to the other cysts.
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Affiliation(s)
- N de Pretis
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - S Mukewar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - A Aryal-Khanal
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Y Bi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - N Takahashi
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - S Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States.
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Brugge WR. Diagnosis and management of cystic lesions of the pancreas. J Gastrointest Oncol 2015; 6:375-88. [PMID: 26261724 DOI: 10.3978/j.issn.2078-6891.2015.057] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 04/23/2015] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cystic lesions (PCLs) are being increasingly identified in recent years. They show a wide spectrum of imaging and clinical features. The diagnosis and discrimination of these lesions are very important because of the risk for concurrent or later development of malignancy. PCLs are usually first diagnosed and characterized by conventional imaging modalities such as trans-abdominal ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI). However, their ability to differentiate the benign and malignant lesions remains limited. Endoscopic US may be more helpful for the diagnosis and differentiation of PCLs because of its high resolution and better imaging characteristics than cross-sectional imaging modalities. It also allows for fine-needle aspiration (FNA) of cystic lesions for biochemical, cytological and DNA analysis that might be further helpful for diagnosis and differentiation. The management options of PCLs are to observe, endoscopic treatment or surgical resection. However, the decision for management is sometimes hampered by limitations in current diagnostic and tissue sampling techniques. As further diagnostic and non-invasive management options become available, clinical decision-making will become much easier for these lesions.
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Pravisani R, Intini SG, Girometti R, Avellini C, Leo CA, Bugiantella W, Risaliti A. Macrocystic serous cystadenoma of the pancreas: Report of 4 cases. Int J Surg 2015; 21 Suppl 1:S98-S101. [PMID: 26118606 DOI: 10.1016/j.ijsu.2015.04.097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 03/27/2015] [Accepted: 04/10/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Macrocystic serous cystadenomas (MaSCA) are rare benign tumor of the pancreas which represent an atypical macroscopic morphologic variant of serous cystadenomas (SCA). They are characterized by a limited number of cysts with a diameter of >2 cm and share imaging features overlapping those of mucinous cystic neoplasm (MCN) and branch-duct intraductal papillary mucinous neoplasm (BD-IPMN), thus frequently making the pre-operative radiologic diagnosis difficult. MATERIALS AND METHODS Four cases of MaSCA, which were surgically treated in our structure, are reported. RESULTS Two women (62 and 39 year-old) presented with upper abdominal pain and palpable mass underwent CT with evidence of a lobulated cystic neoformation (98 × 70 and 94 × 75 mm respectively) originating from the body and the tail of the pancreas respectively. They underwent distal pancreatectomy for suspected MCN. A 38 year-old woman underwent laparoscopic distal pancreatectomy because of the incidental finding of an unilocular cystic lesion in the pancreatic tail (23 mm) of indeterminate origin (MCN, SCA or metastasis). In a 40 year-old woman, admitted for acalculous acute pancreatitis, an unilocular cystic lesion in the body of the pancreas (62 mm) was detected and confirmed after 2 months at CT, therefore she underwent distal pancreatectomy for suspected pseudocyst or SCA. In all of the 4 patients the histological examination of the specimens revealed a MaSCA. CONCLUSION Imaging techniques have a low diagnostic power in terms of differentiation of MaSCA from malignant lesions (as MCNs and BD-IPMN). In the clinical practise of MaSCA, surgery appears to gain indications that are wider than those correlated to the pathologic outcome, because of the necessity of a correct differential diagnosis from potentially malignant cystic tumors and the frequent symptoms requiring treatment.
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Affiliation(s)
- Riccardo Pravisani
- Dipartimento di Scienze Mediche e Biologiche, Universitá degli Studi di Udine, Piazzale Kolbe, 4, 33100 Udine, Italy.
| | - Sergio Giuseppe Intini
- Dipartimento di Scienze Mediche e Biologiche, Universitá degli Studi di Udine, Piazzale Kolbe, 4, 33100 Udine, Italy.
| | - Rossano Girometti
- Institute of Radiology, University Hospital "S. Maria della Misericordia", Udine, Italy.
| | - Claudio Avellini
- Institute of Pathology, University Hospital "S. Maria della Misericordia", Udine, Italy.
| | - Cosimo Alex Leo
- Dipartimento di Scienze Mediche e Biologiche, Universitá degli Studi di Udine, Piazzale Kolbe, 4, 33100 Udine, Italy.
| | - Walter Bugiantella
- General Surgery, AUSL Umbria 2, Italy, PhD School of Biotechnologies, University of Perugia, Italy.
| | - Andrea Risaliti
- Dipartimento di Scienze Mediche e Biologiche, Universitá degli Studi di Udine, Piazzale Kolbe, 4, 33100 Udine, Italy.
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10
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Pinho DF, Rofsky NM, Pedrosa I. Incidental pancreatic cysts: role of magnetic resonance imaging. Top Magn Reson Imaging 2014; 23:117-28. [PMID: 24690615 DOI: 10.1097/rmr.0000000000000018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The widespread adoption of multidetector computed tomography and magnetic resonance imaging (MRI) for evaluation of intraabdominal pathology has resulted to a steady increase in the number of incidentally discovered pancreatic cysts in clinical practice during the last decades. The differential diagnosis of these cysts is broad including pseudocysts, serous cystic neoplasms, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. The MRI has an important role both in the initial characterization of incidentally detected pancreatic cysts and the follow-up of these lesions and has become an integral part of the diagnostic algorithm for pancreatic cysts at many institutions. The inherent soft-tissue contrast of magnetic resonance cholangiopancreatography provides the vehicle for providing a specific diagnosis in many pancreatic cysts. Furthermore, an MRI-based characterization of pancreatic cysts allows for selection of those cysts that are more likely to benefit from endoscopic ultrasound and fine-needle aspiration for analysis of the fluid contents. Moreover, small asymptomatic incidental pancreatic cysts without concerning MRI features such as internal septae and/or nodularity may be safely followed with serial imaging. The lack of risk associated to repeated exposure to ionizing radiation and its ability to characterize pancreatic cysts are strong arguments for selecting MRI as the preferred imaging modality for following up these lesions. However, the recommendations for imaging follow-up continue to evolve, and several of the proposed guidelines are reviewed in this manuscript.
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Affiliation(s)
- Daniella F Pinho
- From the Department of Radiology. University of Texas Southwestern Medical Center, Dallas, TX
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11
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Reid MD, Choi H, Balci S, Akkas G, Adsay V. Serous cystic neoplasms of the pancreas: clinicopathologic and molecular characteristics. Semin Diagn Pathol 2014; 31:475-483. [PMID: 25441309 DOI: 10.1053/j.semdp.2014.08.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We herein summarize the pathology and most recent advances in the molecular genetics of serous cystic neoplasms of the pancreas. They typically present as relatively large, well-demarcated tumors (mean size, 6cm), predominantly occurring in females. Pre-operative diagnosis remains challenging; imaging findings and cyst fluid analysis often prove non-specific and fine-needle aspiration often does not yield diagnostic cells. Pathologically, they are characterized by a distinctive cytology referred to as "serous." Although they have ductal differentiation, they distinctly lack the mucin production that characterizes most other pancreatic ductal tumors, including ductal adenocarcinoma and its variants, intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN). They instead produce abundant glycogen (glycogen-rich adenoma). Serous cystadenomas also lack the molecular alterations that characterize ductal neoplasms, such as mutation of KRAS (high prevalence in most mucinous ductal neoplasms), inactivation of SMAD4 (seen in ductal adenocarcinomas), and mutations in GNAS (seen in some IPMNs) and RNF43 (detected in MCNs and IPMNs). Instead, new molecular and immunohistochemical observations place serous pancreatic tumors closer to "clear cell neoplasms" seen in various other organs that are associated with the von Hippel-Lindau (VHL) pathway, such as clear cell renal cell carcinomas and capillary hemangioblastomas. Patients with VHL syndrome have an increased risk of developing serous pancreatic tumors and somatic mutations of the VHL gene are common in these tumors along with modification of its downstream effectors including hypoxia-inducible factor (HIF1), glucose uptake and transporter-1 (GLUT-1), a common factor in clear cell (glycogen-rich) tumors, as well as expression of vascular endothelial growth factor (VEGF), thought to be a factor in the striking capillarization of serous cystadenomas and other non-pancreatic clear cell tumors. VEGF may prove to be of significant diagnostic value since its elevation in cyst fluid has recently been found highly sensitive and specific for serous neoplasms. These molecular alterations establish serous tumors as prototypes of clear cell tumorigenesis and angiogenesis and may prove helpful both as diagnostic and non-surgical therapeutic targets.
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Affiliation(s)
- Michelle D Reid
- Department of Pathology, Emory University School of Medicine, Atlanta, GA
| | - Hyejeong Choi
- Department of Pathology, Emory University School of Medicine, Atlanta, GA
| | - Serdar Balci
- Department of Pathology, Emory University School of Medicine, Atlanta, GA
| | - Gizem Akkas
- Department of Pathology, Emory University School of Medicine, Atlanta, GA
| | - Volkan Adsay
- Department of Pathology, Emory University School of Medicine, Atlanta, GA.
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12
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El-Hayek KM, Brown N, O'Rourke C, Falk G, Morris-Stiff G, Walsh RM. Rate of growth of pancreatic serous cystadenoma as an indication for resection. Surgery 2013; 154:794-800; discussion 800-2. [PMID: 24074417 DOI: 10.1016/j.surg.2013.07.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 07/02/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The purpose of this study was to examine the natural history and growth rate of pancreatic serous cystadenomas (SCAs) to determine which factors lead to resection for these benign neoplasms. METHODS We reviewed retrospectively a prospectively maintained database, identifying patients diagnosed with SCAs of the pancreas. The diagnosis was made via a combination of classic imaging features with or without cyst aspiration results consistent with SCA. To determine growth rates, gamma regression models were used and the average was modeled using the log function. RESULTS A prospectively maintained database of 1,241 pancreatic cystic neoplasms was queried from 1998 to 2010. A total of 219 patients (18%) were diagnosed with SCA, 194 in the surveillance group and 25 in the resection group. Twenty patients underwent resection after initial imaging principally for presence of symptoms and indeterminate diagnosis, and 5 underwent resection after surveillance for development of symptoms and/or rapid rate of growth. Rate of growth increased at a steady state over time, with an estimated doubling time of 12 years (95% confidence interval, 7.8-21.5). CONCLUSION This study shows that growth patterns are similar for SCAs of the pancreas regardless of initial size. When doubling time is faster than 12 years, resection should be considered.
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Zaheer A, Pokharel SS, Wolfgang C, Fishman EK, Horton KM. Incidentally detected cystic lesions of the pancreas on CT: review of literature and management suggestions. ACTA ACUST UNITED AC 2013; 38:331-41. [PMID: 22534872 DOI: 10.1007/s00261-012-9898-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To facilitate a better understanding of incidentally noted cystic pancreatic lesions, since these lesions often pose a challenge regarding appropriate management. METHODS This article reviews pathophysiology, prevalence, significance, and recommendations for management of the various pancreatic cystic lesions. Illustrative cases are demonstrated. RESULTS Diagnostic benign lesions can be left alone. Cross-sectional imaging can be used to follow-up benign appearing lesions and to stage more aggressive ones. Endoscopic ultrasound with fine needle aspiration and cyst fluid analysis can be performed on certain indeterminate lesions. Lesions with high malignant potential should undergo resection. CONCLUSIONS A better understanding of the variety of incidentally detected pancreatic cystic lesions can help direct appropriate management.
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Affiliation(s)
- Atif Zaheer
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 601 N. Caroline Street, JHOC 3235 A, Baltimore, MD 21231, USA.
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14
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Mortelé KJ. Cystic Pancreatic Neoplasms: Imaging Features and Management Strategy. Semin Roentgenol 2013; 48:253-63. [DOI: 10.1053/j.ro.2013.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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15
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Microcystic serous cystadenoma of the pancreas with subtotal cystic degeneration: another neoplastic mimic of pancreatic pseudocyst. Am J Surg Pathol 2012; 36:726-31. [PMID: 22498822 DOI: 10.1097/pas.0b013e31824cf879] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Pancreatic serous cystadenomas are benign cystic neoplasms. Extensive degeneration mimicking a pancreatic pseudocyst has been described in several types of pancreatic neoplasms but has not been documented in serous cystadenomas. We report subtotal cystic degeneration of microcystic serous cystadenomas (MSCA) that produces radiographic, gross, and microscopic overlap with pancreatic pseudocyst. MATERIALS AND METHODS Resected MSCA with degenerative change were identified from the pathology archives of Memorial Sloan-Kettering Cancer Center and Johns Hopkins Hospital. The clinical, radiographic, gross, and microscopic findings were reviewed. RESULTS Eight MSCAs with subtotal cystic degeneration were retrieved from among 397 resected serous cystadenomas (2.0%). There were 2 men and 6 women (mean age, 52 y). Available radiographic studies showed classic features of MSCA in 2 of 4 cases. Four cysts were unilocular, and 4 were multilocular. Gross features of MSCA were noted focally in the multilocular cases but were not evident in the unilocular examples. The predominant histologic features were those of pancreatic pseudocyst, including a fibrotic cyst wall lacking epithelium and instead composed of myofibroblastic proliferation, hemorrhage, and inflammation. Residual foci of MSCA were embedded in fibrosis, comprising 5% to 60% of the tumor volume. CONCLUSIONS Most pancreatic serous cystadenomas display characteristic morphology, including a glycogen-rich epithelial lining and prominent subepithelial capillaries; however, extensive degenerative macrocystic change can obscure these classic features. This phenomenon is to be distinguished from macrocystic serous cystadenoma, in which thin-walled macrocystic spaces are epithelium lined. Thus, serous cystadenoma should be included in the differential diagnosis of pancreatic masses with extensive degenerative cystic change.
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Incidentally discovered benign pancreatic cystic neoplasms not communicating with the ductal system: MR/MRCP imaging appearance and evolution. Radiol Med 2012; 118:163-80. [PMID: 22744342 DOI: 10.1007/s11547-012-0837-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 10/11/2011] [Indexed: 12/18/2022]
Abstract
PURPOSE The authors sought to determine magnetic resonance/magnetic resonance cholangiopancreatography (MR/MRCP) imaging features of incidentally discovered benign, noncommunicating cystic neoplasms (BNCNs) of the pancreas to assess their evolution over time and identify MR/MRCP imaging features predictive of tumour growth. MATERIAL AND METHODS This was a retrospective study, so informed consent was waived. Sixty-two patients with a diagnosis of BNCN were assessed. Inclusion criteria were incidentally discovered cystic neoplasm of the pancreas with nonmeasurable walls, no mural nodules and no communication with the pancreatic ductal system and who underwent ≥ 1 MR/MRCP examination. Image analysis, performed at diagnosis and during follow-up, included macroscopic pattern (microcystic/macrocystic/mixed), number of cysts (unicystic/oligocystic/multicystic), BNCN maximum diameter and tumour growth rates. RESULTS A total of 64 BNCNs was detected. Macroscopic pattern was mixed in 31/64 (48%), microcystic in 28/64 (44%) and macrocystic in 5/64 (8%). BNCNs appeared multicystic in 38/64 (59%) cases, oligocystic in 22/64 (35%) and unicystic in 4/64(6%). All qualitative parameters remained unchanged during follow-up. At diagnosis, the median maximum BNCN diameter was 35.0 mm and 38.0 mm at the final examination (p<0.001). BNCNs showed a tumour growth rate of 2 mm/year. CONCLUSIONS Mixed and microcystic patterns were the most common, accounting for 48% and 44% of cases, respectively, and showed no change over time. MR/MRCP features predictive of lesion enlargement were a mixed/ macrocystic pattern, and lesion size was >3 cm (both p<0.001).
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Buerke B, Domagk D, Heindel W, Wessling J. Diagnostic and radiological management of cystic pancreatic lesions: important features for radiologists. Clin Radiol 2012; 67:727-37. [PMID: 22520033 DOI: 10.1016/j.crad.2012.02.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Revised: 02/05/2012] [Accepted: 02/13/2012] [Indexed: 01/13/2023]
Abstract
Cystic pancreatic neoplasms are often an incidental finding, the frequency of which is increasing. The understanding of such lesions has increased in recent years, but the numerous types of lesions involved can hinder differential diagnosis. They include, in particular, intraductal papillary mucinous neoplasms (IPMN), serous cystic neoplasms (SCN), and mucinous cystic neoplasms (MCN). Knowledge of their histological and radiological structure, as well as distribution in terms of localization, age, and sex, helps to differentiate such tumours from common pancreatic pseudocysts. Several types of cystic pancreatic neoplasms can undergo malignant transformation and, therefore, require differentiated radiological management. This review aims to develop a broader understanding of the pathological and radiological characteristics of cystic pancreatic neoplasms, and provide a guideline for everyday practice based on current concepts in the radiological management of the given lesions.
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Affiliation(s)
- B Buerke
- Department of Clinical Radiology, University of Muenster, Muenster, Germany.
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Tanaka M, Fernández-del Castillo C, Adsay V, Chari S, Falconi M, Jang JY, Kimura W, Levy P, Pitman MB, Schmidt CM, Shimizu M, Wolfgang CL, Yamaguchi K, Yamao K. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 2012; 12:183-97. [PMID: 22687371 DOI: 10.1016/j.pan.2012.04.004] [Citation(s) in RCA: 1556] [Impact Index Per Article: 129.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 04/06/2012] [Accepted: 04/08/2012] [Indexed: 12/11/2022]
Abstract
The international consensus guidelines for management of intraductal papillary mucinous neoplasm and mucinous cystic neoplasm of the pancreas established in 2006 have increased awareness and improved the management of these entities. During the subsequent 5 years, a considerable amount of information has been added to the literature. Based on a consensus symposium held during the 14th meeting of the International Association of Pancreatology in Fukuoka, Japan, in 2010, the working group has generated new guidelines. Since the levels of evidence for all items addressed in these guidelines are low, being 4 or 5, we still have to designate them "consensus", rather than "evidence-based", guidelines. To simplify the entire guidelines, we have adopted a statement format that differs from the 2006 guidelines, although the headings are similar to the previous guidelines, i.e., classification, investigation, indications for and methods of resection and other treatments, histological aspects, and methods of follow-up. The present guidelines include recent information and recommendations based on our current understanding, and highlight issues that remain controversial and areas where further research is required.
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Affiliation(s)
- Masao Tanaka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan.
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Abstract
Cystic tumors of the pancreas are a subset of rare pancreatic tumors that vary from benign to malignant. Many have specific imaging findings that allow them to be differentiated from each other. This article (1) reviews the imaging features of the common cystic pancreatic lesions, including serous microcystic adenoma, mucinous cystic tumor, intraductal papillary mucinous tumor, and solid pseudopapillary tumor, and including the less common lesions such as cystic endocrine tumors, cystic metastases, cystic teratomas, and lymphangiomas; and (2) provides comprehensive algorithms on how to manage the individual lesions, with recommendations on when to reimage patients.
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MESH Headings
- Adenocarcinoma, Mucinous/diagnosis
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/surgery
- Biopsy, Fine-Needle
- Cystadenocarcinoma/diagnosis
- Cystadenocarcinoma/pathology
- Cystadenocarcinoma/surgery
- Cystadenoma/diagnosis
- Cystadenoma/pathology
- Cystadenoma/surgery
- Cystadenoma, Serous/diagnosis
- Cystadenoma, Serous/pathology
- Cystadenoma, Serous/surgery
- Diagnosis, Differential
- Female
- Humans
- Magnetic Resonance Imaging/methods
- Middle Aged
- Neoplasms, Cystic, Mucinous, and Serous/diagnosis
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/surgery
- Pancreas/diagnostic imaging
- Pancreas/pathology
- Pancreatic Neoplasms/diagnosis
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/surgery
- Tomography, X-Ray Computed/methods
- Ultrasonography
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Affiliation(s)
- Catherine E Dewhurst
- Division of Abdominal Imaging and MRI, Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA
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20
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Yoon WJ, Brugge WR. Pancreatic cystic neoplasms: diagnosis and management. Gastroenterol Clin North Am 2012; 41:103-18. [PMID: 22341252 DOI: 10.1016/j.gtc.2011.12.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PCNs are composed of a wide range of lesions from benign cysts to malignancies . Although a cross-sectional imaging provides a sensitive screening test, EUS with FNA and cyst fluid analysis greatly increase the diagnostic certainty. Cyst fluid CEA offers the greatest accuracy in the differentiation between mucinous and nonmucinous PCNs. In the future, endoscopic ablation therapy might offer an alternative to the traditional surgical approach.
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Affiliation(s)
- Won Jae Yoon
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA 02114, USA
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21
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Pancreatic Cystic Lesions of Nonmucinous Type. Surg Pathol Clin 2011; 4:553-77. [PMID: 26837488 DOI: 10.1016/j.path.2011.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cystic lesions of nonmucinous type can arise within the pancreas or can develop from adjacent structures and appear to involve the pancreas. In addition, some typically solid masses can become cystic or can present as cystic lesions. Nonmucinous cysts can be neoplastic, inflammatory, reactive, or congenital. The vast majority of neoplastic nonmucinous cysts are benign. Because of the difficulty in determining the neoplastic potential of a pancreatic cyst preoperatively, many non-neoplastic cysts are resected. This article reviews the surgical pathology of nonmucinous cysts.
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Macari M, Megibow AJ. Focal cystic pancreatic lesions: variability in radiologists' recommendations for follow-up imaging. Radiology 2011; 259:20-3. [PMID: 21436094 DOI: 10.1148/radiol.11102437] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Sakorafas GH, Smyrniotis V, Reid-Lombardo KM, Sarr MG. Primary pancreatic cystic neoplasms revisited. Part I: serous cystic neoplasms. Surg Oncol 2011; 20:e84-92. [PMID: 21237638 DOI: 10.1016/j.suronc.2010.12.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Revised: 12/13/2010] [Accepted: 12/14/2010] [Indexed: 12/12/2022]
Abstract
Primary pancreatic cystic neoplasms have been recognized increasingly during the two recent decades and include mainly serous cystic neoplasms, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. Serous cystic neoplasms represent about 30% of all cystic neoplasms of the pancreas and are characterized by their microcystic appearance (on imaging, macroscopically, and microscopically) and their benign biologic behavior. Modern diagnostic methodology allows the preoperative diagnosis with an acceptable accuracy. Currently, indications for resection of serous cystic neoplasms of the pancreas include the presence of symptoms, size > 4 cm (because these 'large' neoplasms have a more rapid growth rate and probably will soon become symptomatic), and any uncertainty about the diagnosis of a serous versus a mucinous cystic neoplasm. Resection should also be considered for lesions in the body/tail of the pancreas. Conservative treatment is a reasonable option in selected patients (for example in the presence of small, asymptomatic lesions in the pancreatic head, especially in the frail or elderly patient).
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Affiliation(s)
- George H Sakorafas
- 4th Department of Surgery, Medical School, University of Athens, Attikon University Hospital, Arkadias 19-21, Athens 12462, Greece.
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24
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Abstract
The discovery of a pancreatic cyst in an asymptomatic patient presents an immediate challenge to the interpreting radiologist, the clinician who manages the patient, and patients themselves. When a cyst is discovered on imaging in a patient without symptoms directly referable to the pancreas, the following questions are immediately raised: can the lesion be accurately diagnosed or is the appropriate management clear from the examination, is the best management approach to suggest watchful waiting with follow-up imaging, what is the best method for imaging follow-up, and what is the optimal frequency of follow-up? This article recommends an approach to analyzing patients with incidental pancreatic cysts.
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Affiliation(s)
- Alec J Megibow
- Department of Radiology, New York University Langone Medical Center, New York, NY, USA.
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25
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Berland LL, Silverman SG, Gore RM, Mayo-Smith WW, Megibow AJ, Yee J, Brink JA, Baker ME, Federle MP, Foley WD, Francis IR, Herts BR, Israel GM, Krinsky G, Platt JF, Shuman WP, Taylor AJ. Managing Incidental Findings on Abdominal CT: White Paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2010; 7:754-73. [DOI: 10.1016/j.jacr.2010.06.013] [Citation(s) in RCA: 512] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Accepted: 06/07/2010] [Indexed: 02/06/2023]
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26
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Abstract
Cystic neoplasms of the pancreas are a heterogeneous group of pancreatic tumors that vary in pathophysiology, malignant potential, clinical course, and outcomes. Their management is heavily predicated on establishing an accurate diagnosis. This can be particularly challenging, but can often be achieved by a thorough history and physical examination combined with high-quality, thin-slice computed tomography, although additional diagnostic tools may be required. Once the diagnosis is established, treatment can range from simple observation to total pancreatectomy. This decision rests on a clear and complete understanding of each disease process in the context of the patient's age and comorbidities. This article reviews the most common cystic neoplasms of the pancreas, focusing on their diagnosis and management.
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Sun HY, Kim SH, Kim MA, Lee JY, Han JK, Choi BI. CT imaging spectrum of pancreatic serous tumors: based on new pathologic classification. Eur J Radiol 2010; 75:e45-55. [PMID: 20056368 DOI: 10.1016/j.ejrad.2009.11.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 11/18/2009] [Accepted: 11/18/2009] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this study is to retrospectively analyze the variety of CT findings based on new pathologic classification. MATERIALS AND METHODS During a 10-year period, 59 histopathologically proven pancreatic SCTs and 13 SCTs confirmed with typical image findings and strict clinical criteria were enlisted. Two radiologists analyzed CT images for the following items in consensus: location, size, outer margin, tumor shape, the presence of mural nodule, communication with main pancreatic duct (MPD), the presence and extent of MPD dilatation, calcification, central scar, and attenuation on pre- and post-contrast CT images. In addition, typicality of CT findings was determined. A typical finding was defined as a honeycomb appearance without or with oligocystic portion. In the cases with atypical features, the type of atypical features and differential diagnosis were recorded. For the shape of the tumor, tumors were categorized into the following groups: honeycomb without or with oligocystic, pleomorphic, purely oligolocular, unilocular cystic, hypovascular solid, hypervascular solid without or with oligocystic portion, and fingerlike cystic patterns. RESULTS 28 SCTs (38.9%) presented a honeycomb appearance with (n=14) or without oligocystic portion (n=14) and were classified as typical cases. The remaining 44 atypical cases (61.1%) presented the following: purely oligolocular pattern in 18; hypervascular solid without (n=7) or with oligocystic portion (n=2) in 9; pleomorphic in 8; unilocular cystic in 7; and fingerlike cystic pattern in 2. Most of the lesions manifesting as hypervascular solid lesions were confused with true solid hypervascular tumors such as neuroendocrine tumors or solid pseudopapillary tumors. For most of the remaining atypical lesions, mucinous cystic neoplasm or branch duct type IPMN were included as a differential diagnosis. CONCLUSION Serous cystic tumors of the pancreas can have variable CT appearances ranging from compactly solid hypervascular to clearly unilocular cystic, which reflect a varied macroscopic morphology. Only 38.9% of the SCTs show traditional typical CT features whereas a considerable proportion (61.1%) of SCTs showed atypical appearances, providing diagnostic challenges to radiologists.
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Affiliation(s)
- Hye Young Sun
- Department of Radiology, Seoul National University Hospital, 101 Daehangno, Jongno-gu, Seoul 110-744, Republic of Korea
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28
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Shah AA, Sainani NI, Ramesh AK, Shah ZK, Deshpande V, Hahn PF, Sahani DV. Predictive value of multi-detector computed tomography for accurate diagnosis of serous cystadenoma: Radiologic-pathologic correlation. World J Gastroenterol 2009; 15:2739-47. [PMID: 19522024 PMCID: PMC2695889 DOI: 10.3748/wjg.15.2739] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify multi-detector computed tomography (MDCT) features most predictive of serous cystadenomas (SCAs), correlating with histopathology, and to study the impact of cyst size and MDCT technique on reader performance.
METHODS: The MDCT scans of 164 patients with surgically verified pancreatic cystic lesions were reviewed by two readers to study the predictive value of various morphological features for establishing a diagnosis of SCAs. Accuracy in lesion characterization and reader confidence were correlated with lesion size (≤ 3 cm or ≥ 3 cm) and scanning protocols (dedicated vs routine).
RESULTS: 28/164 cysts (mean size, 39 mm; range, 8-92 mm) were diagnosed as SCA on pathology. The MDCT features predictive of diagnosis of SCA were microcystic appearance (22/28, 78.6%), surface lobulations (25/28, 89.3%) and central scar (9/28, 32.4%). Stepwise logistic regression analysis showed that only microcystic appearance was significant for CT diagnosis of SCA (P = 0.0001). The sensitivity, specificity and PPV of central scar and of combined microcystic appearance and lobulations were 32.4%/100%/100% and 68%/100%/100%, respectively. The reader confidence was higher for lesions > 3 cm (P = 0.02) and for MDCT scans performed using thin collimation (1.25-2.5 mm) compared to routine 5 mm collimation exams (P > 0.05).
CONCLUSION: Central scar on MDCT is diagnostic of SCA but is seen in only one third of SCAs. Microcystic morphology is the most significant CT feature in diagnosis of SCA. A combination of microcystic appearance and surface lobulations offers accuracy comparable to central scar with higher sensitivity.
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A case of serous cystadenoma of the pancreas with a central stellate scar detected on contrast-enhanced ultrasound with perflubutane. Clin J Gastroenterol 2009; 2:232-237. [DOI: 10.1007/s12328-009-0078-8] [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: 11/18/2008] [Accepted: 02/23/2009] [Indexed: 10/20/2022]
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30
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Macari M, Finn ME, Bennett GL, Cho KC, Newman E, Hajdu CH, Babb JS. Differentiating pancreatic cystic neoplasms from pancreatic pseudocysts at MR imaging: value of perceived internal debris. Radiology 2009; 251:77-84. [PMID: 19332847 DOI: 10.1148/radiol.2511081286] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To retrospectively evaluate the sensitivity and specificity of several morphologic findings that may be seen with cystic pancreatic lesions, in the diagnosis of pseudocyst at magnetic resonance (MR) imaging. MATERIALS AND METHODS This study was institutional review board approved and HIPAA compliant. From January 1, 2005, to December 31, 2007, electronic radiology and pathology databases were searched to identify patients with pancreatic cystic neoplasms or pseudocysts who underwent pancreatic MR imaging. Twenty-two patients with cystic pancreatic neoplasms that were confirmed at surgical resection (n = 12) or endoscopic ultrasonography (US) with cystic fluid analysis (n = 10) were identified. Of 20 patients with pancreatic pseudocysts, seven had pseudocysts that were identified at pathologic resection and 13 had a clinical history of pancreatitis, with initial computed tomography (CT) revealing no pancreatic cyst and subsequent follow-up MR imaging depicting cystic lesions. Two abdominal radiologists independently and randomly evaluated each case for presence or absence of septa and internal dependent debris and for external cyst morphology on axial and coronal T2-weighted images and three-dimensional gradient-echo T1-weighted images obtained before and after intravenous contrast agent administration. Logistic regression for correlated data was used to assess the usefulness of internal debris, external morphology, and septa for differentiating cystic neoplasms from pseudocysts. RESULTS The readers' assessments of the presence or absence of cystic debris were concordant for 40 (95%) of the 42 patients, with a kappa coefficient of 0.889, which indicated nearly perfect agreement. Thirteen (93%) of 14 lesions found to have debris by either or both readers were pseudocysts, and only one (4%) of the 22 cystic neoplasms had debris. Both readers were more likely to identify septa within cystic neoplasms than within pseudocysts; however, the difference was not significant for either reader. The readers were more likely to observe microlobulated morphology in cystic neoplasms than in pseudocysts, with the difference between these lesion types, in terms of prevalence of microlobulated morphology, exhibiting a trend toward-but not reaching-statistical significance (P = .0627). CONCLUSION Presence of internal dependent debris appears to be a highly specific MR finding for the diagnosis of pancreatic pseudocyst.
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Affiliation(s)
- Michael Macari
- Department of Radiology, New York University School of Medicine, New York, NY, USA.
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Abstract
Pancreatic cystic lesions are being detected more frequently given increased use of cross-sectional imaging modalities. The most common cysts encountered are mucinous cysts, which have malignant potential. As many of these lesions are incidental findings, it is important to further evaluate them with endoscopic ultrasound-guided fine needle aspiration for diagnostic purposes and risk stratification. These cysts either require surgical resection or surveillance given the malignant risk. Mucinous cystic neoplasms should be resected. Intraductal papillary mucinous neoplasia (IPMN) has consensus-guideline indications for resection. These include main duct diameter > or = 10 mm, a branch duct size > or = 3 cm, presence of a mural nodule, or cytology suspicious for malignancy. Additionally, all symptomatic cysts, regardless of etiology, should undergo resection. Branch duct IPMN is less aggressive that the main duct variety, and may be conservatively followed. However, the development of an established indication for resection should prompt surgery. Despite generalized guidelines, decisions regarding management of pancreatic cysts should be individualized, accounting for the malignant risk of the lesion and the surgical risk of the patient.
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Affiliation(s)
- Kenneth E Fasanella
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Is gadolinium necessary for MRI follow-up evaluation of cystic lesions in the pancreas? Preliminary results. AJR Am J Roentgenol 2009; 192:159-64. [PMID: 19098196 DOI: 10.2214/ajr.08.1068] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The purpose of our study was to determine whether gadolinium is necessary in the follow-up evaluation of pancreatic cystic lesions. MATERIALS AND METHODS Fifty-six patients with pancreatic cystic lesions detected on initial MRI and who underwent follow-up MRI were identified. Mean cyst size was 1.9 cm, and mean follow-up was 9.1 months. MRI included multiacquisition T1- and T2-weighted sequences before contrast administration and 3D fat-suppressed T1-weighted images before and after gadolinium administration. Two radiologists independently reviewed the entire initial examination and follow-up MRI using only unenhanced T1- and T2-weighted sequences from the second examination. Each radiologist made one of three recommendations: 1, no follow-up necessary or follow-up imaging in 6-12 months; 2, cyst aspiration; or 3, cyst resection. Four weeks later, imaging studies were reevaluated with the contrast-enhanced images from the second examination. A second recommendation using the same outcomes was made. Interobserver and intraobserver variations for the same patient were summarized in terms of kappa coefficients and the percentage of times the decisions were concordant. A 95% CI for the percentage of times management decisions would change without and with gadolinium was calculated. RESULTS Concordance between the two different readers for the interpretations (when using the same MRI interpretation technique for follow-up surveillance) was 87.5% with a kappa coefficient to assess interobserver variation of 0.075, suggesting only slight agreement between the two readers. However, treatment recommendations provided by a single reader with and without information from the contrast-enhanced images were discordant only 4.5% of the time. Recommendations were concordant without and with gadolinium 95.5% (107/112; kappa=0.67) of the time, suggesting substantial agreement. A retrospective consensus review of the five cases in which gadolinium effected a change in the observer's recommendation was performed. There was nothing on the gadolinium-enhanced sequences that would specifically alter a change in a management decision, and it is likely that the changes in management decisions in these five cases were simply related to expected variations in categorizing lesions rather than to the use of gadolinium. CONCLUSION The use of gadolinium has minimal impact in the follow-up MR assessment of pancreatic cystic lesions.
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[Importance of endoscopy and endosonography for chronic pancreatitis and benign pancreas tumors]. Radiologe 2008; 48:721-4; 726-31. [PMID: 18679644 DOI: 10.1007/s00117-008-1668-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Endoscopic retrograde pancreatography (ERP) and endoscopic ultrasound (EUS) are superior to cross-sectional imaging procedures for detection of low-grade pancreatitis, but detection of duct alterations is more reliable by middle and high-grade chronic pancreatitis than by low-grade. In addition to assessment of alterations in the pancreatic duct, EUS also allows detection of parenchymatous alterations. Because of the risk of post-ERP pancreatitis, ERP has been mostly eliminated from diagnostic procedures. In contrast, endoscopic retrograde cholangiopancreatography (ERCP) allows an unrivalled access to interventional treatment of inflammatory alterations of the biliopancreatic duct system, by retrograde, non-penetrable papillae even in the rendezvous procedure with EUS-assisted probing of the Ductus Wirsungianus. Despite the technical success of endoscopic procedures, surgical duct decompression has proven to be superior for relief from pancreatitic pain. Biliary drainage is also more likely to be successful on a permanent basis using surgical procedures than by repeat multi-stenting, at least by calcifying pancreatitis. Peroral transgastral transmural therapy of postpancreatitic necroses opens up further options over surgical removal of necroses.
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Pancreatic cystic lesions: discrimination accuracy based on clinical data and high-resolution computed tomographic features. J Comput Assist Tomogr 2008; 32:757-63. [PMID: 18830106 DOI: 10.1097/rct.0b013e318157b100] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To determine the frequency of typical features of pancreatic cystic lesions on high-resolution computed tomography and the combination of features that best influences discrimination. METHODS Ten computed tomography features of 100 proven pancreatic cystic lesions were retrospectively tabulated by 2 blinded imagers. After final diagnosis was revealed, each lesion was categorized as typical or atypical. Stepwise multivariable logistic regression was used to determine which of 10 imaging and 4 clinical features significantly distinguished between benign and malignant lesions. RESULTS There were 38 benign cysts and 62 cystic tumors. Serous lesions presented with greater than 6 cysts (83%) and cysts of less than 2 cm (44%). Mucinous lesions presented with cysts of 2 cm or greater (82%) and less than 6 cysts (64%). Pseudocysts, serous, and mucinous lesions presented typically in 77%, 67%, and 64% of cases, respectively. The significant variables in classifying malignant lesions are pancreatitis history, cyst size, symptoms, and calcification pattern (area under the curve, 0.837). CONCLUSIONS Four specific imaging and clinical features in combination best predict a malignant lesion.
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de Juan C, Sanchez M, Miquel R, Pages M, Ayuso JR, Ayuso C. Uncommon tumors and pseudotumoral lesions of the pancreas. Curr Probl Diagn Radiol 2008; 37:145-64. [PMID: 18502323 DOI: 10.1067/j.cpradiol.2007.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Ductal adenocarcinoma is the most common tumor of the pancreas, accounting for about 80% of all pancreatic tumors. The other 20% of pancreatic tumors is represented by a heterogeneous group of pancreatic neoplasms that includes cystic pancreatic neoplasms, islet cell tumors, and the so-called rare pancreatic tumors. In addition, the pancreatic gland may present a variety of inflammatory and pseudotumoral lesions that may mimic a primary pancreatic neoplasm. These uncommon tumors and pseudotumoral lesions present a wide spectrum of imaging findings and they are often poorly understood by the radiologist, becoming a diagnostic challenge. Some of these lesions may show an appearance similar to ductal adenocarcinoma being radiologically indistinguishable. However, some of these lesions sometimes may present specific features on imaging studies that may help to characterize the mass and to suggest a correct diagnosis. Many of these uncommon tumors and pseudotumoral lesions have a different approach, therapy, and prognosis than ductal adenocarcinoma. Therefore, it is important for the radiologist to be familiar with these entities to include them in the differential diagnosis to initiate an appropriate lesion-specific workup and treatment. In the present article, we review the radiological features of uncommon pancreatic tumors, atypical manifestations of ductal adenocarcinoma, and pseudotumoral masses, focusing on those features that can be helpful for the differential diagnosis.
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Affiliation(s)
- Carmen de Juan
- Department of Radiology, Hospital Clinic, University of Barcelona, Barcelona, Spain.
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Ferreira AM, Vaz A, Viana M, Gil-Agostinho P, Caseiro-Alves F. Case 136: intraductal papillary mucinous tumor (main duct type) of the pancreas. Radiology 2008; 248:695-7. [PMID: 18641258 DOI: 10.1148/radiol.2482031139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ana M Ferreira
- Departments of Radiology, Hospital Infante D Pedro-Aveiro, Aveiro, Portugal.
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Macrocystic pancreatic lesions: differentiation of benign from premalignant and malignant cysts by CT. Eur J Radiol 2008; 71:122-8. [PMID: 18448299 DOI: 10.1016/j.ejrad.2008.03.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2008] [Revised: 03/09/2008] [Accepted: 03/12/2008] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess useful CT features for differentiating benign from premalignant and malignant macrocystic pancreatic lesions. METHODS Seventy-four patients with pathologically proven macrocystic pancreatic lesions were enrolled: 17 benign cysts (macrocystic serous cystadenoma, n=12; congenital cyst; n=5) and 57 premalignant and malignant cysts (mucinous cystic neoplasm, n=28; intraductal papillary mucinous neoplasm of branch duct type, n=20; tumor with cystic change, n=9). Size, location, shape (lobulated, round or oval, or complex cystic with tubular cyst), wall thickness (thin, < or =1mm; thick, >1mm), internal surface (smooth or irregular), and other findings were analyzed with multiphasic CT with thin-section (2.5-3mm) images. CT features between two groups were compared using univariate and multivariate stepwise logistic regression analyses. RESULTS On univariate analysis, the differences for the shape (p=0.007), wall thickness (p=0.011), and internal surface (p=0.012) between benign and premalignant and malignant cysts were significant. A lobulated shape, a thin wall and a smooth internal surface were more frequent in benign cysts, whereas a round or oval shape or a complex cystic shape with tubular cyst, a thick wall and an irregular internal surface were more frequent in premalignant and malignant cysts. On multivariate analysis, the shape (p=0.002) and wall thickness (p=0.025) were significant CT features for differentiating benign from premalignant and malignant cysts. CONCLUSION Shape and wall thickness are the main CT features for differentiating benign from premalignant and malignant macrocystic pancreatic lesions.
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Diagnosis and management of cystic neoplasms of the pancreas: an evidence-based approach. J Am Coll Surg 2008; 207:106-20. [PMID: 18589369 DOI: 10.1016/j.jamcollsurg.2007.12.048] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Revised: 11/30/2007] [Accepted: 12/19/2007] [Indexed: 02/06/2023]
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Colonna J, Plaza JA, Frankel WL, Yearsley M, Bloomston M, Marsh WL. Serous cystadenoma of the pancreas: clinical and pathological features in 33 patients. Pancreatology 2008; 8:135-41. [PMID: 18382099 DOI: 10.1159/000123606] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2007] [Accepted: 09/24/2007] [Indexed: 12/11/2022]
Abstract
AIM To report the clinicopathological features of patients with serous cystadenomas of the pancreas. METHODS Thirty-three cases of serous cystadenoma diagnosed between 1977 and 2006 were retrieved from the files of the Ohio State University Medical Center. Clinical data and microscopic slides were reviewed. RESULTS The patients included 27 women and 6 men with an age range of 38-83 (mean 64.3) years. The clinical presentation included 13 patients with abdominal pain and 8 patients with abdominal mass; 9 tumors were found incidentally. Abdominal CT scans in 25 patients were interpreted as suspicious for carcinoma in 8 (32%), suspicious for serous cystadenoma in 8, neoplasm not otherwise specified in 8, and suspicious for a pseudocyst in 1. Only 7 patients underwent a preoperative biopsy, and 5 of these were diagnosed as having a serous cystadenoma. All but 2 of the patients underwent surgical resection of the tumor. The serous cystadenomas varied in size from 1.0 to up to 13 cm in maximum dimension, and all but one had a multicystic appearance. Of the 33 serous cystadenomas, 20 (61%) were located in the pancreatic tail, 4 (12%) in the pancreatic body, 4 in the pancreatic body and tail, and 5 (15%) in the head of the pancreas. Follow-up in 17 patients (median 3 years, range from 1 month to 11 years) showed no recurrence of serous cystadenomas. One patient had von Hippel-Lindau syndrome, 4 patients had diabetes mellitus, 3 patients had metastatic cancer, and 2 patients had ovarian tumors. CONCLUSIONS Serous cystadenoma is an uncommon neoplasm that can be confused with malignancy both clinically and radiologically; a correct diagnosis is important in order to provide an accurate prognosis.
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Affiliation(s)
- Jorge Colonna
- Department of Pathology, Ohio State University Medical Center, Columbus, Ohio 43210, USA
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Pancreatic cystic lesions: discrimination accuracy based on clinical data and high resolution CT features. J Comput Assist Tomogr 2008; 31:860-7. [PMID: 18043347 DOI: 10.1097/rct.0b013e318039b277] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the accuracy of high-resolution computed tomography in discriminating among pancreatic cystic lesions with and without clinical history. METHODS Multiphasic high-resolution computed tomographic scans of 100 proven cystic pancreatic lesions were retrospectively reviewed by 2 blinded imagers. Before and after a history of pancreatitis was revealed, readers classified lesions as either nontumor-related or tumor-related. Reviewers also classified lesions as benign or malignant and finally categorized each lesion as serous, mucinous, or other lesion. Diagnostic performance parameters for classification were calculated for each reader with and without history. RESULTS Sixty-two lesions were tumor-related and 38 were not. Accuracy for classifying tumor-related from unrelated cysts for both reviewers increased (83%-92%, 85%-91%) when unblinded to pancreatitis history. Specificity also significantly increased (66%-88% and 84%) for both reviewers. CONCLUSIONS Pancreatic-phase computed tomography enabled more than 80% accuracy in discriminating between tumor-related and unrelated lesions and increased with information of pancreatitis history.
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D'Onofrio M, Zamboni G, Faccioli N, Capelli P, Pozzi Mucelli R. Ultrasonography of the pancreas. 4. Contrast-enhanced imaging. ACTA ACUST UNITED AC 2007; 32:171-81. [PMID: 16838218 DOI: 10.1007/s00261-006-9010-6] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The introduction of contrast-enhanced ultrasonography (CEUS) has lead to great developments in the diagnostic capabilities of ultrasound. Second generation contrast media, characterized by harmonic responses at low mechanical index of the ultrasound beam, have already proven usefulness in the study of the liver but other abdominal organs can take advantage from the dynamic study during continuous ultrasonographic scans. The dynamic observation of the enhancement allows the perfect evaluation of the abdominal organs perfusion. The perfusion of the pancreas is well correlated to the semeiology of the gland parenchymography at CEUS. The study of the pancreas is a new and promising application of CEUS. CEUS can be used to better identify pancreatic lesions respect to conventional Ultrasound (US) or to characterize pancreatic lesions already visible at US. Moreover the staging of some pancreatic lesions can be improved by the use of contrast media. This article will review the clinical application of CEUS in the different pancreatic pathologies.
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Affiliation(s)
- M D'Onofrio
- Department of Radiology, G.B. Rossi Hospital, University of Verona, Piazzale L.A. Scuro 10, 37134 Verona, Italy.
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Goh BKP, Tan YM, Thng CH, Cheow PC, Chung YFA, Chow PKH, Wong WK, Ooi LLPJ. How useful are clinical, biochemical, and cross-sectional imaging features in predicting potentially malignant or malignant cystic lesions of the pancreas? Results from a single institution experience with 220 surgically treated patients. J Am Coll Surg 2007; 206:17-27. [PMID: 18155564 DOI: 10.1016/j.jamcollsurg.2007.06.312] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2007] [Accepted: 06/25/2007] [Indexed: 12/22/2022]
Abstract
BACKGROUND This study aims to determine the use of preoperative clinical, biochemical, and cross-sectional imaging features for predicting malignancy in cystic lesions of the pancreas (CLP). STUDY DESIGN Two hundred twenty patients who underwent operations for CLP or suspected CLP were reviewed. Patients were divided into two groups, patients undergoing operations for pseudocysts and patients undergoing operations for suspected cystic neoplasms. The predictive effect of various preoperative factors on the malignant potential of CLP was evaluated. RESULTS Forty-four patients with a preoperative diagnosis of pseudocysts underwent operations for complications of pseudocyst. Forty-two were confirmed pathologically to have pseudocysts, but two were found, unexpectedly, to harbor malignant lesions. One hundred seventy-six patients underwent operations for suspected pancreatic cystic neoplasms. There were 70 benign, 51 potentially malignant, and 55 malignant CLP. On multivariate analysis, three factors, ie, elevated serum carcinoembryonic antigen (CEA) or carbohydrate antigen 19-9; cyst size > 3 cm; and presence of one or more of three morphologic features, such as solid component; peripheral calcification; and main duct dilation on cross-sectional imaging were independent predictors of malignancy. Presence of two or three of these factors had a positive predictive value of 88% in predicting a premalignant or malignant CLP. CONCLUSIONS Most pancreatic pseudocysts can be accurately diagnosed preoperatively. In patients with suspected pancreatic cystic neoplasms, elevated serum CEA or carbohydrate antigen 19-9, cyst size > 3 cm, and presence of suspicious morphologic features on imaging are predictors of potentially malignant or malignant CLP. Patients with a high likelihood of a potentially malignant or malignant lesion based on these three factors should undergo operation without additional investigations.
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Affiliation(s)
- Brian K P Goh
- Department of Surgery, Singapore General Hospital, Singapore
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Abstract
This article presents the approach to the most commonly encountered pancreatic cystic masses that the authors employ at the University of Pittsburgh Medical Center. Variations on this approach are to be expected, based on several factors, including the availability of sophisticated imaging equipment and personnel.
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Affiliation(s)
- Michael P Federle
- Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite 3950, Pittsburgh, PA 15213, USA.
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Tann M, Sandrasegaran K, Jennings SG, Skandarajah A, McHenry L, Schmidt CM. Positron-emission tomography and computed tomography of cystic pancreatic masses. Clin Radiol 2007; 62:745-51. [PMID: 17604762 DOI: 10.1016/j.crad.2007.01.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2006] [Revised: 01/22/2007] [Accepted: 01/30/2007] [Indexed: 02/06/2023]
Abstract
AIM To investigate the sensitivity and specificity of computed tomography (CT), positron-emission tomography (PET), and both methods in combination, for determining whether cystic pancreatic tumours are malignant. MATERIALS AND METHODS We retrospectively identified all patients with cystic pancreatic tumours who underwent separate PET and contrast-enhanced CT examinations within a 1-month interval. Tumours were classified as benign or malignant on CT (two radiologists, independently), PET [a reported standardized uptake value (SUV) of 2.5 was taken as the cut-off between benign and malignant], and with PET and CT images together (two radiologists, in consensus). Readers were blinded to pathological and other radiological findings. Mean patient age and lesion size were compared between benign and malignant groups using Student's t-test. For CT findings, odds ratios (OR) and confidence intervals (CI) were calculated using multivariate logistic regression models. For CT, PET, and the combined images, sensitivities and specificities were calculated, and compared between groups using Fisher's exact test. RESULTS Thirty patients were identified. The best CT predictor of malignancy was size; mean diameter was 2.3 cm (benign) and 4.1 cm (malignant) (p<0.01); OR was 2.80 (95% CI, 1.26-6.20). Sensitivities of CT, PET and combined PET/CT images were 67-71, 57, and 86%, respectively. PET/CT was more sensitive than PET (p<0.01) or CT (p<0.01) alone. Specificities of CT, PET, and combined PET/CT images were 87-90, 65, and 91%, respectively. PET/CT was more specific than PET (p<0.01) but not CT (p>0.05). CONCLUSION The sensitivity and specificity of combined PET and CT images is comparable with or superior to either CT or PET alone in determining malignancy in cystic pancreatic lesions.
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Affiliation(s)
- M Tann
- Departments of Radiology, Biochemistry/Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, USA
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Wang RF, Chou YH, Hwang JI, Tiu CM, Chiou HJ, Chen SP, Chiang JH, Tsay SH. Primary small cell carcinoma of the pancreas with an unusual sonographic appearance. JOURNAL OF CLINICAL ULTRASOUND : JCU 2007; 35:82-4. [PMID: 17206725 DOI: 10.1002/jcu.20291] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
We present a case of primary pancreatic small cell carcinoma with an unusual sonographic feature. A 75-year-old woman presented with poor appetite and weight loss. Abdominal sonographic examination revealed a diffusely enlarged pancreas with relative increased echogenicity and smooth contour. CT also confirmed the diffuse infiltrative pattern of the tumor. The diagnosis was confirmed via sonographically guided biopsy. The tumor was composed of small cells with hyperchromatic nuclei and scanty cytoplasm infiltrating the pancreatic tissue, consistent with small cell carcinoma of the pancreas. Primary pancreatic small cell carcinoma rarely presents as the diffuse infiltrating type. These unusual sonographic features must be differentiated from other pancreatic tumors presenting as diffuse pancreatic enlargement.
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Affiliation(s)
- Ruei-Fang Wang
- Department of Emergency Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, and School of Medicine, Fu-Jen Catholic University, no. 95, Wunchang Rd., Shihlin District, Taipei City 111, Taiwan, ROC
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Kim SY, Lee JM, Kim SH, Shin KS, Kim YJ, An SK, Han CJ, Han JK, Choi BI. Macrocystic neoplasms of the pancreas: CT differentiation of serous oligocystic adenoma from mucinous cystadenoma and intraductal papillary mucinous tumor. AJR Am J Roentgenol 2006; 187:1192-8. [PMID: 17056905 DOI: 10.2214/ajr.05.0337] [Citation(s) in RCA: 126] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of our study was to determine useful CT criteria for differentiating serous oligocystic adenomas of the pancreas from other similarly presenting neoplasms, such as mucinous cystadenoma and intraductal papillary mucinous tumor of the branch duct type. MATERIALS AND METHODS Forty-one patients with histologically confirmed macrocystic neoplasms of the pancreas were enrolled: serous oligocystic adenoma in 10 patients, mucinous cystadenoma in 13, and intraductal papillary mucinous tumor in 18. Location, greatest dimension, shape, presence of mural nodules, presence of wall calcification, and the extent and degree of main pancreatic duct (MPD) dilatation were analyzed with CT. The lesions were categorized into seven groups according to their shapes: multicystic, lobulated contour with and without internal septation, smooth contour with and without internal septation, pleomorphic cystic, and clubbed fingerlike cystic. Comparative studies were performed using Fisher's exact test and the Mann-Whitney U test. RESULTS Significant differences in lesion shape were found between serous oligocystic adenoma and the other macrocystic neoplasms (mucinous cystadenoma [p < 0.05], intraductal papillary mucinous tumor [p < 0.05]). Serous oligocystic adenoma had a multicystic or lobulated contour with or without septation, whereas mucinous cystadenoma had a smooth contour with or without septation and intraductal papillary mucinous tumor had either a pleomorphic or a clubbed fingerlike cystic shape. Serous oligocystic adenoma showed proximal MPD dilatation from the lesion, whereas intraductal papillary mucinous tumor showed distal or whole MPD dilatation (p < 0.05). No significant difference was apparent among the three diseases in terms of location, greatest dimension, or presence of calcification or mural nodules. CONCLUSION Serous oligocystic adenoma of the pancreas has characteristic CT findings that differentiate it from other cystic tumors. It appears as a multicystic or lobulated cystic lesion with septation.
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Affiliation(s)
- Sang Youn Kim
- Department of Radiology and Institute of Radiation Medicine, Seoul National University Hospital and College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea
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Goh BKP, Tan YM, Yap WM, Cheow PC, Chow PKH, Chung YFA, Wong WK, Ooi LLPJ. Pancreatic serous oligocystic adenomas: clinicopathologic features and a comparison with serous microcystic adenomas and mucinous cystic neoplasms. World J Surg 2006; 30:1553-9. [PMID: 16773248 DOI: 10.1007/s00268-005-0749-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The preoperative distinction between serous cystic neoplasms (SCNs) and mucinous cystic neoplasms (MCNs) is essential, as all MCNs are considered malignant or potentially malignant and should be surgically resected, whereas SCNs are almost always benign. However, the radiologic distinction between SCNs and MCNs is frequently difficult especially with serous oligocystic adenoma (SOA), a morphologic variant of SCN, as both SOA and MCN appear on cross-sectional imaging as a solitary macrocystic lesion in the pancreas. We reviewed all SOAs managed at our institution to determine if any clinicopathologic features would prove useful for establishing a preoperative diagnosis. METHODS Over a 15-year period, 64 patients with a pathologically confirmed diagnosis of a pancreatic cystadenoma or cystadenocarcinoma treated at Singapore General Hospital were retrospectively reviewed. There were 27 MCNs and 37 SCNs including 12 SOAs. In addition, 40 cases of SOA previously reported in the literature were reviewed and analyzed together with the 12 patients, making this a series of 52 SOAs. RESULTS In our experience, SOAs comprised 32.4% of the SCNs, and females predominated (7/12). The median age of the patients was 42.5 years (range 22-74 years), and only 4 of the 12 patients were symptomatic. Most of the cysts were located in the body or tail of the pancreas (9/12), and the median cyst size was 52.5 mm (range 10-190 mm). When the clinicopathologic features of SOAs and serous microcystic adenomas (SMAs) were compared, there was no difference between the patients with SOAs and SMAs in terms of age, sex, presence of symptoms, cyst size, or site of the lesion. However, SOAs occurred in the women less frequently (67.3% vs. 96.3%, P=0.004), were smaller [40 mm (range 10-190 mm) vs. 95 mm (range 25-180 mm), P<0.001], and occurred more commonly in the head of the pancreas [25 (48.1%) vs. 2(7.4%)] compared to MCNs. None of the SOAs were frankly malignant compared to the 29.6% of MCNs that were. CONCLUSIONS SOAs and SMAs have similar clinicopathologic features. On the other hand, SOAs differ from MCNs by their relatively higher male/female ratio, higher frequency of tumors occurring in the head of the pancreas, and smaller cyst size. Knowledge of these distinguishing clinical features when used in combination with other diagnostic modalities such as endoscopic ultrasonography/fine-needle aspiration will enable clinicians to better differentiate these two pathologic entities preoperatively.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Cystadenocarcinoma, Mucinous/diagnosis
- Cystadenocarcinoma, Mucinous/surgery
- Cystadenocarcinoma, Serous/diagnosis
- Cystadenocarcinoma, Serous/surgery
- Cystadenoma, Mucinous/diagnosis
- Cystadenoma, Mucinous/surgery
- Cystadenoma, Serous/diagnosis
- Cystadenoma, Serous/surgery
- Female
- Humans
- Male
- Middle Aged
- Pancreatectomy
- Pancreatic Neoplasms/diagnosis
- Pancreatic Neoplasms/surgery
- Preoperative Care
- Retrospective Studies
- Tomography, X-Ray Computed
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Affiliation(s)
- Brian K P Goh
- Department of Surgery, Singapore General Hospital, Outram Road, Singapore, 169608.
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Abstract
Cystic tumors of the pancreas are less frequent than solid lesions and are often detected incidentally, as many of these lesions are small and asymptomatic. However, they may be associated with pancreatitis or have malignant potential. With advancements in diagnostic imaging, cystic lesions of the pancreas are being detected with increasing frequency. Many lesions can cause a pancreatic cyst, most being non-neoplastic while approximately 10% are cystic tumors, ranging from benign to highly malignant tumors. With increasing experience it is becoming clear that the prevalence of pseudocyst among cystic lesions of the pancreas is lower than usually presumed. A presumptive diagnosis of pseudocyst based on imaging appearance alone can cause a diagnostic error, and neoplastic cysts of the pancreas are particularly susceptible to this misdiagnosis, which can result in inappropriate treatment. Cystic tumors of the pancreas are formed by serous or mucinous structures showing all stages of cellular differentiation. According to the WHO classification, they can be subdivided on the basis of their histological type and biological behavior into benign tumors, borderline tumors, and malignant tumors. Cystic pancreatic tumors can be subdivided into peripheral (serous cystadenomas, mucinous cystic tumors, solid and papillary epithelial neoplasms, cystic islet cell tumors), which do not communicate with the main pancreatic duct, and ductal tumors (mucinous tumor), according to their site of origin. On the basis of imaging criteria alone, it can be very difficult to differentiate non-tumoral cystic lesions from neoplastic ones. The management of these patients is complex, and it is important to correlate imaging findings with knowledge of the patient’s symptoms and of the natural history and predictors of malignancy in pancreatic cysts.
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Affiliation(s)
- Giovanni Morana
- Department of Radiology, Hospital Ca' Foncello, Treviso, Italy.
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