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Elmi N, McEvoy D, McInnes MDF, Alabousi M, Hecht EM, Luk L, Asghar S, Jajodia A, de Carvalho TL, Warnica WJ, Zha N, Ullah S, van der Pol CB. Percentage of Pancreatic Cysts on MRI With a Pancreatic Carcinoma: Systematic Review and Meta-Analysis. J Magn Reson Imaging 2024; 60:1063-1075. [PMID: 38053468 DOI: 10.1002/jmri.29168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Pancreatic cystic lesions (PCLs) are frequent on MRI and are thought to be associated with pancreatic adenocarcinoma (PDAC) necessitating long-term surveillance based on older studies suffering from selection bias. PURPOSE To establish the percentage of patients with PCLs on MRI with a present or future PDAC. STUDY TYPE Systematic review, meta-analysis. POPULATION Adults with PCLs on MRI and a present or future diagnosis of PDAC were eligible. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus were searched to April 2022 (PROSPERO:CRD42022320502). Studies limited to PCLs not requiring surveillance, <100 patients, or those with a history/genetic risk of PDAC were excluded. FIELD STRENGTH/SEQUENCE ≥1.5 T with ≥1 T2-weighted sequence. ASSESSMENT Two investigators extracted data, with discrepancies resolved by a third. QUADAS-2 assessed bias. PDAC was diagnosed using a composite reference standard. STATISTICAL TESTS A meta-analysis of proportions was performed at the patient-level with 95% confidence intervals (95% CI). RESULTS Eight studies with 1289 patients contributed to the percentage of patients with a present diagnosis of PDAC, and 10 studies with 3422 patients to the percentage with a future diagnosis. Of patients with PCLs on MRI, 14.8% (95% CI 2.4-34.9) had a PDAC at initial MRI, which decreased to 6.0% (2.2-11.3) for studies at low risk of bias. For patients without PDAC on initial MRI, 2.0% (1.1-3.2) developed PDAC during surveillance, similar for low risk of bias studies at 1.9% (0.7-3.6), with no clear trend of increased PDAC for longer surveillance durations. For patients without worrisome features or high-risk stigmata, 0.9% (0.1-2.2) developed PDAC during surveillance. Of 10, eight studies had a median surveillance ≥3 years (range 3-157 months). Sources of bias included retrospectively limiting PCLs to those with histopathology and inconsistent surveillance protocols. DATA CONCLUSION A low percentage of patients with PCLs on MRI develop PDAC while on surveillance. The first MRI revealing a PCL should be scrutinized for PDAC. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Nika Elmi
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - David McEvoy
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Matthew D F McInnes
- Department of Radiology and Epidemiology, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medical Imaging, Ottawa Hospital Research Institute Clinical Epidemiology Program, The Ottawa Hospital-Civic Campus, Ottawa, Ontario, Canada
| | - Mostafa Alabousi
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Elizabeth M Hecht
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - Lyndon Luk
- Department of Radiology, New York Presbyterian-Columbia University Medical Center, New York, New York, USA
| | - Sunna Asghar
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Ankush Jajodia
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Tiago Lins de Carvalho
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - William J Warnica
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Nanxi Zha
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sadaf Ullah
- Library Services, Unity Health Toronto St. Michael's Hospital, East Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Christian B van der Pol
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
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Kobayashi M, Niimi M, Katsuda H, Akahoshi K, Kinowaki Y, Sasaki M, Hirakawa A, Tateishi U, Tanabe M, Okamoto R. Optimization of Endoscopic Ultrasound Characteristics in the Diagnosis of Malignant Intraductal Papillary Mucinous Neoplasm. Pancreas 2024; 53:e521-e527. [PMID: 38888840 DOI: 10.1097/mpa.0000000000002329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
OBJECTIVES Endoscopic ultrasound (EUS) is an excellent diagnostic tool that provides high-resolution images of pancreatic cystic lesions. However, its role in the diagnosis of malignant intraductal papillary mucinous neoplasm (IPMN) remains limited and unclear. We aimed to determine the usefulness of this modality for such diagnosis. METHODS Overall, 246 patients who underwent EUS for IPMN after computed tomography (CT)/magnetic resonance imaging (MRI) from April 2018 to June 2021 were followed up until March 2022. We assessed the added value of performing EUS after CT or MRI for diagnosing malignant IPMN, using receiver operating characteristic curve analysis. Walls as thick as 2 mm were considered thickened in this study if they were highly uneven. RESULTS EUS clearly enhanced accuracy in identifying enhancing nodules and thickened walls. The areas under the receiver operating characteristic curve and corresponding 95% confidence intervals were 0.655 (0.549-0.760) and 0.566 (0.478-0.654) upon CT/MRI but 0.853 (0.763-0.942) and 0.725 (0.634-0.817) when observed using EUS. The combination of nodule size, thickened wall, and main duct size yielded the highest area under the receiver operating characteristic curve (0.944 [0.915-0.973]). CONCLUSIONS EUS more accurately detects malignant IPMN, as uneven wall thickening and certain nodules cannot be identified with CT/MRI.
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Affiliation(s)
- Masanori Kobayashi
- From the Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Mao Niimi
- From the Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Hiromune Katsuda
- From the Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Keiichi Akahoshi
- Department of Hepatobiliary and Pancreatic Surgery, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yuko Kinowaki
- Department of Comprehensive Pathology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Masanao Sasaki
- Department of Clinical Biostatistics, Tokyo Medical and Dental University (TMDU), Tokyo, Japan; and
| | - Akihiro Hirakawa
- Department of Clinical Biostatistics, Tokyo Medical and Dental University (TMDU), Tokyo, Japan; and
| | - Ukihide Tateishi
- Department of Diagnostic Radiology and Nuclear Medicine, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Ryuichi Okamoto
- From the Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
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Moyer MT, Canakis A. Endoscopic Ultrasound-Guided Ablation of Pancreatic Mucinous Cysts. Gastrointest Endosc Clin N Am 2024; 34:537-552. [PMID: 38796298 DOI: 10.1016/j.giec.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Endoscopic ultrasound (EUS) has rapidly evolved from a diagnostic to a therapeutic tool with applications for various pancreaticobiliary diseases. As part of this evolution, EUS-guided chemoablation for neoplastic pancreatic cysts is developing as a minimally invasive treatment option for appropriately selected mucinous cysts, which can spare patients major resective surgery and may reduce progression to pancreatic cancer. Chemotherapeutic cyst ablation has demonstrated encouraging complete resolution rates, while an alcohol-free chemoablation protocol has demonstrated a significant decrease in adverse events without a compromise to complete ablation rates when compared with previous alcohol-based protocols. Most pancreatic cysts are small, low risk, and best managed by surveillance per accepted guidelines. Cysts with features suggestive of overt malignancy are best discussed by a multidisciplinary committee, and surgery is considered if appropriate. However, for patients in the middle ground with cysts that are structurally suitable for chemoablation, alcohol-free chemoablation has been shown to allow effective, safe, and durable results especially for those who are not ideal operative candidates. EUS-guided alcohol-free chemoablation is promising and continues to evolve; however, as a relatively novel treatment option it has areas of uncertainty that will require further investigation and development.
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Affiliation(s)
- Matthew T Moyer
- Division of Gastroenterology and Hepatology, Penn State Cancer Institute, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA
| | - Andrew Canakis
- Division of Gastroenterology & Hepatology, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201, USA.
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Moyer MT, Heinle JW, Rhoades SE, Birkholz JH, Peng JS. Successful EUS-guided pancreatic cyst chemoablation safely allows reduction in the frequency of radiographic surveillance: long-term follow-up of randomized prospective data. Gastrointest Endosc 2024; 99:962-970. [PMID: 38092127 DOI: 10.1016/j.gie.2023.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/17/2023] [Accepted: 12/04/2023] [Indexed: 05/20/2024]
Abstract
BACKGROUND AND AIMS Endoscopic ultrasound-guided pancreatic cyst chemoablation is safe and effective for appropriately selected patients; however, the proper frequency of radiographic surveillance after successful chemoablation is unknown. Here we report the long-term follow-up of 2 randomized prospective Chemotherapy for Ablation and Resolution of Mucinous Pancreatic Cysts (ChARM) clinical trials. In addition, the performance of a postablation-reduced radiographic surveillance protocol was evaluated according to clinical and economic outcomes and patient experience metrics. METHODS Patients who successfully completed 1 of the 2 ChARM randomized control trials were evaluated for durability of response and clinical outcomes. Patients were eligible if 2 years or more of follow-up were available and complete. We calculated economic outcomes according to Medicare allowable costs applicable to endoscopic ultrasound, magnetic resonance imaging, and outpatient clinic visits. We modeled costs of a patient followed by the ChARM Post-treatment Reduced Radiographic Surveillance Protocol compared with a similar patient followed under Fukuoka or American College of Gastroenterology (ACG) guidelines over 5 years. In addition, patients under long-term surveillance in our clinic were interviewed via a 4-question Likert-type questionnaire. RESULTS A total of 52 patients were eligible and included in the study. At the most recent follow-up of the 52 patients, 36 (69.2%) achieved complete response, an additional 11 (21.2%) showed partial response, and only 5 (9.6%) showed nonresponse. All patients were successfully reduced to annual or less surveillance without recurrence or the development of cyst-associated malignancy. Compared with Fukukoa or ACG guidelines, a patient treated and followed under the ChARM Post-treatment Reduced Radiographic Surveillance Protocol incurred a Medicare allowable cost of $7200.00 versus $19,437.44 and $12,526.52 if untreated and observed under Fukukoa and ACG guidelines, respectively. The patient experience questionnaire was returned completed by 49 participants. CONCLUSIONS The ChARM Post-treatment Reduced Radiographic Surveillance Protocol safely allows a reduction in radiographic surveillance. A reduction in cost associated with cyst management under the ChARM protocol, compared with management following Fukukoa or ACG guidelines, was shown. According to the questionnaire, most patients reported a moderate level of logistical and emotional burden associated with magnetic resonance imaging surveillance, and a majority were in favor of reducing the frequency of radiographic surveillance if it could be done without a marked increase in oncologic risk.
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Affiliation(s)
- Matthew T Moyer
- Division of Gastroenterology and Hepatology, Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Penn State Cancer Institute, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - James Westley Heinle
- Penn State Cancer Institute, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Sydney E Rhoades
- Penn State Cancer Institute, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - James H Birkholz
- Division of Abdominal Imaging, Department of Radiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - June S Peng
- Division of Surgical Oncology, Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Parker RA, Zhou Y, Puttock EJ, Chen W, Lustigova E, Wu BU. Early features of pancreatic cancer on magnetic resonance imaging (MRI): a case-control study. Abdom Radiol (NY) 2024; 49:1489-1501. [PMID: 38580790 DOI: 10.1007/s00261-024-04271-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 02/25/2024] [Accepted: 02/25/2024] [Indexed: 04/07/2024]
Abstract
PURPOSE Magnetic resonance imaging has been recommended as a primary imaging modality among high-risk individuals undergoing screening for pancreatic cancer. We aimed to delineate potential precursor lesions for pancreatic cancer on MR imaging. METHODS We conducted a case-control study at Kaiser Permanente Southern California (2008-2018) among patients that developed pancreatic cancer who had pre-diagnostic MRI examinations obtained 2-36 months prior to cancer diagnosis (cases) matched 1:2 by age, gender, race/ethnicity, contrast status and year of scan (controls). Patients with history of acute/chronic pancreatitis or prior pancreatic surgery were excluded. Images underwent blind review with assessment of a priori defined series of parenchymal and ductal features. We performed logistic regression to assess the associations between individual factors and pancreatic cancer. We further assessed the interaction among features as well as performed a sensitivity analysis stratifying based on specific time-windows (2-3 months, 4-12 months, 13-36 months prior to cancer diagnosis). RESULTS We identified 141 cases (37.9% stage I-II, 2.1% III, 31.4% IV, 28.6% unknown) and 292 matched controls. A solid mass was noted in 24 (17%) of the pre-diagnostic MRI scans. Compared to controls, pre-diagnostic images from cancer cases more frequently exhibited the following ductal findings: main duct dilatation (51.4% vs 14.3%, OR [95% CI]: 7.75 [4.19-15.44], focal pancreatic duct stricture with distal (upstream) dilatation (43.6% vs 5.6%, OR 12.71 [6.02-30.89], irregularity (42.1% vs 6.0%, OR 9.73 [4.91-21.43]), focal pancreatic side branch dilation (13.6% vs1.6%, OR 11.57 [3.38-61.32]) as well as parenchymal features: atrophy (57.9% vs 27.4%, OR 46.4 [2.71-8.28], focal area of signal abnormality (39.3% vs 4.8%, OR 15.69 [6.72-44,78]), all p < 0.001). CONCLUSION In addition to potential missed lesions, we have identified a series of ductal and parenchymal features on MRI that are associated with increased odds of developing pancreatic cancer.
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Affiliation(s)
- Rex A Parker
- Department of Radiology, University of Kansas Medical Center, 3901 Rainbow Blvd., Mail Stop 4032, Kansas City, KS, 66160, USA.
| | - Yichen Zhou
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles, 2Nd Floor, Pasadena, CA, 91101, USA
| | - Eric J Puttock
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles, 2Nd Floor, Pasadena, CA, 91101, USA
| | - Wansu Chen
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles, 2Nd Floor, Pasadena, CA, 91101, USA
| | - Eva Lustigova
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S Los Robles, 2Nd Floor, Pasadena, CA, 91101, USA
| | - Bechien U Wu
- Center for Pancreatic Care, Department of Gastroenterology, Los Angeles Medical Center, Southern California Permanente Medical Group, Los Angeles, CA, USA
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Kazmi SZ, Jung HS, Han Y, Yun WG, Cho YJ, Lee M, Kwon W, Castillo CFD, Del Chiaro M, Marchegiani G, Goh BKP, Hijioka S, Majumder S, Nakai Y, Shin A, Jang JY. Systematic review on surveillance for non-resected branch-duct intraductal papillary mucinous neoplasms of the pancreas. Pancreatology 2024; 24:463-488. [PMID: 38480047 DOI: 10.1016/j.pan.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 01/08/2024] [Accepted: 02/24/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND The management of branch-duct type intraductal papillary mucinous neoplasms (BD-IPMN) varies in existing guidelines. This study investigated the optimal surveillance protocol and safe discontinuation of surveillance considering natural history in non-resected IPMN, by systematically reviewing the published literature. METHODS This review was guided by PRISMA. Research questions were framed in PICO format "CQ1-1: Is size criteria helpful to determine surveillance period? CQ1-2: How often should surveillance be carried out? CQ1-3: When should surveillance be discontinued? CQ1-4: Is nomogram predicting malignancy useful during surveillance?". PubMed was searched from January-April 2022. RESULTS The search generated 2373 citations. After screening, 83 articles were included. Among them, 33 studies were identified for CQ1-1, 19 for CQ1-2, 26 for CQ1-3 and 12 for CQ1-4. Cysts <1.5 or 2 cm without worrisome features (WF) were described as more indolent, and most studies advised an initial period of surveillance. The median growth rate of cysts <2 cm ranged from 0.23 to 0.6 mm/year. Patients with cysts <2 cm showing no morphological changes and no WF after 5-years of surveillance have minimal malignancy risk of 0-2%. Two nomograms created with over 1000 patients had AUCs of around 0.8 and appear to be feasible in a real-world practice. CONCLUSIONS For patients with suspected BD-IPMN <2 cm and no other WF, less frequent surveillance is recommended. Surveillance may be discontinued for cysts that remain stable during 5-year surveillance, with consideration of patient condition and life expectancy. With this updated surveillance strategy, patients with non-worrisome BD-IPMN should expect more streamlined management and decreased healthcare utilization.
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Affiliation(s)
- Sayada Zartasha Kazmi
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hye-Sol Jung
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Won-Gun Yun
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Young Jae Cho
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Mirang Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Giovanni Marchegiani
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Padova University Hospital, Padova, Italy
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital & National Cancer Centre Singapore, Singapore
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Aesun Shin
- Department of Preventive Medicine and Cancer Research Institute, Seoul National University, Seoul, South Korea.
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea.
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Dane B, Kim J, Qian K, Megibow A. Pancreatic cyst prevalence and detection with photon counting CT compared with conventional energy integrating detector CT. Eur J Radiol 2024; 175:111437. [PMID: 38520805 DOI: 10.1016/j.ejrad.2024.111437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/19/2024] [Indexed: 03/25/2024]
Abstract
PURPOSE To calculate the prevalence of pancreatic cysts on photon counting CT (PCCT) and compare with that of 128-slice conventional energy-integrating detector CT (EIDCT). METHOD A retrospective single institution database search identified all contrast-enhanced abdominal CT examinations performed at an outpatient facility that has both a PCCT and EIDCT between 4/11/2022 and 7/26/2022. The presence and size of pancreatic cysts were recorded. In patients with PCCT reported pancreatic cysts, prior CT imaging (EIDCT) was reviewed for reported pancreatic cysts. Fisher's exact test was used to compare the pancreatic cyst detection rate for PCCT and EIDCT. Wilcoxon rank sum test was used to compare cyst size and patient age. A p <.05 indicated statistical significance. RESULTS 2494 patients were included. Our pancreatic cyst detection rate was 4.9 % (49/1009) with PCCT and 3.0 % (44/1485) for EIDCT (p =.017). For CT angiograms, pancreatic cysts were detected in 6.6 % (21/319) with PCCT and 0.0 % (0/141) with EIDCT (p <.001). Pancreatic cyst detection rate was not statistically different for portal venous, enterography, renal mass, pancreas, 3-phase liver, or venogram protocols (all p >.05). Mean[SD] pancreatic cyst size was 13.7[9.7]mm for PCCT and 15.3[14.7] for EIDCT (p =.95). 55.1 % (27/49) of PCCT and 61.4 % (27/44) of EIDCT that described pancreatic cysts had prior contrast-enhanced EIDCTs. Of these, 40.7 % (11/27) of PCCT and 14.8 % (4/27) of EIDCT described pancreatic cysts were not previously reported (p =.027). CONCLUSIONS Photon-counting CT afforded greater pancreatic cyst detection than conventional energy-integrating detector CT, particularly with CT angiograms.
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Affiliation(s)
- Bari Dane
- Department of Radiology, NYU Langone Health, 660 1(st) Avenue, New York, NY 10016.
| | - Jesi Kim
- Department of Radiology, NYU Langone Health, 660 1(st) Avenue, New York, NY 10016
| | - Kun Qian
- NYU Langone Health Department of Biostatistics, 180 Madison Avenue, New York, NY 10016
| | - Alec Megibow
- Department of Radiology, NYU Langone Health, 660 1(st) Avenue, New York, NY 10016
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Ohtsuka T, Fernandez-Del Castillo C, Furukawa T, Hijioka S, Jang JY, Lennon AM, Miyasaka Y, Ohno E, Salvia R, Wolfgang CL, Wood LD. International evidence-based Kyoto guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas. Pancreatology 2024; 24:255-270. [PMID: 38182527 DOI: 10.1016/j.pan.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/14/2023] [Accepted: 12/22/2023] [Indexed: 01/07/2024]
Abstract
This study group aimed to revise the 2017 international consensus guidelines for the management of intraductal papillary mucinous neoplasm (IPMN) of the pancreas, and mainly focused on five topics; the revision of high-risk stigmata (HRS) and worrisome features (WF), surveillance of non-resected IPMN, surveillance after resection of IPMN, revision of pathological aspects, and investigation of molecular markers in cyst fluid. A new development from the prior guidelines is that systematic reviews were performed for each one of these topics, and published separately to provide evidence-based recommendations. One of the highlights of these new "evidence-based guidelines" is to propose a new management algorithm, and one major revision is to include into the assessment of HRS and WF the imaging findings from endoscopic ultrasound (EUS) and the results of cytological analysis from EUS-guided fine needle aspiration technique, when this is performed. Another key element of the current guidelines is to clarify whether lifetime surveillance for small IPMNs is required, and recommends two options, "stop surveillance" or "continue surveillance for possible development of concomitant pancreatic ductal adenocarcinoma", for small unchanged BD-IPMN after 5 years surveillance. Several other points are also discussed, including identifying high-risk features for recurrence in patients who underwent resection of non-invasive IPMN with negative surgical margin, summaries of the recent observations in the pathology of IPMN. In addition, the emerging role of cyst fluid markers that can aid in distinguishing IPMN from other pancreatic cysts and identify those IPMNs that harbor high-grade dysplasia or invasive carcinoma is discussed.
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Affiliation(s)
- Takao Ohtsuka
- Department of Digestive Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.
| | | | - Toru Furukawa
- Department of Investigative Pathology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Jin-Young Jang
- Division of Hepatobiliary-Pancreatic Surgery, Departments of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Anne Marie Lennon
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Yoshihiro Miyasaka
- Department of Surgery, Fukuoka University Chikushi Hospital, and Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Fujita Health University, Toyoake, Aichi, Japan
| | - Roberto Salvia
- Department of Surgery, Dentistry, Paediatrics and Gynaecology University of Verona, Verona, Italy
| | | | - Laura D Wood
- Departments of Pathology and Oncology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Wood LD, Adsay NV, Basturk O, Brosens LAA, Fukushima N, Hong SM, Kim SJ, Lee JW, Luchini C, Noë M, Pitman MB, Scarpa A, Singhi AD, Tanaka M, Furukawa T. Systematic review of challenging issues in pathology of intraductal papillary mucinous neoplasms. Pancreatology 2023; 23:878-891. [PMID: 37604731 DOI: 10.1016/j.pan.2023.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMNs) are a cystic precursor to pancreatic cancer. IPMNs deemed clinically to be at high-risk for malignant progression are frequently treated with surgical resection, and pathological examination of the pancreatectomy specimen is a key component of the clinical care of IPMN patients. METHODS Systematic literature reviews were conducted around eight topics of clinical relevance in the examination of pathological specimens in patients undergoing resection of IPMN. RESULTS This review provides updated perspectives on morphological subtyping of IPMNs, classification of intraductal oncocytic papillary neoplasms, nomenclature for high-grade dysplasia, assessment of T stage, distinction of carcinoma associated or concomitant with IPMN, role of molecular assessment of IPMN tissue, role of intraoperative assessment by frozen section, and preoperative evaluation of cyst fluid cytology. CONCLUSIONS This analysis provides the foundation for data-driven approaches to several challenging issues in the pathology of IPMNs.
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Affiliation(s)
- Laura D Wood
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - N Volkan Adsay
- Department of Pathology, Koç University Hospital and Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey
| | - Olca Basturk
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Noriyoshi Fukushima
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Joo Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae W Lee
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134, Verona, Italy; ARC-Net Research Center, University of Verona, 37134, Verona, Italy
| | - Michaël Noë
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134, Verona, Italy; ARC-Net Research Center, University of Verona, 37134, Verona, Italy
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mariko Tanaka
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toru Furukawa
- Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
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10
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Kawakami Y, Koshita S, Kanno Y, Ogawa T, Kusunose H, Sakai T, Yonamine K, Miyamoto K, Kozakai F, Okada T, Oikawa M, Tsuchiya T, Noda Y, Sawai T, Nakase H, Ito K. Pancreatic ductal adenocarcinomas concomitant with intraductal papillary mucinous neoplasms of the pancreas: A investigation of those clinicopathological features by analyzing 48 patients who underwent surgery for those lesions. Pancreatology 2023; 23:674-681. [PMID: 37604732 DOI: 10.1016/j.pan.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Differences between pancreatic ductal adenocarcinomas (PDACs) concomitant with intraductal papillary mucinous neoplasm (IPMN) (C-PDACs), those without IPMN (NC-PDACs) and invasive cancers derived from IPMN (IC-Ds) have not been fully clarified. METHODS Forty-eight patients with C-PDAC were included to investigate the differences in 1) clinicopathological features and 2) post-operative courses among the three invasive cancer groups. RESULTS 1) Characteristics of C-PDACs were mostly similar to those of NC-PDACs; whereas, between C-PDACs and IC-Ds, the rate of mucinous carcinoma (2%/25%, p = 0.003) and pathological stage (IA, 15%/36%, p = 0.033; III, 31%/4%, p = 0.015) significantly differed. Most C-PDACs coexisted with small, multifocal IPMNs without mural nodules. 2) Cumulative 5-year recurrence-free survival (RFS) rate related to extra-pancreatic recurrence was significantly worse in C-PDACs than in IC-Ds (35%/69%, p = 0.008) and was not significantly different between C-PDACs and NC-PDACs (35%/18%). This related to intra-pancreatic recurrence tended to be poor in the order of IC-Ds, C-PDACs, and NC-PDACs (69%/82%/93%). CONCLUSIONS Because characteristics of IPMNs remarkably differed between C-PDACs and IC-Ds, another algorithm specific to the early detection of C-PDACs is necessary. Appropriate post-operative managements according to the two types of recurrences may contribute to the improvement in the prognoses of C-PDACs/IC-Ds.
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Affiliation(s)
- Yujiro Kawakami
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan; Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Shinsuke Koshita
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan.
| | - Yoshihide Kanno
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Takahisa Ogawa
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Hiroaki Kusunose
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Toshitaka Sakai
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Keisuke Yonamine
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Kazuaki Miyamoto
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Fumisato Kozakai
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
| | - Takaho Okada
- Department of Surgery, Sendai City Medical Center, Sendai, Japan
| | - Masaya Oikawa
- Department of Surgery, Sendai City Medical Center, Sendai, Japan
| | - Takashi Tsuchiya
- Department of Surgery, Sendai City Medical Center, Sendai, Japan
| | - Yutaka Noda
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan; Department of Pathology, Sendai City Medical Center, Sendai, Japan
| | - Takashi Sawai
- Department of Pathology, Sendai City Medical Center, Sendai, Japan
| | - Hiroshi Nakase
- Department of Gastroenterology and Hepatology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Kei Ito
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
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11
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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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12
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Triantopoulou C, Gourtsoyianni S, Karakaxas D, Delis S. Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Challenging Diagnosis. Diagnostics (Basel) 2023; 13:2015. [PMID: 37370909 DOI: 10.3390/diagnostics13122015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/31/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023] Open
Abstract
Intraductal papillary mucinous neoplasm of the pancreas (IPMN) was classified as a distinct entity from mucinous cystic neoplasm by the WHO in 1995. It represents a mucin-producing tumor that originates from the ductal epithelium and can evolve from slight dysplasia to invasive carcinoma. In addition, different aspects of tumor progression may be seen in the same lesion. Three types are recognized, the branch duct variant, the main duct variant, which shows a much higher prevalence for malignancy, and the mixed-type variant, which combines branch and main duct characteristics. Advances in cross-sectional imaging have led to an increased rate of IPMN detection. The main imaging characteristic of IPMN is the dilatation of the pancreatic duct without the presence of an obstructing lesion. The diagnosis of a branch duct IPMN is based on the proof of its communication with the main pancreatic duct on MRI-MRCP examination. Early identification by imaging of the so-called worrisome features or predictors for malignancy is an important and challenging task. In this review, we will present recent imaging advances in the diagnosis and characterization of different types of IPMNs, as well as imaging tools available for early recognition of worrisome features for malignancy. A critical appraisal of current IPMN management guidelines from both a radiologist's and surgeon's perspective will be made. Special mention is made of complications that might arise during the course of IPMNs as well as concomitant pancreatic neoplasms including pancreatic adenocarcinoma and pancreatic endocrine neoplasms. Finally, recent research on prognostic and predictive biomarkers including radiomics will be discussed.
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Affiliation(s)
| | - Sofia Gourtsoyianni
- 1st Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Areteion Hospital, 11528 Athens, Greece
| | - Dimitriοs Karakaxas
- Department of Surgery, Konstantopouleio General Hospital, 14233 Athens, Greece
| | - Spiros Delis
- Department of Surgery, Konstantopouleio General Hospital, 14233 Athens, Greece
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13
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Ormsby EL, Kojouri K, Chang PC, Lin TY, Vuong B, Ramirez RM, Schueler KM, Sweet CF, Herrinton LJ. Association of Standardized Radiology Reporting and Management of Abdominal CT and MRI With Diagnosis of Pancreatic Cancer. Clin Gastroenterol Hepatol 2023; 21:644-652.e2. [PMID: 35436626 DOI: 10.1016/j.cgh.2022.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/24/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Follow-up of abdominal computed tomography (CT) and magnetic resonance imaging (MRI) findings suspicious for pancreatic cancer may be delayed if documentation is unclear. We evaluated whether standardized reporting and follow-up of imaging results reduced time to diagnosis of pancreatic cancer. METHODS We used a quasi-experimental stepped-wedge cluster design to evaluate the effectiveness of newly implemented radiology reporting system. The system standardizes the reporting of CT and MRI reports using hashtags that classify pancreatic findings. The system also automates referral of patients with findings suspicious for pancreatic cancer to a multidisciplinary care team for rapid review and follow-up. The study examined 318,331 patients who underwent CT or MRI that included the abdomen from 2016 through 2019 who had not had an eligible CT or MRI in the preceding 24 months. We evaluated the association of the intervention with incidence of pancreatic cancer within 60 days and 120 days after imaging. RESULTS Thirty-eight percent of patients received the intervention, and 1523 patients (0.48%) were diagnosed with pancreatic cancer. In multivariable analysis accounting for age, race/ethnicity, sex, Charlson comorbidity, history of cancer, diabetes, and 4-month calendar period, the intervention was associated with nearly 50% greater odds of diagnosing pancreatic cancer within 60 days (adjusted odds ratio, 1.47; 95% confidence interval, 1.05-2.06) and 120 days (adjusted odds ratio, 1.46; 95% confidence interval, 1.04-2.06). CONCLUSIONS In this large quasi-experimental, community-based observational study, implementing standardized reporting of abdominal CT and MRI reports with clinical navigation was effective for increasing the detection and diagnosis of pancreatic cancer.
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Affiliation(s)
| | | | | | - Teresa Y Lin
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Brooke Vuong
- Department of Surgical Oncology, Oakland, California
| | | | | | | | - Lisa J Herrinton
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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14
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Yamaguchi A, Kato N, Sugata S, Hamada T, Furuya N, Mizumoto T, Tamaru Y, Kusunoki R, Kuwai T, Kouno H, Toyota N, Sudo T, Kuraoka K, Kohno H. Effectiveness of Abdominal Ultrasonography for Improving the Prognosis of Pancreatic Cancer during Medical Checkup: A Single Center Retrospective Analysis. Diagnostics (Basel) 2022; 12:diagnostics12122913. [PMID: 36552920 PMCID: PMC9777348 DOI: 10.3390/diagnostics12122913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 11/08/2022] [Accepted: 11/22/2022] [Indexed: 11/25/2022] Open
Abstract
Recent advancements in surgical and anti-cancer therapies have provided significant hope of long survival in patients with pancreatic cancer (PC). To realize this hope, routine medical checkups of asymptomatic people should be performed to identify operable PCs. In this study, we evaluated the efficacy of medical checkups using abdominal ultrasonography (US). We retrospectively analyzed 374 patients with PC at our institute between 2010 and 2021. We divided these patients into several groups according to the diagnostic approach and compared their background and prognosis. These groups comprised PCs diagnosed through (a) symptoms, 242 cases; (b) US during medical checkup for asymptomatic individuals, 17; and other means. Of the 374 patients, 192 were men (51.3%), and the median age was 74 years (34−105). Tumors were located in the pancreatic tail in 67 patients (17.9%). Excision ratio and 5-year survival rate were significantly better in group (b) than in (a) (58.8% vs. 23.1%, p < 0.01 and 42.2% vs. 9.4%, p < 0.001, respectively). The prognosis of patients diagnosed using US during medical checkup was better than that of patients identified through symptomatic presentation of PC. US for asymptomatic individuals with PC might be one of the useful modalities for promoting better prognosis of PCs.
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Affiliation(s)
- Atsushi Yamaguchi
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
- Correspondence: ; Tel.: +81-823223-111; Fax: +81-823-21-0478
| | - Naohiro Kato
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Shuhei Sugata
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Takuro Hamada
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Nao Furuya
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Takeshi Mizumoto
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Yuzuru Tamaru
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Ryusaku Kusunoki
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Toshio Kuwai
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Hirotaka Kouno
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Naoyuki Toyota
- Department of Radiology, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Takeshi Sudo
- Department of Surgery, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Kazuya Kuraoka
- Department of Pathology, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
| | - Hiroshi Kohno
- Department of Gastroenterology, Kure Medical Center and Chugoku Cancer Center, Kure 737-0023, Japan
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15
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Hashimoto D, Satoi S, Yamamoto T, Yamaki S, Ishida M, Hirooka S, Shibata N, Boku S, Ikeura T, Sekimoto M. Long-term outcomes of patients with multifocal intraductal papillary mucinous neoplasm following pancreatectomy. Pancreatology 2022; 22:1046-1053. [PMID: 35871123 DOI: 10.1016/j.pan.2022.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/29/2022] [Accepted: 07/11/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The decision to perform surgery is complicated by the presence of multifocal (MF) intraductal papillary mucinous neoplasms (IPMNs), which are characterized by two or more cysts located in different areas of the pancreas. OBJECTIVES We aimed to establish a suitable treatment strategy and surgical indications in patients with MF-IPMNs. METHODS This single-center retrospective study included patients with IPMNs who underwent pancreatic resection from 2006 to 2020. Patients with distant metastasis and patients with IPMNs of the main pancreatic duct were excluded from the analysis. RESULTS After excluding 22 patients, 194 patients were included. One hundred thirteen patients (58.2%) had unifocal IPMNs, while 81 patients (41.8%) had MF-IPMNs. There were no significant differences in the 5-year disease-specific survival (DSS) rate (92.3% vs. 92.4%, p = 0.976) and the 5-year disease-free survival rate (88.6% vs. 86.5%, p = 0.461). The multivariate analysis identified high-risk stigmata, invasive carcinoma, and lymph node metastasis as independent predictors of DSS. The presence of cystic lesions in the pancreatic remnant was not a predictor of survival. Even in the MF-IPMN group, there were no significant differences in DSS when stratified by procedure (total pancreatectomy vs. segmental pancreatectomy, p = 0.268) or presence of cystic lesions in the pancreatic remnant (p = 0.476). The multivariate analysis identified lymph node metastasis as an independent predictor of DSS in the MF-IPMN group. CONCLUSIONS In patients with MF-IPMNs, each cyst should be evaluated individually for the presence of features associated with malignancy.
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Affiliation(s)
- Daisuke Hashimoto
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan; Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Tomohisa Yamamoto
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
| | - So Yamaki
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
| | - Mitsuaki Ishida
- Department of Pathology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan
| | - Satoshi Hirooka
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
| | - Nobuhiro Shibata
- Cancer Treatment Center, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
| | - Shogen Boku
- Cancer Treatment Center, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
| | - Tsukasa Ikeura
- Third Department of Internal Medicine, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata City, Osaka, 573-1010, Japan
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16
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Non-tumor forming and diffusely spreading invasive pancreatic cancer. Clin J Gastroenterol 2022; 15:1185-1192. [DOI: 10.1007/s12328-022-01705-6] [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: 06/04/2022] [Accepted: 09/14/2022] [Indexed: 11/07/2022]
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17
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Usefulness of Practitioner-Led Pancreatic Cancer Screening. Diagnostics (Basel) 2022; 12:diagnostics12092257. [PMID: 36140658 PMCID: PMC9498137 DOI: 10.3390/diagnostics12092257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/11/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
The 5-year survival rate for pancreatic cancer has improved (10%) but remains worse than that for other cancers. Early pancreatic cancer diagnosis is challenging, and delayed diagnosis can delay treatment, which impairs survival. Practitioners do not promptly refer cases to a general hospital, causing delayed discovery. Herein, we aimed to examine the usefulness of the Pancreatic Cancer Project in Matsue, whose objective is to detect pancreatic cancer in patients presenting at any medical institution in Matsue City. Clinical data were extracted from medical records, and abdominal ultrasonography and tumor marker blood level assessments were performed (n = 234; median age, 71 [range, 41–94] years; 51% male). Cases with abnormal abdominal ultrasonography or blood test findings were referred for specialist imaging and followed up. The pancreatic cancer detection rate was 6.0% (n = 14); all cases were referred to a general hospital by practitioners within 1 month. Patients had stage IA (n = 1), IIA (n = 6), IIB (n = 2), III (n = 1), and IV (n = 4) disease. Overall, pancreatic cancer could be detected at an earlier stage (I–II), but referral to a general hospital by visiting practitioners should be prompt. The Pancreatic Cancer Project in Matsue may help improve the detection and prognosis of pancreatic cancer.
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18
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Exhaled breath condensate proteomic signatures potentially distinguish adenocarcinoma from benign cystic lesions of the pancreas. Curr Res Transl Med 2022; 70:103361. [PMID: 35963150 DOI: 10.1016/j.retram.2022.103361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/26/2022] [Accepted: 07/29/2022] [Indexed: 01/31/2023]
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19
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Matsumoto I. Invited Editorial: Comprehensive Analysis of Molecular Biological Characteristics of Pancreatic Ductal Adenocarcinoma Concomitant with Intraductal Papillary Mucinous Neoplasm. Ann Surg Oncol 2022; 29:4683-4685. [PMID: 35419756 DOI: 10.1245/s10434-022-11713-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Osakasayama, Osaka, Japan.
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20
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Sotozono H, Kanki A, Yasokawa K, Yamamoto A, Sanai H, Moriya K, Tamada T. Value of 3-T MR imaging in intraductal papillary mucinous neoplasm with a concomitant invasive carcinoma. Eur Radiol 2022; 32:8276-8284. [PMID: 35665843 DOI: 10.1007/s00330-022-08881-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/26/2022] [Accepted: 05/12/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To examine the value of 3-T MRI for evaluating the difference between the pancreatic parenchyma of intraductal papillary mucinous neoplasm with a concomitant invasive carcinoma (IPMN-IC) and the pancreatic parenchyma of patients without an IPMN-IC. METHODS A total of 132 patients underwent abdominal 3-T MRI. Of the normal pancreatic parenchymal measurements, the pancreas-to-muscle signal intensity ratio in in-phase imaging (SIR-I), SIR in opposed-phase imaging (SIR-O), SIR in T2-weighted imaging (SIR-T2), ADC (×10-3 mm2/s) in DWI, and proton density fat fraction (PDFF [%]) in multi-echo 3D DIXON were calculated. The patients were divided into three groups (normal pancreas group: n = 60, intraductal papillary mucinous neoplasm (IPMN) group: n = 60, IPMN-IC group: n = 12). RESULTS No significant differences were observed among the three groups in age, sex, body mass index, prevalence of diabetes mellitus, and hemoglobin A1c (p = 0.141 to p = 0.657). In comparisons among the three groups, the PDFF showed a significant difference (p < 0.001), and there were no significant differences among the three groups in SIR-I, SIR-O, SIR-T2, and ADC (p = 0.153 to p = 0.684). The PDFF of the pancreas was significantly higher in the IPMN-IC group than in the normal pancreas group or the IPMN group (p < 0.001 and p < 0.001, respectively), with no significant difference between the normal pancreas group and the IPMN group (p = 0.916). CONCLUSIONS These observations suggest that the PDFF of the pancreas is associated with the presence of IPMN-IC. KEY POINTS • The cause and risk factors of IPMN with a concomitant invasive carcinoma have not yet been clarified. • The PDFF of the pancreas was significantly higher in the IPMN-IC group than in the normal pancreas group or the IPMN group. • Pancreatic PDFF may be a potential biomarker for the development of IPMN with a concomitant invasive carcinoma.
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Affiliation(s)
- Hidemitsu Sotozono
- Department of Radiology, Kawasaki Medical School, 577 Matsushima, Kurashiki city, Okayama, 701-0192, Japan.
| | - Akihiko Kanki
- Department of Radiology, Kawasaki Medical School, 577 Matsushima, Kurashiki city, Okayama, 701-0192, Japan
| | - Kazuya Yasokawa
- Department of Radiology, Kawasaki Medical School, 577 Matsushima, Kurashiki city, Okayama, 701-0192, Japan
| | - Akira Yamamoto
- Department of Radiology, Kawasaki Medical School, 577 Matsushima, Kurashiki city, Okayama, 701-0192, Japan
| | - Hiroyasu Sanai
- Department of Radiology, Kawasaki Medical School, 577 Matsushima, Kurashiki city, Okayama, 701-0192, Japan
| | - Kazunori Moriya
- Department of Radiology, Kawasaki Medical School, 577 Matsushima, Kurashiki city, Okayama, 701-0192, Japan
| | - Tsutomu Tamada
- Department of Radiology, Kawasaki Medical School, 577 Matsushima, Kurashiki city, Okayama, 701-0192, Japan
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21
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Chhoda A, Singh S, Sheth AH, Grimshaw AA, Gunderson CG, Sharma P, Kunstman JW, Sharma A, Ahuja N, Gonda TA, Farrell JJ. Benefit of Extended Surveillance of Low-Risk Pancreatic Cysts After 5-Year Stability: A Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2022; 21:1430-1446. [PMID: 35568304 DOI: 10.1016/j.cgh.2022.04.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS Low-risk branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) lacking worrisome features (WF) and high-risk stigmata (HRS) warrant surveillance. However, their optimal duration, especially among cysts with initial 5 years of size stability, warrants further investigation. We systematically reviewed the surveillance of low-risk BD-IPMNs and investigated the incidence of WF/HRS and advanced neoplasia, high-grade dysplasia, and pancreatic cancer during the initial (<5 years) and extended surveillance period (>5-years). METHODS A systematic search (CRD42020117120) identified studies investigating long-term IPMN surveillance outcomes of low-risk IPMN among the Cochrane Library, Embase, Google Scholar, Ovid Medline, PubMed, Scopus, and Web of Science, from inception until July 9, 2021. The outcomes included the incidence of WF/HRS and advanced neoplasia, disease-specific mortality, and surveillance-related harm (expressed as percentage per patient-years). The meta-analysis relied on time-to-event plots and used a random-effects model. RESULTS Forty-one eligible studies underwent systematic review, and 18 studies were meta-analyzed. The pooled incidence of WF/HRS among low-risk BD-IPMNs during initial and extended surveillance was 2.2% (95% CI, 1.0%-3.7%) and 2.9% (95% CI, 1.0%-5.7%) patient-years, respectively, whereas the incidence of advanced neoplasia was 0.6% (95% CI, 0.2%-1.00%) and 1.0% (95% CI, 0.6%-1.5%) patient-years, respectively. The pooled incidence of disease-specific mortality during initial and extended surveillance was 0.3% (95% CI, 0.1%-0.6%) and 0.6% (95% CI, 0.0%-1.6%) patient-years, respectively. Among BD-IPMNs with initial size stability, extended surveillance had a WF/HRS and advanced neoplasia incidence of 1.9% (95% CI, 1.2%-2.8%) and 0.2% (95% CI, 0.1%-0.5%) patient-years, respectively. CONCLUSIONS A lower incidence of advanced neoplasia during extended surveillance among low-risk, stable-sized BD-IPMNs was a key finding of this study. However, the survival benefit of surveillance among this population warrants further exploration through high-quality studies before recommending surveillance cessation with certainty.
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Affiliation(s)
- Ankit Chhoda
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut
| | - Sidhant Singh
- Yale Waterbury Internal Medicine Program,Yale School of Medicine, New Haven, Connecticut
| | | | - Alyssa A Grimshaw
- Cushing/Whitney Medical Library, Yale University, New Haven, Connecticut
| | - Craig G Gunderson
- Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Prabin Sharma
- Department of Advanced Gastroenterology, NYU Winthrop Hospital, Mineola, New York
| | - John W Kunstman
- Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Anup Sharma
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Nita Ahuja
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Tamas A Gonda
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Langone Health, New York, New York
| | - James J Farrell
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut.
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22
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Yamada D, Kobayashi S, Takahashi H, Yoshioka T, Iwagami Y, Tomimaru Y, Shigekawa M, Akita H, Noda T, Asaoka T, Gotoh K, Tanemura M, Doki Y, Eguchi H. Pancreatic CT density is an optimal imaging biomarker for earlier detection of malignancy in the pancreas with intraductal papillary mucinous neoplasm. Pancreatology 2022; 22:488-496. [PMID: 35396159 DOI: 10.1016/j.pan.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/04/2022] [Accepted: 03/22/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMNs) are typically detected as incidental findings by computed tomography (CT); however, the conventional surveillance is not valid for the early detection of concomitant pancreatic cancer. The pancreas of IPMN is often accompanied by fatty infiltration in the parenchyma, and pancreatic fatty infiltration could be evaluated by pancreatic CT density (pancreatic index, PI). We aimed to investigate whether PI could be an imaging biomarker for the early prediction of malignancies in the pancreas with IPMN. METHODS Two different cohorts were investigated. (Investigation cohort): A total of 1137 patients with initially low-risk IPMN were compensated by initial IPMN findings, and 2 groups (malignancy/possible benign, 50 cases each) were investigated for yearly changes in PI and for the cutoff value of PI indicating the development of malignancies. (Validation cohort): To validate the cutoff value, 256 patients radiologically suspected of having IPMNs were investigated. RESULTS (Investigation-cohort): The malignancy group showed a gradual decrease in PI every year, and PI significantly differed among the 2 groups 1 year prior to the last investigation. The cutoff value of PI was set at 0.65. (Validation-cohort): A total of 55% of the patients with a PI below the cutoff value had malignancy in the pancreas, including concomitant pancreatic cancer, and the cutoff value was the most significant risk factors for the development of malignancies in the pancreas compared to the conventional risk factors for IPMN. CONCLUSIONS Decreasing PI would be an optimal imaging biomarker for earlier detection of malignancies in the pancreas with IPMN.
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Affiliation(s)
- Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan.
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Teppei Yoshioka
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Yoshito Tomimaru
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Minoru Shigekawa
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Hirofumi Akita
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Tadafumi Asaoka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan; Department of Surgery, Osaka Police Hospital, Tennoji-ku Kitayamacho 10-31, Osaka, 543-0035, Japan
| | - Kunihito Gotoh
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Masahiro Tanemura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan; Department of Gastroenterological Surgery, Rinku General Medical Center, Rinku-Ourai-Kita 2-23, Izumisano, Osaka, 598-8577, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
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23
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Kishimoto Y, Okano N, Ito K, Takuma K, Hara S, Iwasaki S, Yoshimoto K, Ymada Y, Watanabe K, Kimura Y, Nakagawa H, Igarashi Y. Peroral Pancreatoscopy with Videoscopy and Narrow-Band Imaging in Intraductal Papillary Mucinous Neoplasms with Dilatation of the Main Pancreatic Duct. Clin Endosc 2021; 55:270-278. [PMID: 34865339 PMCID: PMC8995986 DOI: 10.5946/ce.2021.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 07/27/2021] [Indexed: 12/02/2022] Open
Abstract
Background/Aims Endoscopic evaluation of intraductal papillary mucinous neoplasms (IPMNs) is useful in determining whether the lesions are benign or malignant. This study aimed to examine the usefulness of peroral pancreatoscopy (POPS) in determining the prognosis of IPMNs.
Methods POPS with videoscopy was performed using the mother–baby scope technique. After surgery, computed tomography/magnetic resonance cholangiopancreatography or ultrasonography and blood tests were performed every 6 months during the follow-up.
Results A total of 39 patients with main pancreatic duct (MPD)–type IPMNs underwent POPS using a videoscope, and the protrusions in the MPD were observed in 36 patients. The sensitivity and specificity of cytology/biopsy performed at the time of POPS were 85% and 87.5%, respectively. Of 19 patients who underwent surgery, 18 (95%) patients had negative surgical margins and 1 (5%) patient had a positive margin.
Conclusions In IPMNs with dilatation of the MPD, POPS is considered effective if the lesions can be directly observed. The diagnosis of benign and malignant lesions is possible depending on the degree of lesion elevation. However, in some cases, slightly elevated lesions may increase in size during the follow-up or multiple lesions may be simultaneously present; therefore, careful follow-up is necessary.
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Affiliation(s)
- Yui Kishimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Naoki Okano
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Ken Ito
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Kensuke Takuma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Seiichi Hara
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Susumu Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Kensuke Yoshimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Yuuto Ymada
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Koji Watanabe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Yuusuke Kimura
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Hiroki Nakagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Yoshinori Igarashi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
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24
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Miller FH, Lopes Vendrami C, Recht HS, Wood CG, Mittal P, Keswani RN, Gabriel H, Borhani AA, Nikolaidis P, Hammond NA. Pancreatic Cystic Lesions and Malignancy: Assessment, Guidelines, and the Field Defect. Radiographics 2021; 42:87-105. [PMID: 34855543 DOI: 10.1148/rg.210056] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The widespread use of high-spatial-resolution cross-sectional imaging has led to an increase in detection of incidental pancreatic cystic lesions. These lesions are a diverse group, ranging from indolent and premalignant lesions to invasive cancers. The diagnosis of several of these lesions can be suggested on the basis of their imaging appearance, while many other lesions require follow-up imaging and/or aspiration. The smaller cystic lesions, often branch-duct intraductal papillary mucinous neoplasms, have overlapping imaging characteristics that make diagnostic assessment of the natural history and malignancy risk confusing. Expert panels have developed societal guidelines, based on a consensus, for surveillance of these lesions. However, these guidelines are often inconsistent and are constantly evolving as additional scientific data are accumulated. Identification of features associated with increased risk of malignancy is important for proper management. The concept of field defect, whereby pancreatic adenocarcinoma develops at a site different from the site of the pancreatic cyst, adds to the complexity of screening guidelines. As a result of the differences in guidelines, key stakeholders (eg, radiologists, gastroenterologists, and surgeons) must review and come to a consensus regarding which guideline, or combination of guidelines, to follow at their individual institutions. Standardized reporting and macros are helpful for ensuring the uniformity of interpretations. Radiologists play a critical role in the detection and characterization of pancreatic cystic lesions, in the follow-up recommendations for these lesions, and in the detection of associated cancer. An invited commentary by Zaheer is available online. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Frank H Miller
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Camila Lopes Vendrami
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Hannah S Recht
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Cecil G Wood
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Pardeep Mittal
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Rajesh N Keswani
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Helena Gabriel
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Amir A Borhani
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Paul Nikolaidis
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Nancy A Hammond
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
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25
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Kaida H, Miyasaka Y, Morishita M, Koreeda N, Hirano Y, Ohmiya T, Uwatoko S, Kawamoto M, Komono A, Sakamoto R, Shibata R, Higashi D, Nimura S, Watanabe M. Laparoscopic distal pancreatectomy for intraductal papillary mucinous neoplasm-associated pancreatic cancer: A case report. Int J Surg Case Rep 2021; 87:106376. [PMID: 34537524 PMCID: PMC8455712 DOI: 10.1016/j.ijscr.2021.106376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/25/2021] [Accepted: 09/02/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction and importance Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is often found incidentally during examination for other diseases. In addition to the risk of malignant transformation, patients with IPMN are at risk of developing pancreatic cancer. We report a case of pancreatic tail cancer that developed separately from a preexisting IPMN after minimally invasive esophagectomy for cancer of the esophagogastric junction and was resected successfully by laparoscopic distal pancreatectomy. Case presentation A 72-year-old man underwent thoracoscopic and laparoscopic esophagectomy for esophagogastric junction cancer. He had undergone surgery for ascending colon cancer 20 years ago. At that time, IPMN was confirmed in the pancreatic body by a preoperative examination. Computed tomography was regularly performed for postoperative work-up and follow-up of the IPMN, and a solid lesion with cystic components was detected in the pancreatic tail 9 months after the operation. On detailed examination, pancreatic ductal adenocarcinoma concomitant with IPMN, accompanied by a retention cyst, was considered. Laparoscopic distal pancreatectomy was successfully performed after neoadjuvant chemotherapy. Pathological diagnosis of the lesion in the pancreatic tail was of an invasive intraductal papillary mucinous carcinoma (ypT3ypN0yM0 ypStageIIA). Clinical discussion If an IPMN is detected during preoperative examination for malignancies of other organs, careful follow-up is necessary due to the high risk of pancreatic cancer development. Furthermore, initial operation with minimally invasive surgery may reduce adhesion and facilitate subsequent surgeries. Conclusion We have provided evidence that supports the importance of a careful follow-up of IPMNs, even if they are low risk. Intraductal papillary mucinous neoplasm of the pancreas is found incidentally. A pre-existing neoplasm led to pancreatic tail cancer in one patient. Due to careful follow-up of the neoplasm, the secondary cancer was detected rapidly. It was resected successfully by laparoscopic distal pancreatectomy. Careful follow is necessary if this neoplasm is detected.
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Affiliation(s)
- Hiroki Kaida
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Yoshihiro Miyasaka
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Marina Morishita
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Nobuhiko Koreeda
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Yousuke Hirano
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Toshihiro Ohmiya
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Shugo Uwatoko
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Makoto Kawamoto
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Akira Komono
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Ryohei Sakamoto
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Ryosuke Shibata
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Daijiro Higashi
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Satoshi Nimura
- Department of Pathology, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Masato Watanabe
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan.
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26
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Fung CI, Bigam DL, Wong CKW, Hurrell C, Bird JR, Brahm GL, Kirkpatrick IDC. Recommendations for the Management of Incidental Pancreatic Findings in Adults by the Canadian Association of Radiologists Incidental Findings Working Group. Can Assoc Radiol J 2021; 73:312-319. [PMID: 34154391 DOI: 10.1177/08465371211021079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The Canadian Association of Radiologists Incidental Findings Working Group consists of both academic subspecialty and general radiologists and is tasked with adapting and expanding upon the American College of Radiology incidental findings white papers to more closely apply to Canadian practice patterns, particularly more comprehensively dealing with the role of ultrasound and pursuing more cost-effective approaches to the workup of incidental findings without compromising patient care. Presented here are the 2021 Canadian guidelines for the management of pancreatic incidental findings. Topics covered include anatomic variants, fatty atrophy, pancreatic calcifications, ductal ectasia, and management of incidental pancreatic cysts.
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Affiliation(s)
- Christopher I Fung
- Department of Radiology and Diagnostic Imaging, 3158University of Alberta, Edmonton, Alberta, Canada
| | - David L Bigam
- Department of Surgery, 3158University of Alberta, Edmonton, Alberta, Canada
| | - Clarence K W Wong
- Division of Gastroenterology, Department of Medicine, 3158University of Alberta, Edmonton, Alberta, Canada
| | - Casey Hurrell
- Canadian Association of Radiologists, Ottawa, Ontario, Canada
| | - Jeffery R Bird
- Department of Medical Imaging, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Gary L Brahm
- Department of Medical Imaging, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Iain D C Kirkpatrick
- Department of Diagnostic Radiology, University of Manitoba, Winnipeg, Manitoba, Canada
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27
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Transabdominal Ultrasound for Follow-Up of Incidentally Detected Low-Risk Pancreatic Cysts: A Prospective Multicenter Study. AJR Am J Roentgenol 2021; 216:1521-1529. [PMID: 33826357 DOI: 10.2214/ajr.20.22965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE. The purpose of this study is to investigate the detection rate of transabdominal ultrasound (TAUS) for pancreatic cysts incidentally detected on CT or MRI as well as the factors that influence detection rates. SUBJECTS AND METHODS. Fifty-seven patients with low-risk pancreatic cysts (n = 77; cyst size, 5 mm to 3 cm) that were incidentally detected on CT or MRI were prospectively enrolled at five institutions. At each institution, TAUS was independently performed by two radiologists who assessed detection of cysts, cyst location and size, and the diameter of the main pancreatic duct (MPD). Cyst detection rates based on cyst size, location, and multiplicity and the body mass index of the patient were compared using the Mann-Whitney test. Kappa statistics and the interclass correlation coefficient were used to evaluate interobserver agreement regarding cyst detection and consistency of cyst size and the diameter of the MPD on TAUS versus prior CT or MRI. RESULTS. The detection rate for known low-risk pancreatic cysts was 81.8% (63/77) and 83.1% (64/77) for TAUS conducted by each of the two radiologists. The detection rate for larger (≥ 10 mm) cysts was significantly higher than that for smaller cysts (89.0% vs 63.6% for TAUS performed and interpreted by radiologist 1 [TAUS 1] and 89.0% vs 68.2% for TAUS conducted and interpreted by radiologist 2 [TAUS 2]; p < .05). A higher detection rate was noted for cysts located outside the tail of the pancreas compared with those located in the tail (89.5% vs 65.0% for TAUS 2; p = .01), and the detection rate was also significantly higher for single cysts than for multiple cysts (90.9% vs 69.7% for TAUS 1; p = .02). However, no significant difference was observed for body mass index. Interobserver agreement was excellent regarding the size of the detected cysts (inter-class correlation coefficient: 0.964 [95% CI, 0.940-0.979] for CT, TAUS 1, and TAUS 2 and 0.965 [95% CI. 0.924-986] for MRI, TAUS 1, and TAUS 2) and the diameter of the MPD (interclass correlation coefficient, 0.934; 95% CI, 0.898-0.959). CONCLUSION. TAUS could be a useful alternative imaging tool for surveillance of known low-risk pancreatic cysts, especially single pancreatic cysts and those that are of larger size (≥ 1 cm) or are located outside the tail.
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28
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Pancreatic Ductal Adenocarcinoma: Epidemiology and Risk Factors. Diagnostics (Basel) 2021; 11:diagnostics11030562. [PMID: 33804776 PMCID: PMC8003883 DOI: 10.3390/diagnostics11030562] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 02/07/2023] Open
Abstract
The number of new cases of pancreatic ductal adenocarcinoma is increasing with a cumulative total of 495,773 cases worldwide, making it the fourteenth most common malignancy. However, it accounts for 466,003 deaths per year and is the seventh leading cause of cancer deaths. Regional differences in the number of patients with pancreatic ductal adenocarcinoma appear to reflect differences in medical care, as well as racial differences. Compared to the prevalence of other organ cancers in Japan, pancreatic ductal adenocarcinoma ranks seventh based on the number of patients, eighth based on morbidity, and fourth based on the number of deaths, with a continuing increase in the mortality rate. Risk factors for developing pancreatic ductal adenocarcinoma include family history, genetic disorders, diabetes, chronic pancreatitis, and intraductal papillary mucinous neoplasms. An issue that hinders improvement in the prognosis of patients with pancreatic ductal adenocarcinoma is the development of a strategy to identify patients with these risk factors to facilitate detection of the disease at a stage when intervention will improve survival.
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29
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Matsubayashi H, Ishiwatari H, Sasaki K, Uesaka K, Ono H. Detecting Early Pancreatic Cancer: Current Problems and Future Prospects. Gut Liver 2020; 14:30-36. [PMID: 31009958 PMCID: PMC6974337 DOI: 10.5009/gnl18491] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/05/2019] [Accepted: 01/25/2019] [Indexed: 12/13/2022] Open
Abstract
The number of patients with pancreatic cancer (PC) is currently increasing in both Korea and Japan. The 5-year survival rate of patients with PC 13.0%; however, resection with minimal invasion (tumor size: ≤10 mm) increases the 5-year survival rate to 80%. For this reason, early detection is essential, but most patients with early-stage PC are asymptomatic. Early detection of PC has been reported to require screening of high-risk individuals (HRIs), such as those with a family history of PC, inherited cancer syndromes, intraductal papillary mucinous neoplasm, or chronic pancreatitis. Studies on screening of these HRIs have confirmed a significantly better prognosis among patients with PC who were screened than for patients with PC who were not screened. However, to date in Japan, most patients with early-stage PC diagnosed in routine clinics were not diagnosed during annual health checks or by surveillance; rather, PC was detected in these patients by incidental findings during examinations for other diseases. We need to increase the precision of the PC screening and diagnostic processes by introducing new technologies, and we need to pay greater attention to incidental clinical findings.
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Affiliation(s)
- Hiroyuki Matsubayashi
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan.,Division of Genetic Medicine Promotion, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Keiko Sasaki
- Division of Pathology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
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Sharib J, Esserman L, Koay EJ, Maitra A, Shen Y, Kirkwood KS, Ozanne EM. Cost-effectiveness of consensus guideline based management of pancreatic cysts: The sensitivity and specificity required for guidelines to be cost-effective. Surgery 2020; 168:601-609. [PMID: 32739138 PMCID: PMC8754171 DOI: 10.1016/j.surg.2020.04.052] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/25/2020] [Accepted: 04/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Detection of cystic lesions of the pancreas has outpaced our ability to stratify low-grade cystic lesions from those at greater risk for pancreatic cancer, raising a concern for overtreatment. METHODS We developed a Markov decision model to determine the cost-effectiveness of guideline-based management for asymptomatic pancreatic cysts. Incremental costs per quality-adjusted life year gained and survival were calculated for current management guidelines. A sensitivity analysis estimated the effect on cost-effectiveness and mortality if overtreatment of low-grade cysts is avoided, and the sensitivity and specificity thresholds required of methods of cyst stratification to improve costs expended. RESULTS "Surveillance" using current management guidelines had an incremental cost-effectiveness ratio of $171,143/quality adjusted life year compared with no surveillance or operative treatment ("do nothing"). An incremental cost-effectiveness ratio for surveillance decreases to $80,707/quality adjusted life year if the operative overtreatment of low-grade cysts was avoided. Assuming a societal willingness-to-pay of $100,000/quality adjusted life year, the diagnostic specificity for high-risk cysts must be >67% for surveillance to be preferred over surgery and "do nothing." Changes in sensitivity alone cannot make surveillance cost-effective. Most importantly, survival in surveillance is worse than "do nothing" for 3 years after cyst diagnosis, although long-term survival is improved. The disadvantage is eliminated when overtreatment of low-grade cysts is avoided. CONCLUSION Current management of pancreatic cystic lesions is not cost-effective and may increase mortality owing to overtreatment of low-grade cysts. The specificity for risk stratification for high-risk cysts must be greater than 67% to make surveillance cost-effective.
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Affiliation(s)
- Jeremy Sharib
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA
| | - Laura Esserman
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA
| | - Eugene J Koay
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anirban Maitra
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yu Shen
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kimberly S Kirkwood
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA.
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
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Harrington KA, Williams TL, Lawrence SA, Chakraborty J, Al Efishat MA, Attiyeh MA, Askan G, Chou Y, Pulvirenti A, McIntyre CA, Gonen M, Basturk O, Balachandran VP, Kingham TP, D’Angelica MI, Jarnagin WR, Drebin JA, Do RK, Allen PJ, Simpson AL. Multimodal radiomics and cyst fluid inflammatory markers model to predict preoperative risk in intraductal papillary mucinous neoplasms. J Med Imaging (Bellingham) 2020; 7:031507. [PMID: 32613028 PMCID: PMC7315109 DOI: 10.1117/1.jmi.7.3.031507] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 06/10/2020] [Indexed: 12/14/2022] Open
Abstract
Purpose: Our paper contributes to the burgeoning field of surgical data science. Specifically, multimodal integration of relevant patient data is used to determine who should undergo a complex pancreatic resection. Intraductal papillary mucinous neoplasms (IPMNs) represent cystic precursor lesions of pancreatic cancer with varying risk for malignancy. We combine previously defined individual models of radiomic analysis of diagnostic computed tomography (CT) with protein markers extracted from the cyst fluid to create a unified prediction model to identify high-risk IPMNs. Patients with high-risk IPMN would be sent for resection, whereas patients with low-risk cystic lesions would be spared an invasive procedure. Approach: Retrospective analysis of prospectively acquired cyst fluid and CT scans was undertaken for this study. A predictive model combining clinical features with a cyst fluid inflammatory marker (CFIM) was applied to patient data. Quantitative imaging (QI) features describing radiomic patterns predictive of risk were extracted from scans. The CFIM model and QI model were combined into a single predictive model. An additional model was created with tumor-associated neutrophils (TANs) assessed by a pathologist at the time of resection. Results: Thirty-three patients were analyzed (7 high risk and 26 low risk). The CFIM model yielded an area under the curve (AUC) of 0.74. Adding the QI model improved performance with an AUC of 0.88. Combining the CFIM, QI, and TAN models further increased performance to an AUC of 0.98. Conclusions: Quantitative analysis of routinely acquired CT scans combined with CFIMs provides accurate prediction of risk of pancreatic cancer progression. Although a larger cohort is needed for validation, this model represents a promising tool for preoperative assessment of IPMN.
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Affiliation(s)
- Kate A. Harrington
- Memorial Sloan Kettering Cancer Center, Department of Radiology, New York, United States
| | - Travis L. Williams
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, New York, United States
| | - Sharon A. Lawrence
- Memorial Sloan Kettering Cancer Center, Department of Surgery, New York, United States
| | - Jayasree Chakraborty
- Memorial Sloan Kettering Cancer Center, Department of Surgery, New York, United States
| | | | - Marc A. Attiyeh
- Memorial Sloan Kettering Cancer Center, Department of Surgery, New York, United States
| | - Gokce Askan
- Memorial Sloan Kettering Cancer Center, Department of Pathology, New York, United States
| | - Yuting Chou
- Memorial Sloan Kettering Cancer Center, Department of Surgery, New York, United States
| | - Alessandra Pulvirenti
- Memorial Sloan Kettering Cancer Center, Department of Surgery, New York, United States
| | - Caitlin A. McIntyre
- Memorial Sloan Kettering Cancer Center, Department of Surgery, New York, United States
| | - Mithat Gonen
- Memorial Sloan Kettering Cancer Center, Department of Epidemiology and Biostatistics, New York, United States
| | - Olca Basturk
- Memorial Sloan Kettering Cancer Center, Department of Pathology, New York, United States
| | - Vinod P. Balachandran
- Memorial Sloan Kettering Cancer Center, Department of Surgery, New York, United States
| | - T. Peter Kingham
- Memorial Sloan Kettering Cancer Center, Department of Surgery, New York, United States
| | - Michael I. D’Angelica
- Memorial Sloan Kettering Cancer Center, Department of Surgery, New York, United States
| | - William R. Jarnagin
- Memorial Sloan Kettering Cancer Center, Department of Surgery, New York, United States
| | - Jeffrey A. Drebin
- Memorial Sloan Kettering Cancer Center, Department of Surgery, New York, United States
| | - Richard K. Do
- Memorial Sloan Kettering Cancer Center, Department of Radiology, New York, United States
| | - Peter J. Allen
- Memorial Sloan Kettering Cancer Center, Department of Surgery, New York, United States
| | - Amber L. Simpson
- Queen’s University, School of Computing, Kingston, Ontario, Canada
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32
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Takahashi Y, Seki H. Gastric volvulus with perforation 1 year after total pancreatectomy: a case report. Surg Case Rep 2020; 6:74. [PMID: 32303917 PMCID: PMC7165202 DOI: 10.1186/s40792-020-00840-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 04/08/2020] [Indexed: 02/08/2023] Open
Abstract
Background Because of its rare indication and relatively simple reconstruction procedure (only choledochojejunostomy and gastrojejunostomy) compared to those for pancreatoduodenectomy, the technical tips and pitfalls of total pancreatectomy are rarely discussed. Herein, we discuss a rare case of gastric volvulus 1 year after total pancreatectomy and provide advice to prevent such cases. Case presentation A 66-year-old woman underwent total pancreatectomy with splenectomy for mixed-type intraductal papillary mucinous neoplasm of the pancreas. Choledochojejunostomy (retro-colic route) and gastrojejunostomy (ante-colic route, Billroth II method) were performed for reconstruction. The final diagnosis was mixed-type intraductal papillary mucinous adenoma of the pancreas without malignant neoplasm. She had no clinical symptoms, such as abdominal pain and fever, during postoperative follow-up. However, at 1 year postoperatively, she complained of abdominal pain. Contrast-enhanced abdominal computed tomography showed volvulus and perforation of the stomach. Emergent surgery was performed. The stomach fornix was located on the right side and was partly perforated. We resected the perforation site with a linear cutter® (New Type Linear Cutter, Ethicon, USA) and released the gastric volvulus. Moreover, we fixed the stomach to the left abdominal wall using non-absorbable thread. The cause of the perforation was clinically and pathologically unclear. Her serum albumin and cholinesterase levels temporarily decreased postoperatively, but gradually increased. A recurrence of volvulus-related symptoms has not been observed. Conclusions After total pancreatectomy with splenectomy, although the stomach is connected with the jejunum, it is typically fixed only by the pedicle of the left gastric artery and vein. In the present case, this anatomical change may have been a cause of the gastric volvulus. Thus, it might be better to fix the remnant stomach in total pancreatectomy with splenectomy.
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Affiliation(s)
- Yusuke Takahashi
- Department of Hepatobiliary Pancreatic Surgery, Nagano Municipal Hospital, 1333-1 Tomitake, Nagano City, Nagano, 381-8551, Japan.
| | - Hitoshi Seki
- Department of Hepatobiliary Pancreatic Surgery, Nagano Municipal Hospital, 1333-1 Tomitake, Nagano City, Nagano, 381-8551, Japan
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Matsubayashi H, Notohara K, Hruban RH, Satoh T, Kaneko J, Sato J, Ishiwatari H, Ashida R, Uesaka K, Kiyozumi Y, Ono H. Multiple Carcinomas and Intraepithelial Neoplasms in a Case of Familial Pancreatic Cancer: Rapid Morphological Changes in the Pancreatic Cyst and Pathological Lesions Undetected by Clinical Images. Intern Med 2020; 59:1041-1046. [PMID: 31915314 PMCID: PMC7205531 DOI: 10.2169/internalmedicine.3882-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 69-year-old woman with a family history of pancreatic cancer was referred because of imaging changes of a pancreas cyst. Magnetic resonance cholangiopancreatography showed a faintly dilated main pancreatic duct and a pancreas body cyst that had changed rapidly over the past year. Computed tomography demonstrated an emerging enhancing lesion in the pancreatic cyst. Endoscopic ultrasonography revealed an irregular-margined, heterogeneous-echoic pancreatic mass, without findings of early chronic pancreatitis. She underwent distal pancreatectomy. A histologic examination of the resected specimen revealed invasive adenocarcinoma with numerous multicentric foci of pancreatic intraepithelial neoplasia (PanIN), including high-grade PanIN, apparently separate from the main cancer.
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Affiliation(s)
- Hiroyuki Matsubayashi
- Division of Endoscopy, Shizuoka Cancer Center, Japan
- Division of Genetic Medicine Promotion, Shizuoka Cancer Center, Japan
| | - Kenji Notohara
- Department of Anatomic Pathology, Kurashiki Central Hospital, Japan
| | - Ralph H Hruban
- Department of Pathology, the Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins Medical University, USA
| | | | | | - Junya Sato
- Division of Endoscopy, Shizuoka Cancer Center, Japan
| | | | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Japan
| | - Yoshimi Kiyozumi
- Division of Genetic Medicine Promotion, Shizuoka Cancer Center, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Japan
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Kwon JE, Jang KT, Ryu Y, Kim N, Shin SH, Heo JS, Choi DW, Han IW. Subtype of intraductal papillary mucinous neoplasm of the pancreas is important to the development of metachronous high-risk lesions after pancreatectomy. Ann Hepatobiliary Pancreat Surg 2019; 23:365-371. [PMID: 31825003 PMCID: PMC6893048 DOI: 10.14701/ahbps.2019.23.4.365] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/26/2019] [Indexed: 12/22/2022] Open
Abstract
Backgrounds/Aims Although intraductal papillary mucinous neoplasm (IPMN) has showed a favorable prognosis compared to pancreatic ductal adenocarcinoma, its recurrence patterns have somewhat questionable in detail. After partial pancreatectomy for IPMN, the evaluation for risk of metachronous occurrence of high-risk lesions (HRL) in the residual pancreas is important to establish a postoperative surveillance modality and duration of follow-up. This study aimed to evaluate the factors that may predict the metachronous occurrence of HRL in the remnant pancreas after surgery of the IPMN. Methods From 2005 to 2016, clinicopathologic and surveillance data for 346 consecutive patients who underwent surgical resection for IPMN were reviewed retrospectively. Histologic subtype was classified as gastric, intestinal, pancreato-biliary, or oncocytic type. Results All of IPMN were classified as main duct (n=64, 18.5%), branch duct (n=171, 49.4%), and mixed type (n=111, 32.1%). Forty-eight patients (13.9%) experienced recurrence during follow-up. Among these, 9 patients (2.6%) were identified to metachronous development of HRL in the remnant pancreas. After multivariate analysis, high-grade dysplasia (HGD) or invasive carcinoma (IC) compared to low- or intermediate dysplasia was only independent risk factor for recurrence (HR 3.688, 95% CI 2.124– 12.524, p=0.009). The independent risk factors for metachronous development were HGD/IC (HR 8.414, 95% CI 4.310– 16.426, p=0.001), and intestinal/pancreato-biliary subtype compared to gastric subtype (HR 7.874, 95% CI 3.650– 27.027, p=0.010). Conclusions Patients with high-grade dysplasia or invasive carcinoma, and with intestinal or pancreatobiliary subtype should undergo close, long-term surveillance of the remnant pancreas after initial resection.
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Affiliation(s)
- Ji Eun Kwon
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Kee-Taek Jang
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Youngju Ryu
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Naru Kim
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Sang Hyun Shin
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Jin Seok Heo
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Dong Wook Choi
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - In Woong Han
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
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35
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Antoñanzas J, Cienfuegos JA, Hurtado-Pardo L, Panadero P, Benito A, Pardo F, Rotellar F, Martí-Cruchaga P, Zozaya G, Valentí V, Hernández Lizoain JL. Intraductal papillary mucinous neoplasm (IPMN) of the pancreas: clinicopathological features and long-term outcomes following a pancreatectomy. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 110:768-774. [PMID: 30168337 DOI: 10.17235/reed.2018.5646/2018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE the objective of this study was to analyze the anatomical and clinical features and long-term oncologic outcomes of 25 patients that underwent surgery due to intraductal papillary mucinous neoplasm of the pancreas. MATERIAL AND METHODS patients undergoing surgery for intraductal papillary mucinous neoplasm of the pancreas were identified from a prospective database of pancreatic resections. Demographic data, symptoms, type of surgery and type of lesion (branch type, main duct or mixed) were recorded. The lesions were classified into invasive (high grade dysplasia and carcinoma) and noninvasive (low- or intermediate-grade dysplasia). Postoperative complications were analyzed as well as the pattern of recurrence and disease-free survival at five and ten years. RESULTS the most common symptoms in the 25 patients (14 males and eleven females) were abdominal pain and weight loss. Eight (32%) cases were diagnosed incidentally. Twelve (48%) of the lesions were of the branch type, three affected the main duct and ten (40%) were mixed. Twelve cephalic duodenopancreatectomies and seven total pancreatectomies were performed; three were central; two, distal; and one, enucleation. Seven cases (32%) had an invasive phenotype. Three patients had locoregional and distant recurrence at six, 16 and 46 months after surgery with a median follow-up of 7.7 years. Disease-free survival at five and ten years for the noninvasive type was 94% and 57% for invasive phenotypes (p < 0.05). CONCLUSIONS intraductal papillary mucinous neoplasm is a heterogeneous entity with well differentiated phenotypes, which requires a tailored strategy and treatment, as established in the current consensus guidelines due to its malignant potential.
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Affiliation(s)
| | | | | | - Pablo Panadero
- Anatomía Patológica, Clínica Universidad de Navarra, España
| | | | - Fernando Pardo
- Cirugía General y del Aparato Digestivo, Clínica Universidad de Navarra, España
| | - Fernando Rotellar
- Cirugía General y del Aparato Digestivo, Clínica Universidad de Navarra, España
| | | | - Gabriel Zozaya
- Cirugía General y del Aparato Digestivo, Clínica Universidad de Navarra, España
| | - Víctor Valentí
- Cirugía General y Aparato Digestivo, Clínica Universidad de Navarra, España
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Hashimoto S, Hirooka Y, Kawabe N, Nakaoka K, Yoshioka K. Role of transabdominal ultrasonography in the diagnosis of pancreatic cystic lesions. J Med Ultrason (2001) 2019; 47:389-399. [PMID: 31522338 DOI: 10.1007/s10396-019-00975-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/26/2019] [Indexed: 12/11/2022]
Abstract
Pancreatic cystic lesions (PCLs) are incidental findings that are being increasingly identified because of recent advancements in abdominal imaging technologies. PCLs include different entities, with each of them having a peculiar biological behavior, and they range from benign to premalignant or malignant neoplasms. Therefore, accurate diagnosis is important to determine the best treatment strategy. As transabdominal ultrasonography (US) is noninvasive, inexpensive, and widely available, it is considered to be the most appropriate imaging modality for the initial evaluation of abdominal diseases, including PCLs, and for follow-up assessment. We present a review of the possibilities and limits of US in the diagnosis of PCLs, the technical development of US, and the ultrasonographic characteristics of PCLs.
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Affiliation(s)
- Senju Hashimoto
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutukake-cho, Toyoake, Aichi, 470-1192, Japan.
| | - Yoshiki Hirooka
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Naoto Kawabe
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Kazunori Nakaoka
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Kentaro Yoshioka
- Department of Liver, Biliary Tract and Pancreas Diseases, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutukake-cho, Toyoake, Aichi, 470-1192, Japan
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Moyer MT, Maranki JL, DeWitt JM. EUS-Guided Pancreatic Cyst Ablation: a Clinical and Technical Review. Curr Gastroenterol Rep 2019; 21:19. [PMID: 31016391 DOI: 10.1007/s11894-019-0686-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE OF REVIEW Pancreatic cystic lesions represent a growing public health dilemma, particularly as our population ages and cross-sectional imaging becomes more sensitive. Mucinous cysts carry a clinically significant risk of developing pancreatic cancer, which carries an extremely poor prognosis. Determining which cysts will develop cancer may be challenging, and surgical resection of the pancreas carries significant morbidity. The goal of this paper is to review the rationale for cyst ablation and discuss prior and current research on cyst ablation techniques and efficacy. Indications, contraindications, and factors related to optimal patient selection are outlined. RECENT FINDINGS Endoscopic ultrasound-guided chemoablation of pancreatic cysts has been performed in neoplastic cysts, with varying levels of efficacy. Safety concerns arose due to the risk of pancreatitis in alcohol-based treatments; however, the most recent data using a non-alcohol chemoablation cocktail suggests that ablation is effective without the need for alcohol, resulting in a significantly more favorable adverse event profile. Endoscopic ultrasound-guided chemoablation of neoplastic pancreatic cysts is a promising, minimally invasive approach for treatment of cysts, with recent significant advances in safety and efficacy, suggesting that it should play a role in the treatment algorithm.
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Affiliation(s)
- Matthew T Moyer
- Division of Gastroenterology and Hepatology, Penn State Cancer Institute, Penn State Hershey Medical Center, Hershey, PA, USA.
| | - Jennifer L Maranki
- Division of Gastroenterology and Hepatology, Penn State Cancer Institute, Penn State Hershey Medical Center, Hershey, PA, USA
| | - John M DeWitt
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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Torisu Y, Takakura K, Kinoshita Y, Tomita Y, Nakano M, Saruta M. Pancreatic cancer screening in patients with presumed branch-duct intraductal papillary mucinous neoplasms. World J Clin Oncol 2019; 10:67-74. [PMID: 30815373 PMCID: PMC6390120 DOI: 10.5306/wjco.v10.i2.67] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 12/08/2018] [Accepted: 01/10/2019] [Indexed: 02/06/2023] Open
Abstract
Because delayed diagnosis is one of the causes of poor prognosis in pancreatic ductal adenocarcinoma (PDAC), early detection is a key for overall improvement of prognosis. Towards this end, periodic screening is recommended for individuals considered high-risk for PDAC. Advances in diagnostic imaging modalities have increased the frequency of incidental findings of pancreatic cysts, including the intraductal papillary mucinous neoplasm (IPMN) - a major risk factor of PDAC, having 1% annual prevalence of concomitance with IPMN. Proper retainment of patients with IPMN and regular follow-up by routine imaging examination will likely improve early detection and better prognosis of PDAC. Unfortunately, current guidelines only address management of PDAC derived from IPMN and overlook PDAC concomitant with IPMN. Screening of patients with IPMN, by endoscopic ultrasonography (currently the most reliable modality for detecting small PDAC), may facilitate early detection of both IPMN-derived and -concomitant PDAC. Prospective studies to evaluate the usefulness of endoscopic ultrasonography in screening of IPMN-concomitant PDAC will also help in determining the optimal surveillance strategy for more widespread applications.
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Affiliation(s)
- Yuichi Torisu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Minato-ku, Tokyo 105-8461, Japan
| | - Kazuki Takakura
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Minato-ku, Tokyo 105-8461, Japan
| | - Yuji Kinoshita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Minato-ku, Tokyo 105-8461, Japan
| | - Yoichi Tomita
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Minato-ku, Tokyo 105-8461, Japan
| | - Masanori Nakano
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Minato-ku, Tokyo 105-8461, Japan
| | - Masayuki Saruta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, Minato-ku, Tokyo 105-8461, Japan
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Kim TH, Woo YS, Chon HK, Hwang JH, Yoo KS, Lee WJ, Lee KH, Lee JK, Dong SH, Park CH, Park ET, Moon JH, Kim HG, Cho KB, Kim HJ, Lee SO, Cheon YK, Lee JM, Park JW, Kim MH. Predictors of Malignancy in "Pure" Branch-Duct Intraductal Papillary Mucinous Neoplasm of the Pancreas without Enhancing Mural Nodules on CT Imaging: A Nationwide Multicenter Study. Gut Liver 2019; 12:583-590. [PMID: 29730906 PMCID: PMC6143451 DOI: 10.5009/gnl17582] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 01/21/2018] [Accepted: 01/30/2018] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Presence of enhanced mural nodules, which can be visualized using computed tomography (CT), is one of high-risk stigmata in branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs). Conversely, the absence of enhanced mural nodules on preoperative imaging does not exclude malignant risk. The present study aimed to investigate other morphological features as predictors of malignancy in "pure" BD-IPMNs without enhanced mural nodules on CT. Methods This retrospective study included 180 patients with surgically confirmed "pure" BD-IPMNs of the pancreas and no enhanced mural nodules on preoperative CT. The study was conducted at 15 tertiary referral centers throughout South Korea. Univariate and multivariate analyses were used to identify significant predictors of malignancy. Results BD-IPMNs with low-grade (n=84) or moderate-grade (n=76) dysplasia were classified as benign; those with high-grade dysplasia (n=8) or invasive carcinoma (n=12) were classified as malignant. The multivariate analysis revealed that cyst size ≥30 mm (odds ratio, 8.6; p=0.001) and main pancreatic duct diameter ≥5 mm (odds ratio, 4.1; p=0.01) were independent risk factors for malignancy in "pure" BD-IPMNs without enhanced mural nodules on CT. Endoscopic ultrasound detected enhanced mural nodules (6/82) that had been missed on CT, and two IPMNs with enhanced mural nodules were malignant. Conclusions In patients with "pure" BD-IPMNs who have no enhanced mural nodules on CT, cyst size ≥30 mm and main pancreatic duct diameter ≥5 mm may be associated with malignancy.
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Affiliation(s)
- Tae-Hyeon Kim
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Young-Sik Woo
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyung-Ku Chon
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University College of Medicine, Seongnam, Korea
| | - Kyo-Sang Yoo
- Department of Internal Medicine, Hanyang University College of Medicine, Guri, Korea
| | - Woo-Jin Lee
- Pancreatobiliary Cancer Clinic, Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Kwang-Hyuck Lee
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Kyun Lee
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok-Ho Dong
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Chang-Hwan Park
- Department of Internal Medicine, Chonnam University College of Medicine, Gwangju, Korea
| | - Eun-Taek Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Jong-Ho Moon
- Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, Korea
| | - Ho-Gak Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Kwang-Bum Cho
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Hong-Ja Kim
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Seung-Ok Lee
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Young-Koog Cheon
- Digestive Disease Center, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jeong-Mi Lee
- Department of Public Health, Wonkwang University Graduate School, Iksan, Korea
| | - Jin-Woo Park
- Department of Internal Medicine, Hepatobiliary and Pancreas Center, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Abstract
Intraductal papillary mucinous neoplasm (IPMN) is the most common pancreatic cystic neoplasm (PCN). The increased attention to IPMN is due to its unique features of malignant progression, being different between main duct IPMN and branch duct IPMN, and increased de novo development of conventional pancreatic ductal adenocarcinoma elsewhere in the pancreas. The increased interest in IPMN led to publication of many guidelines on its clinical management. This chapter aims to summarize and compare characteristics of nine guidelines on the clinical management of IPMN and other PCNs published in the English literature and further to show a current strategy for surgical decision making in the management of IPMN.
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Affiliation(s)
- Masao Tanaka
- Shimonoseki City Hospital, Kyushu University, Shimonoseki, Yamaguchi, Japan.
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Sharib JM, Fonseca AL, Swords DS, Jaradeh K, Bracci PM, Firpo MA, Hatcher S, Scaife CL, Wang H, Kim GE, Mulvihill SJ, Maitra A, Koay EJ, Kirkwood KS. Surgical overtreatment of pancreatic intraductal papillary mucinous neoplasms: Do the 2017 International Consensus Guidelines improve clinical decision making? Surgery 2018; 164:1178-1184. [DOI: 10.1016/j.surg.2018.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/24/2018] [Accepted: 07/10/2018] [Indexed: 12/17/2022]
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Rossi RE, Massironi S. Intraductal papillary mucinous neoplasms of the pancreas: a clinical challenge. Expert Rev Gastroenterol Hepatol 2018; 12:1123-1133. [PMID: 30264593 DOI: 10.1080/17474124.2018.1530111] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The incidental detection rate of intraductal papillary mucinous neoplasms (IPMNs) has significantly increased. However, little is known about the natural history of these tumors. Their optimal management and appropriate follow-up are still unclear. We have, therefore, reviewed the available literature on IPMN focusing on their diagnosis, treatment according to the risk of malignant transformation, and follow-up. Areas covered: Bibliographical searches were performed in PubMed for the terms 'intraductal papillary mucinous neoplasm' and 'natural history' and 'diagnosis' and 'treatment' and 'surgery' and 'follow-up' and 'prognosis.' PubMed was used to search for all the relevant articles published over the last 10 years. A total of 7244 records were identified. After filtering for year range, English language, human studies, article types, and removing duplicates, 74 articles were left with the strongest level of evidence. Expert commentary: Available guidelines for IPMN management are mainly based on expert opinions and may lack strong evidence. Further studies are warranted to better predict the risk of recurrence/future malignancy and to establish standardized guidelines. IPMNs management should be based on multidisciplinary discussion and treatment should be tailored to an individual patient according to patient and tumor characteristics.
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Affiliation(s)
- Roberta Elisa Rossi
- a Division of Gastroenterology and Digestive Endoscopy , Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico , Milan , Italy.,b Department of Pathophysiology and Organ Transplant , Università degli Studi di Milano , Milan , Italy
| | - Sara Massironi
- a Division of Gastroenterology and Digestive Endoscopy , Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico , Milan , Italy
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Sun MRM, Strickland CD, Tamjeedi B, Brook A, Mortele KJ, Brook OR, Kane RA, Siewert B. Utility of transabdominal ultrasound for surveillance of known pancreatic cystic lesions: prospective evaluation with MRI as reference standard. Abdom Radiol (NY) 2018; 43:1180-1192. [PMID: 28765979 DOI: 10.1007/s00261-017-1269-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To prospectively assess the utility of transabdominal ultrasound in surveillance of known pancreatic cystic lesions (PCL) using same day MRI as reference standard. METHODS In an IRB-approved study with written informed consent, patients with known PCL underwent pancreas US on same day as surveillance MRI. US was performed blinded to same date MRI results. Transverse (TR), antero-posterior (AP), cranio-caudal (CC), and longest any plane diameter, were measured for each PCL at US and MRI. Visualization was correlated with patient (weight, abdominal diameter, thickness of abdominal fat, sex) and cyst (location, size, internal complexity) factors. RESULTS 252 PCLs evaluated in 57 subjects (39 females; mean age 67 (range 39-86) yrs). Mean maximum PCL diameter 8.5 (range 2-92) mm. US identified 100% (5/5) of cysts ≥3 cm; 92% (12/13) ≥2 and <3 cm; 78% (43/55) ≥1 and <2 cm; 35% (27/78) ≥5 mm and <1 cm; and 16% (16/101) <5 mm. US visualization correlated with PCL location (<0.0001), size (p < 0.0001), patient gender (p = 0.005), participation of attending radiologist (p = 0.03); inversely with patient weight (p = 0.012) and AP abdominal diameter (p = 0.01). CONCLUSION Many PCLs are visualized and accurately measured at follow-up with transabdominal ultrasound. Visualization correlates with lesion size, location, patient sex, weight, and abdominal diameter.
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Intraductal Papillary Mucinous Neoplasm of the Pancreas as the Main Focus for Early Detection of Pancreatic Adenocarcinoma. Pancreas 2018; 47:544-550. [PMID: 29702531 DOI: 10.1097/mpa.0000000000001047] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
For early detection of pancreatic cancer, interests are now focused on the detection of high-risk individuals to undergo screening examinations. Intraductal papillary mucinous neoplasm (IPMN) is a unique dual precursor of pancreatic cancer, characterized by progression to invasive cancer and the development of pancreatic adenocarcinoma either concomitantly (synchronous occurrence) or even after resection of IPMN (metachronous occurrence). Careful examination and surveillance of patients with IPMN may therefore lead to early detection of pancreatic cancer. By reviewing only reports describing detailed breakdown of the morphological types of IPMN and numbers of patients with noninvasive and invasive carcinoma in each type, the rough frequencies of noninvasive carcinoma in main duct IPMNs and branch duct IPMNs (BD-IPMNs) are 20% and 10%, respectively, and those of invasive carcinoma are 40% and 13%, respectively. Roughly 5% of all patients with IPMN had concomitant adenocarcinoma. The real frequency of carcinoma in BD-IPMNs would be far lower because most patients with small asymptomatic BD-IPMNs do not undergo resection. Intraductal papillary mucinous neoplasm can be the main focus for early detection of pancreatic cancer to achieve favorable prognosis after surgical resection. The optimal protocol for surveillance and method for early detection of pancreatic cancer are to be determined.
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Elta GH, Enestvedt BK, Sauer BG, Lennon AM. ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts. Am J Gastroenterol 2018; 113:464-479. [PMID: 29485131 DOI: 10.1038/ajg.2018.14] [Citation(s) in RCA: 358] [Impact Index Per Article: 59.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 01/05/2018] [Indexed: 02/07/2023]
Abstract
Pancreatic cysts are very common with the majority incidentally identified. There are several types of pancreatic cysts; some types can contain cancer or have malignant potential, whereas others are benign. However, even the types of cysts with malignant potential rarely progress to cancer. At the present time, the only viable treatment for pancreatic cysts is surgical excision, which is associated with a high morbidity and occasional mortality. The small risk of malignant transformation, the high risks of surgical treatment, and the lack of high-quality prospective studies have led to contradictory recommendations for their immediate management and for their surveillance. This guideline will provide a practical approach to pancreatic cyst management and recommendations for cyst surveillance for the general gastroenterologist.
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Affiliation(s)
- Grace H Elta
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Brintha K Enestvedt
- Division of Gastroenterology, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Bryan G Sauer
- Division of Gastroenterology, University of Virginia, Charlottesville, Virginia, USA
| | - Anne Marie Lennon
- Division of Gastroenterology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Hoshi H, Zaheer A, El Abiad RG, Maxwell JE, Chu LC, Gerke H, Chan CH. Management of pancreatic intraductal papillary mucinous neoplasm. Curr Probl Surg 2018; 55:126-152. [DOI: 10.1067/j.cpsurg.2018.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/11/2018] [Indexed: 12/16/2022]
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Tanaka M. Intraductal Papillary Mucinous Neoplasm as the Focus for Early Detection of Pancreatic Cancer. Gastroenterology 2018; 154:475-478. [PMID: 29337154 DOI: 10.1053/j.gastro.2018.01.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Masao Tanaka
- Department of Surgery, Shimonoseki City Hospital, Shimonoseki, Japan.
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Fritz S, Küper-Steffen R, Feilhauer K, Sommer CM, Richter GM, Hennig R, Köninger J. Resection of benign side-branch intraductal papillary mucinous neoplasm of the pancreas-is long term follow-up indicated?: A case report and review of the literature. Medicine (Baltimore) 2018; 97:e9894. [PMID: 29443760 PMCID: PMC5839808 DOI: 10.1097/md.0000000000009894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
RATIONALE Intraductal papillary mucinous neoplasms of the pancreas (IPMNs) are benign cystic tumors with a relevant risk of malignant transformation over time. Currently, follow-up after surgical resection of benign IPMNs remains controversial. PATIENT CONCERNS This is a case report of a 68-year-old male who underwent pancreatic head resection for a multicystic side-branch IPMN with low-grade epithelial dysplasia in March 2009 at the Katharinenhospital Stuttgart, Germany. DIAGNOSES During postoperative follow-up, a new solid, slightly hypodense lesion in the tail of the pancreas measuring 2.4 cm in diameter was diagnosed in July 2016. Preoperative staging revealed no signs of distant metastasis. INTERVENTION Subsequently, the patient underwent pancreatic tail resection including splenectomy. Histology revealed IPMN-associated adenocarcinoma of the pancreas pT3, pN1 (2/24), M0, R0. OUTCOMES Patients with IPMN bare a relatively high overall risk of developing pancreatic cancer. The 5-year incidence has been described to be as high as 6.9%. The current Consensus-Guidelines therefore recommend a structural life-time follow-up. In contrast, in 2015 the American Gastroenterological Association (AGA) explicitly states that follow-up is not recommended for resected benign IPMN. Currently, a general and international consensus is lacking. LESSONS The presented case demonstrates that even more than 5 years following resection of benign IPMN, pancreatic cancer can occur in a separate location of the pancreatic gland. We believe that IPMNs can be considered as indicator lesions for pancreatic cancer. Patients with resected side-branch IPMN should therefore undergo long term follow-up.
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Surveillance of patients with intraductal papillary mucinous neoplasm with and without pancreatectomy with special reference to the incidence of concomitant pancreatic ductal adenocarcinoma. Surgery 2017; 163:291-299. [PMID: 29221879 DOI: 10.1016/j.surg.2017.09.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 08/15/2017] [Accepted: 09/12/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The presence of an intraductal papillary mucinous neoplasm is important in the detection of concomitant pancreatic ductal adenocarcinoma. The aim of this study was to elucidate the incidence and timing of development of concomitant pancreatic ductal adenocarcinoma in patients with and without pancreatectomy for intraductal papillary mucinous neoplasm. METHODS We reviewed retrospectively the surveillance data for 22 patients who underwent pancreatectomy for pancreatic ductal adenocarcinoma concomitant with intraductal papillary mucinous neoplasm (pancreatic ductal adenocarcinoma-resection group), 180 who underwent pancreatectomy for intraductal papillary mucinous neoplasm (intraductal papillary mucinous neoplasm-resection group), and 263 whose intraductal papillary mucinous neoplasms were left untreated (nonresection group). The incidence and timing of the development of a concomitant pancreatic ductal adenocarcinoma during the surveillance of patients with and without partial pancreatectomy for intraductal papillary mucinous neoplasm were investigated using the Kaplan-Meier method. RESULTS During a median surveillance period of 40 months (range 6-262 months), 5 patients in the pancreatic ductal adenocarcinoma-resection group, 6 in the intraductal papillary mucinous neoplasm-resection group, and 8 in the nonresection group developed concomitant pancreatic ductal adenocarcinoma. The estimated 5-year (17%) and 10-year (56%) cumulative incidences of secondary pancreatic ductal adenocarcinoma in the pancreatic ductal adenocarcinoma-resection group were significantly greater than those in the other two groups (P < .01). Conversely, the difference in the estimated cumulative incidence of concomitant pancreatic ductal adenocarcinoma between the intraductal papillary mucinous neoplasm-resection and nonresection groups was not significant (5-year, 5.0% vs 2.2%; 10-year, 5.0% vs 8.7%; P = .87). CONCLUSION Long-term (≥5-year) surveillance in patients with intraductal papillary mucinous neoplasm is necessary and important because of the potential for development of concomitant pancreatic ductal adenocarcinoma. Those with a history of resection of concomitant pancreatic ductal adenocarcinoma at the time of the initial operation are at quite high risk for the development of secondary pancreatic ductal adenocarcinoma.
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