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Hernandez-Barco YG, Fernandez-Del Castillo C, Fradelos E, Matos Ruiz PM, Bazerbachi F, Dhandibhotla S, Lillemoe KD, Casey BW, Kambadakone A, Qadan M. The multidisciplinary pancreatic cyst clinic: A collaborative approach to streamlined management. Pancreatology 2024; 24:764-770. [PMID: 38796308 DOI: 10.1016/j.pan.2024.05.525] [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: 09/27/2023] [Revised: 05/10/2024] [Accepted: 05/18/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Pancreatic cysts are often incidentally detected on routine imaging studies. Of these, mucinous cysts have a malignant potential. Several guidelines propose different management strategies, and implementation in patient care is inconsistent in the absence of dedicated infrastructure. METHODS To address the challenges of pancreatic cyst diagnosis and management, we established a multidisciplinary pancreas cyst clinic (PCC) within our health system. This clinic encompasses both tertiary care academic centers and community hospitals, with leadership from surgical oncology, gastroenterology, and radiology. Our PCC's primary goal is to provide accurate diagnosis and tailored management recommendations for all patients with pancreatic cysts. Additionally, we maintain a prospective database to study the disease's natural history and the outcomes of various treatment strategies. CLINIC INFRASTRUCTURE The clinic meets once per week for 45 min virtually via Zoom in the mornings. Patients are referred via electronic medical record (EMR) order, telephone call, or email from patient or referring provider. A dedicated advanced practice provider reviews referrals several times per day, calls patients to gather clinical data, ensures imaging is uploaded, and coordinates logistical aspects of the meeting during the dedicated time. Conferences are attended by representatives from surgery, radiology, medical pancreatology, and interventional gastroenterology. Each patient case is reviewed in detail and recommendations are submitted to referring providers and patients via an EMR message and letter. For patients requiring imaging surveillance, patients are followed longitudinally by the referring provider, gastroenterology team, or surgical team. For patients requiring endoscopic ultrasound (EUS) or surgical consultation, expedited referral to these services is made with prompt subsequent evaluation. RESULTS A total of 1052 patients from our health system were evaluated between 2020 and 2021. Of these, 196 (18.6 %) underwent EUS, 41 (3.9 %) underwent upfront surgical resection, and the remainder were referred to gastroenterology (141-13.4 %), surgery (314-29.8 %), or back to their referring provider (597-56.7 %) for ongoing surveillance in collaboration with their primary care provider (PCP). Of cysts under surveillance, 61.3 % remained stable, 13.2 % increased in size, and 2 % decreased in size. A total of 2.3 % of patients were recommended to discontinue surveillance. CONCLUSIONS The PCC provides infrastructure that has served to provide multidisciplinary review and consensus recommendations to patients with pancreatic cysts. This has served to improve the application of guidelines while providing individualized recommendations to each patient, while aiding non-expert referring providers throughout the region.
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Affiliation(s)
- Yasmin G Hernandez-Barco
- Pancreas and Biliary Program, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Evangelos Fradelos
- Pancreas and Biliary Program, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy, St. Cloud Hospital, St. Cloud, MN, USA
| | - Sarvani Dhandibhotla
- Pancreas and Biliary Program, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | - Keith D Lillemoe
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Brenna W Casey
- Pancreas and Biliary Program, Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Motaz Qadan
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA.
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2
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Gardner TB, Park WG, Allen PJ. Diagnosis and Management of Pancreatic Cysts. Gastroenterology 2024; 167:454-468. [PMID: 38442782 DOI: 10.1053/j.gastro.2024.02.041] [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: 10/09/2023] [Revised: 01/01/2024] [Accepted: 02/18/2024] [Indexed: 03/07/2024]
Abstract
As pancreatic cyst incidence rises, likely due to the ubiquitous increase in cross-sectional imaging, their management presents multiple challenges for both the practitioner and patient. It is critical that all pancreatic cysts are appropriately characterized, as treatment decisions depend on an accurate diagnosis. Diagnostic modalities such as cytology, biopsy, and cyst fluid biomarkers allow for definitive diagnosis of virtually all lesions. Some cysts, such as intraductal papillary mucinous neoplasms, mucinous cystic neoplasms, and cystic pancreatic endocrine neoplasms, have malignant potential and must be surveyed. Other cysts, such as serous cystadenomas and pancreatic fluid collections, do not have malignant potential. Surveillance strategies vary widely depending on cyst type and size and while multiple medical societies advocate surveillance, their published surveillance guidelines are heterogenous. Cysts with high-risk stigmata or worrisome features are usually resected, depending on the patient's surgical fitness. In patients unfit for resection, newer endoscopic ablative techniques are advocated. Controversial aspects regarding cyst management include whether surveillance can be stopped, how surveillance should be performed, and the extensive financial burden cyst management places on the health care system. Further study into the natural history of cystic lesions, including definitive determination of the rate of malignant transformation for each cyst type, is essential.
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Affiliation(s)
- Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Walter G Park
- Section of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California
| | - Peter J Allen
- Division of Surgical Oncology, Duke University Medical Center, Durham, North Carolina
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3
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Nakai Y, Hamada T, Oyama H. Can Endoscopic Ultrasound-guided Ablation Prolong Disease-specific Survival In Pancreatic Cysts? Clin Gastroenterol Hepatol 2024:S1542-3565(24)00415-4. [PMID: 38729402 DOI: 10.1016/j.cgh.2024.04.012] [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: 04/26/2024] [Accepted: 04/29/2024] [Indexed: 05/12/2024]
Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Hepato-Biliary-Pancreatic Medicine, The Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiroki Oyama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Vargas A, Dutta P, Carpenter ES, Machicado JD. Endoscopic Ultrasound-Guided Ablation of Premalignant Pancreatic Cysts and Pancreatic Cancer. Diagnostics (Basel) 2024; 14:564. [PMID: 38473035 DOI: 10.3390/diagnostics14050564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
Pancreatic cancer is on the rise and expected to become the second leading cause of cancer-related death by 2030. Up to a one-fifth of pancreatic cancers may arise from mucinous pancreatic cysts, which are frequently present in the general population. Currently, surgical resection is the only curative approach for pancreatic cancer and its cystic precursors. However, only a dismal proportion of patients are eligible for surgery. Therefore, novel treatment approaches to treat pancreatic cancer and precancerous pancreatic cysts are needed. Endoscopic ultrasound (EUS)-guided ablation is an emerging minimally invasive method to treat pancreatic cancer and premalignant pancreatic cysts. Different ablative modalities have been used including alcohol, chemotherapy agents, and radiofrequency ablation. Cumulative data over the past two decades have shown that endoscopic ablation of mucinous pancreatic cysts can lead to cyst resolution in a significant proportion of the treated cysts. Furthermore, novel data are emerging about the ability to endoscopically ablate early and locally advanced pancreatic cancer. In this review, we aim to summarize the available data on the efficacy and safety of the different EUS-ablation modalities for the management of premalignant pancreatic cysts and pancreatic cancer.
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Affiliation(s)
- Alejandra Vargas
- Department of Medicine, Eastern Virginia Medical School, Norfolk, VA 23510, USA
| | - Priyata Dutta
- Department of Medicine, Trinity Health, Ann Arbor, MI 48197, USA
| | - Eileen S Carpenter
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jorge D Machicado
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI 48109, USA
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5
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Zhang Y, Yao J, Liu F, Cheng Z, Qi E, Han Z, Yu J, Dou J, Liang P, Tan S, Dong X, Li X, Sun Y, Wang S, Wang Z, Yu X. Radiomics Based on Contrast-Enhanced Ultrasound Images for Diagnosis of Pancreatic Serous Cystadenoma. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:2469-2475. [PMID: 37749013 DOI: 10.1016/j.ultrasmedbio.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/23/2023] [Accepted: 08/08/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE The purpose of the study was to develop and validate a radiomics model by using contrast-enhanced ultrasound (CEUS) data for pre-operative differential diagnosis of pancreatic cystic neoplasms (PCNs), especially pancreatic serous cystadenoma (SCA). METHODS Patients with pathologically confirmed PCNs who underwent CEUS examination at Chinese PLA hospital from May 2015 to August 2022 were retrospectively collected. Radiomic features were extracted from the regions of interest, which were obtained based on CEUS images. A support vector machine algorithm was used to construct a radiomics model. Moreover, based on the CEUS image features, the CEUS and the combined models were constructed using logistic regression. The performance and clinical utility of the optimal model were evaluated by area under the receiver operating characteristic curve (AUC), sensitivity, specificity and decision curve analysis. RESULTS A total of 113 patients were randomly split into the training (n = 79) and test cohorts (n = 34). These patients were pathologically diagnosed with SCA, mucinous cystadenoma, intraductal papillary mucinous neoplasm and solid-pseudopapillary tumor. The radiomics model achieved an AUC of 0.875 and 0.862 in the training and test cohorts, respectively. The sensitivity and specificity of the radiomics model were 81.5% and 86.5% in the training cohort and 81.8% and 91.3% in the test cohort, respectively, which were higher than or comparable with that of the CEUS model and the combined model. CONCLUSION The radiomics model based on CEUS images had a favorable differential diagnostic performance in distinguishing SCA from other PCNs, which may be beneficial for the exploration of personalized management strategies.
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Affiliation(s)
- Yiqiong Zhang
- Department of Interventional Ultrasound, First Medical Centre, Chinese PLA General Hospital, Beijing, China; Chinese PLA Medical School, Beijing, China
| | - Jundong Yao
- Department of Interventional Ultrasound, First Medical Centre, Chinese PLA General Hospital, Beijing, China; Department of Ultrasound, First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Fangyi Liu
- Department of Interventional Ultrasound, Fifth Medical Centre, Chinese PLA Hospital, Beijing, China
| | - Zhigang Cheng
- Department of Interventional Ultrasound, Fifth Medical Centre, Chinese PLA Hospital, Beijing, China
| | - Erpeng Qi
- Department of Interventional Ultrasound, First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Zhiyu Han
- Department of Interventional Ultrasound, Fifth Medical Centre, Chinese PLA Hospital, Beijing, China
| | - Jie Yu
- Department of Interventional Ultrasound, Fifth Medical Centre, Chinese PLA Hospital, Beijing, China
| | - Jianping Dou
- Department of Interventional Ultrasound, Fifth Medical Centre, Chinese PLA Hospital, Beijing, China
| | - Ping Liang
- Department of Interventional Ultrasound, Fifth Medical Centre, Chinese PLA Hospital, Beijing, China
| | - Shuilian Tan
- Department of Interventional Ultrasound, First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Xuejuan Dong
- Department of Interventional Ultrasound, First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Xin Li
- Department of Interventional Ultrasound, First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Ya Sun
- Department of Ultrasound, Aerospace Center Hospital, Beijing, China
| | - Shuo Wang
- Department of Interventional Ultrasound, First Medical Centre, Chinese PLA General Hospital, Beijing, China; Chinese PLA Medical School, Beijing, China
| | - Zhen Wang
- Department of Interventional Ultrasound, First Medical Centre, Chinese PLA General Hospital, Beijing, China; Chinese PLA Medical School, Beijing, China
| | - Xiaoling Yu
- Department of Interventional Ultrasound, First Medical Centre, Chinese PLA General Hospital, Beijing, China.
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Machicado JD, Napoleon B, Akshintala V, Bazarbashi AN, Bilal M, Corral JE, Dugum M, Han S, Hussain FS, Johnson AM, Jovani M, Kolb JM, Leonor P, Lee PJ, Mulki R, Shah H, Singh H, Sánchez-Luna SA, Shah SL, Singla A, Vargas EJ, Tielleman T, Nikahd M, Fry M, Culp S, Krishna SG. Structured training program on confocal laser endomicroscopy for pancreatic cystic lesions: a multicenter prospective study among early-career endosonographers (with video). Gastrointest Endosc 2023; 98:953-964. [PMID: 37473969 PMCID: PMC10771632 DOI: 10.1016/j.gie.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/08/2023] [Accepted: 07/17/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND AND AIMS Data on how to teach endosonographers needle-based confocal laser endomicroscopy (nCLE)-guided histologic diagnosis of pancreatic cystic lesions (PCLs) are limited. Hence, we developed and tested a structured educational program to train early-career endosonographers in nCLE-guided diagnosis of PCLs. METHODS Twenty-one early-career nCLE-naïve endosonographers watched a teaching module outlining nCLE criteria for diagnosing PCLs. Participants then reviewed 80 high-yield nCLE videos, recorded diagnoses, and received expert feedback (phase 1). Observers were then randomized to a refresher feedback session or self-learning at 4 weeks. Eight weeks after training, participants independently assessed the same 80 nCLE videos without feedback and provided histologic predictions (phase 2). Diagnostic performance of nCLE to differentiate mucinous versus nonmucinous PCLs and to diagnose specific subtypes were analyzed using histopathology as the criterion standard. Learning curves were determined using cumulative sum analysis. RESULTS Accuracy and diagnostic confidence for differentiating mucinous versus nonmucinous PCLs improved as endosonographers progressed through nCLE videos in phase 1 (P < .001). Similar trends were observed with the diagnosis of PCL subtypes. Most participants achieved competency interpreting nCLE, requiring a median of 38 assessments (range, 9-67). During phase 2, participants independently differentiated PCLs with high accuracy (89%), high confidence (83%), and substantial interobserver agreement (κ = .63). Accuracy for nCLE-guided PCL subtype diagnoses ranged from 82% to 96%. The learned nCLE skills did not deteriorate at 8 weeks and were not impacted by a refresher session. CONCLUSIONS We developed a practical, effective, and durable educational intervention to train early-career endosonographers in nCLE-guided diagnosis of PCLs.
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Affiliation(s)
- Jorge D Machicado
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Bertrand Napoleon
- Gastroenterology Department, Hopital Privé Jean Mermoz, Ramsay Generale de Sante, Lyon, France
| | - Venkata Akshintala
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | | | - Mohammad Bilal
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Juan E Corral
- Division of Gastroenterology and Hepatology, Presbyterian Hospital, Albuquerque, New Mexico, USA
| | | | - Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Alyson M Johnson
- Division of Gastroenterology, Duke University, Durham, North Carolina, USA
| | - Manol Jovani
- Division of Gastroenterology, Maimonides Medical Center, SUNY Downstate University, Brooklyn, New York, USA
| | - Jennifer M Kolb
- Division of Digestive Diseases, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Paul Leonor
- Division of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
| | - Peter J Lee
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ramzi Mulki
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology & Hepatology, Department of Internal Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Hamza Shah
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Harkirat Singh
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sergio A Sánchez-Luna
- Basil I. Hirschowitz Endoscopic Center of Excellence, Division of Gastroenterology & Hepatology, Department of Internal Medicine, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Shawn L Shah
- Division of Digestive and Liver Diseases, Veterans Affairs North Texas Health Care System, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Anand Singla
- Division of Gastroenterology, University of Washington, Seattle, Washington, USA
| | - Eric J Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas Tielleman
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Melica Nikahd
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Megan Fry
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Stacey Culp
- Department of Biomedical Informatics, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Salvia R, Burelli A, Nepi A, Caravati A, Tomelleri C, Dall'Olio T, Casciani F, Crinò SF, Perri G, Marchegiani G. Pancreatic cystic neoplasms: Still high rates of preoperative misdiagnosis in the guidelines and endoscopic ultrasound era. Surgery 2023; 174:1410-1415. [PMID: 37758634 DOI: 10.1016/j.surg.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 06/01/2023] [Accepted: 07/13/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND A wrong diagnosis of nature is common in pancreatic cystic neoplasms. The aim of the current study is to reappraise the diagnostic errors for presumed pancreatic cystic neoplasms in patients undergoing surgery. METHODS All pancreatic resections for presumed pancreatic cystic neoplasms following international guidelines between 2011 and 2020 were analyzed. Misdiagnosis was defined as the discrepancy between preoperative diagnosis of nature and final pathology. Mismatch was defined as the discrepancy between the preoperative suspect of malignancy (or its absence) and final pathology. RESULTS A total of 601 patients were included. Endoscopic ultrasound was performed in 301 (50%) patients. Overall misdiagnosis and mismatch were 19% and 34%, respectively, with no significant benefit for those patients who underwent endoscopic ultrasound. The highest rate of misdiagnosis was reached for cystic neuroendocrine tumors (61%) and the lowest for solid pseudopapillary tumors (6%). Several diagnostic errors had clinical relevance, including 7 (13%) presumed serous cystic neoplasms eventually found to be other malignant entities, 50 (24%) intraductal papillary mucinous neoplasms with high-risk stigmata revealed to be non-malignant, and 38 (33%) intraductal papillary mucinous neoplasms without high-risk stigmata revealed to be malignant at final pathology. A preoperative presumption of malignant mucinous cystic neoplasm was correct in only 20 (16%) patients. CONCLUSIONS Despite not always being clinically relevant, diagnostic errors are still common among resected pancreatic cystic neoplasms when applying international guidelines. New diagnostic tools beyond endoscopic ultrasound are needed to refine the diagnosis of those lesions at higher risk for unnecessary surgery or accidentally observed, nevertheless being malignant.
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Affiliation(s)
- Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Italy.
| | - Anna Burelli
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Italy
| | - Angelica Nepi
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Italy
| | - Andrea Caravati
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Italy
| | - Claudia Tomelleri
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Italy
| | - Tommaso Dall'Olio
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Italy
| | - Fabio Casciani
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Italy
| | | | - Giampaolo Perri
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Italy; Hepatopancreatobiliary and Liver Transplant Surgery, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Italy
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8
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Beger HG, Mayer B, Poch B. Duodenum-Preserving Pancreatic Head Resection for Benign and Premalignant Tumors-a Systematic Review and Meta-analysis of Surgery-Associated Morbidity. J Gastrointest Surg 2023; 27:2611-2627. [PMID: 37670106 PMCID: PMC10661729 DOI: 10.1007/s11605-023-05789-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/08/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Pancreatic benign, cystic, and neuroendocrine neoplasms are increasingly detected and recommended for surgical treatment. In multiorgan resection pancreatoduodenectomy or parenchyma-sparing, local extirpation is a challenge for decision-making regarding surgery-related early and late postoperative morbidity. METHODS PubMed, Embase, and Cochrane Libraries were searched for studies reporting early surgery-related complications following pancreatoduodenectomy (PD) and duodenum-preserving total (DPPHRt) or partial (DPPHRp) pancreatic head resection for benign tumors. Thirty-four cohort studies comprising data from 1099 patients were analyzed. In total, 654 patients underwent DPPHR and 445 patients PD for benign tumors. This review and meta-analysis does not need ethical approval. RESULTS Comparing DPPHRt and PD, the need for blood transfusion (OR 0.20, 95% CI 0.10-0.41, p<0.01), re-intervention for serious surgery-related complications (OR 0.48, 95% CI 0.31-0.73, p<0.001), and re-operation for severe complications (OR 0.50, 95% CI 0.26-0.95, p=0.04) were significantly less frequent following DPPHRt. Pancreatic fistula B+C (19.0 to 15.3%, p=0.99) and biliary fistula (6.3 to 4.3%; p=0.33) were in the same range following PD and DPPHRt. In-hospital mortality after DPPHRt was one of 350 patients (0.28%) and after PD eight of 445 patients (1.79%) (OR 0.32, 95% CI 0.10-1.09, p=0.07). Following DPPHRp, there was no mortality among the 192 patients. CONCLUSION DPPHR for benign pancreatic tumors is associated with significantly fewer surgery-related, serious, and severe postoperative complications and lower in-hospital mortality compared to PD. Tailored use of DPPHRt or DPPHRp contributes to a reduction of surgery-related complications. DPPHR has the potential to replace PD for benign tumors and premalignant cystic and neuroendocrine neoplasms of the pancreatic head.
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Affiliation(s)
- Hans G Beger
- c/o University of Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
- Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany.
| | - Benjamin Mayer
- Centre for Oncologic, Endocrine and Minimal Invasive Surgery, Donau-Klinikum Neu-Ulm, Neu-Ulm, Germany
| | - Bertram Poch
- Institute for Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
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Nikiforova MN, Wald AI, Spagnolo DM, Melan MA, Grupillo M, Lai YT, Brand RE, O’Broin-Lennon AM, McGrath K, Park WG, Pfau PR, Polanco PM, Kubiliun N, DeWitt J, Easler JJ, Dam A, Mok SR, Wallace MB, Kumbhari V, Boone BA, Marsh W, Thakkar S, Fairley KJ, Afghani E, Bhat Y, Ramrakhiani S, Nasr J, Skef W, Thiruvengadam NR, Khalid A, Fasanella K, Chennat J, Das R, Singh H, Sarkaria S, Slivka A, Gabbert C, Sawas T, Tielleman T, Vanderveldt HD, Tavakkoli A, Smith LM, Smith K, Bell PD, Hruban RH, Paniccia A, Zureikat A, Lee KK, Ongchin M, Zeh H, Minter R, He J, Nikiforov YE, Singhi AD. A Combined DNA/RNA-based Next-Generation Sequencing Platform to Improve the Classification of Pancreatic Cysts and Early Detection of Pancreatic Cancer Arising From Pancreatic Cysts. Ann Surg 2023; 278:e789-e797. [PMID: 37212422 PMCID: PMC10481930 DOI: 10.1097/sla.0000000000005904] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE We report the development and validation of a combined DNA/RNA next-generation sequencing (NGS) platform to improve the evaluation of pancreatic cysts. BACKGROUND AND AIMS Despite a multidisciplinary approach, pancreatic cyst classification, such as a cystic precursor neoplasm, and the detection of high-grade dysplasia and early adenocarcinoma (advanced neoplasia) can be challenging. NGS of preoperative pancreatic cyst fluid improves the clinical evaluation of pancreatic cysts, but the recent identification of novel genomic alterations necessitates the creation of a comprehensive panel and the development of a genomic classifier to integrate the complex molecular results. METHODS An updated and unique 74-gene DNA/RNA-targeted NGS panel (PancreaSeq Genomic Classifier) was created to evaluate 5 classes of genomic alterations to include gene mutations (e.g., KRAS, GNAS, etc.), gene fusions and gene expression. Further, CEA mRNA ( CEACAM5 ) was integrated into the assay using RT-qPCR. Separate multi-institutional cohorts for training (n=108) and validation (n=77) were tested, and diagnostic performance was compared to clinical, imaging, cytopathologic, and guideline data. RESULTS Upon creation of a genomic classifier system, PancreaSeq GC yielded a 95% sensitivity and 100% specificity for a cystic precursor neoplasm, and the sensitivity and specificity for advanced neoplasia were 82% and 100%, respectively. Associated symptoms, cyst size, duct dilatation, a mural nodule, increasing cyst size, and malignant cytopathology had lower sensitivities (41-59%) and lower specificities (56-96%) for advanced neoplasia. This test also increased the sensitivity of current pancreatic cyst guidelines (IAP/Fukuoka and AGA) by >10% and maintained their inherent specificity. CONCLUSIONS PancreaSeq GC was not only accurate in predicting pancreatic cyst type and advanced neoplasia but also improved the sensitivity of current pancreatic cyst guidelines.
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Affiliation(s)
- Marina N. Nikiforova
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Abigail I. Wald
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Daniel M. Spagnolo
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Melissa A. Melan
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Maria Grupillo
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Yi-Tak Lai
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Randall E. Brand
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anne Marie O’Broin-Lennon
- The Sol Goldman Pancreatic Cancer Research Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Kevin McGrath
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Walter G. Park
- Department of Medicine, Stanford University, Stanford, CA
| | - Patrick R. Pfau
- Department of Medicine, University of Wisconsin, Madison, WI
| | - Patricio M. Polanco
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Nisa Kubiliun
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - John DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN
| | - Jeffrey J. Easler
- Department of Gastroenterology and Hepatology, Indiana University Health Medical Center, Indianapolis, IN
| | - Aamir Dam
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL
| | - Shaffer R. Mok
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL
| | - Michael B. Wallace
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, FL
- Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, FL
| | - Brian A. Boone
- Department of Surgery, West Virginia University Health Sciences Center, Morgantown, WV
| | - Wallis Marsh
- Department of Surgery, West Virginia University Health Sciences Center, Morgantown, WV
| | - Shyam Thakkar
- Department of Medicine, Section of Gastroenterology & Hepatology, West Virginia University Health Sciences Center, Morgantown, WV
| | - Kimberly J. Fairley
- Department of Medicine, Section of Gastroenterology & Hepatology, West Virginia University Health Sciences Center, Morgantown, WV
| | - Elham Afghani
- The Sol Goldman Pancreatic Cancer Research Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Yasser Bhat
- Department of Gastroenterology, Palo Alto Medical Foundation (PAMF), Mountain View, CA
| | - Sanjay Ramrakhiani
- Department of Gastroenterology, Palo Alto Medical Foundation (PAMF), Mountain View, CA
| | - John Nasr
- Department of Medicine, Wheeling Hospital, West Virginia University Health Sciences Center, Morgantown, WV
| | - Wasseem Skef
- Division of Gastroenterology and Hepatology, Department of Medicine, Loma Linda University Medical Center, Loma Linda, CA
| | - Nikhil R. Thiruvengadam
- Division of Gastroenterology and Hepatology, Department of Medicine, Loma Linda University Medical Center, Loma Linda, CA
| | - Asif Khalid
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kenneth Fasanella
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jennifer Chennat
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Rohit Das
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Harkirat Singh
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Savreet Sarkaria
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Charles Gabbert
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tarek Sawas
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Thomas Tielleman
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Anna Tavakkoli
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Lynette M. Smith
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE
| | - Katelyn Smith
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Phoenix D. Bell
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ralph H. Hruban
- The Sol Goldman Pancreatic Cancer Research Center, Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Alessandro Paniccia
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Amer Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kenneth K. Lee
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Melanie Ongchin
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Herbert Zeh
- Department of Clinical Sciences, Surgery, University of Texas Southwestern, Dallas, TX
| | - Rebecca Minter
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Jin He
- The Sol Goldman Pancreatic Cancer Research Center, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Yuri E. Nikiforov
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Aatur D. Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
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10
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Ye M, Zhang B, Han X, Wei X, Wang Y, Cao W, Wu J, Chen C, Sun X, Sun K, Li H, Zhang Q, Liang T. Low-Pass Genomic Sequencing Reveals Novel Subtypes of Pancreatic Cystic Neoplasms. Ann Surg Oncol 2023; 30:5804-5812. [PMID: 37249723 DOI: 10.1245/s10434-023-13676-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/08/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Over the years, the detection rate of pancreatic cystic neoplasms (PCNs) has significantly increased; however, the differential diagnosis and identification of high-risk PCNs remain challenging. We sought to investigate whether chromosomal instability (CIN) features in cell-free DNA in the cystic fluid of PCNs could help to identify high-risk PCNs. METHODS Pancreatic cystic fluid samples from 102 patients with PCNs were intraoperatively collected for detection of CIN using an ultrasensitive chromosomal aneuploidy detector. Clinical and imaging data were retrospectively collected, and statistical analysis was performed to assess the potential role of CIN in clinical practice. RESULTS CIN was investigated in a total of 100 patients. Sixteen of 26 serous cystic cystadenomas (SCAs) harbored deletions of chr3p and/or chr6p, whereas low rates of CIN were detected in mucinous cystic neoplasms. Most malignant PCNs presented with more than one type of CIN; amplification of chr1q and chr8q found in nine and seven of 11 malignant PCNs (81.8% and 63.6%), respectively, could aid in distinguishing high-risk IPMNs from low-risk ones, with a higher sensitivity than imaging. A combination of the mural nodule imaging feature and amplification of chr1q and chr8q achieved a sensitivity of 70.0% and a specificity of 82.4% in identifying high-risk IPMNs. CONCLUSIONS Our work revealed the distinct CIN signature of different types of PCNs. Deletions of chr3p and chr6p defined a subtype of SCAs. Gains of chr1q and chr8q were associated with insidious malignant PCNs and helped identify high-risk IPMNs.
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Affiliation(s)
- Mao Ye
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- The Innovation Center for the Study of Pancreatic Diseases of Zhejiang Province, Hangzhou, China
| | - Bo Zhang
- Department of General Surgery, Luohu People's Hospital, The Third Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Xu Han
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaobao Wei
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yangyang Wang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wanyue Cao
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiangchao Wu
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Cao Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xu Sun
- Department of General Surgery, Huzhou Central Hospital, Zhejiang University School of Medicine, Huzhou, China
| | - Ke Sun
- Zhejiang University Cancer Center, Hangzhou, China
- Department of Pathology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haijun Li
- Department of General Surgery, Luohu People's Hospital, The Third Affiliated Hospital of Shenzhen University, Shenzhen, China.
| | - Qi Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- The Innovation Center for the Study of Pancreatic Diseases of Zhejiang Province, Hangzhou, China.
- Zhejiang University Cancer Center, Hangzhou, China.
- Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, Zhejiang Province, China.
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- The Innovation Center for the Study of Pancreatic Diseases of Zhejiang Province, Hangzhou, China.
- Zhejiang University Cancer Center, Hangzhou, China.
- Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, Zhejiang Province, China.
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11
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Fong ZV, Hernandez-Barco YG, Castillo CFD. A Clinical Guide to the Management of Intraductal Papillary Mucinous Neoplasms: the Need for a More Graded Approach in Clinical Decision-making. J Gastrointest Surg 2023; 27:1988-1998. [PMID: 37495820 DOI: 10.1007/s11605-022-05536-1] [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: 07/02/2022] [Accepted: 10/30/2022] [Indexed: 07/28/2023]
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) have become a very common diagnosis and represent a spectrum of disease that ranges from benign to malignant lesions. Presently, clinical and radiographic features are used to predict the presence of high-grade dysplasia and invasive cancer to inform treatment decisions of whether to pursuit surgical resection or continued surveillance. However, the natural history of IPMNs is still not completely understood, with guidelines from different societies providing contradictory recommendations. This underscores the challenge in balancing the risk of missing cancer with long-term surveillance and the morbidity associated with surgical resection. In this review, we aim to reconcile the differences in the guidelines' recommendations and provide a clinical framework to the management of IPMNs with hopes of adding clarity to how treatment decisions should be made. We also highlight recent advances made in the field and future efforts that can minimize rates of missing cancer while also reducing the number of unnecessary operations.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Yasmin G Hernandez-Barco
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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12
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Yang KS, O'Shea A, Zelga P, Liss AS, Del Castillo CF, Weissleder R. Extracellular vesicle analysis of plasma allows differential diagnosis of atypical pancreatic serous cystadenoma. Sci Rep 2023; 13:10969. [PMID: 37414831 PMCID: PMC10325992 DOI: 10.1038/s41598-023-37966-5] [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: 04/17/2023] [Accepted: 06/30/2023] [Indexed: 07/08/2023] Open
Abstract
Increased use of cross-sectional imaging has resulted in frequent detection of incidental cystic pancreatic lesions. Serous cystadenomas (SCAs) are benign cysts that do not require surgical intervention unless symptomatic. Unfortunately, up to half of SCAs do not have typical imaging findings ("atypical SCAs"), overlap with potentially malignant precursor lesions, and thus pose a diagnostic challenge. We tested whether the analysis of circulating extracellular vesicle (EV) biomarkers using a digital EV screening technology (DEST) could enhance the discrimination of cystic pancreatic lesions and avoid unnecessary surgical intervention in these atypical SCAs. Analysis of 25 different protein biomarkers in plasma EV from 68 patients identified a putative biomarker signature of Das-1, Vimentin, Chromogranin A, and CAIX with high discriminatory power (AUC of 0.99). Analysis of plasma EV for multiplexed markers may thus be helpful in clinical decision-making.
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Affiliation(s)
- Katherine S Yang
- Center for Systems Biology, Massachusetts General Hospital, 185 Cambridge St, CPZN 5206, Boston, MA, 02114, USA
- Department of Radiology, Massachusetts General Hospital, 32 Fruit St, Boston, MA, 02114, USA
| | - Aileen O'Shea
- Center for Systems Biology, Massachusetts General Hospital, 185 Cambridge St, CPZN 5206, Boston, MA, 02114, USA
- Department of Radiology, Massachusetts General Hospital, 32 Fruit St, Boston, MA, 02114, USA
| | - Piotr Zelga
- Department of Surgery, Massachusetts General Hospital, 32 Fruit St, Boston, MA, 02114, USA
| | - Andrew S Liss
- Department of Surgery, Massachusetts General Hospital, 32 Fruit St, Boston, MA, 02114, USA
| | | | - Ralph Weissleder
- Center for Systems Biology, Massachusetts General Hospital, 185 Cambridge St, CPZN 5206, Boston, MA, 02114, USA.
- Department of Radiology, Massachusetts General Hospital, 32 Fruit St, Boston, MA, 02114, USA.
- Department of Systems Biology, Harvard Medical School, 200 Longwood Ave, Boston, MA, 02115, USA.
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13
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Søreide K. Burgeoning rise in intraductal papillary mucinous neoplasia (IPMN) - a blessing in disguise. Scand J Gastroenterol 2023; 58:1101-1104. [PMID: 37022179 DOI: 10.1080/00365521.2023.2197095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 04/07/2023]
Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Gastrointestinal Translational Research Group, Laboratory for Molecular Medicine, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- SAFER Surgery, Surgical Research Group, Stavanger University Hospital, Stavanger, Norway
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14
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Machicado JD, Napoleon B, Lennon AM, El-Dika S, Pereira SP, Tan D, Pannala R, Girotra M, Kongkam P, Bertani H, Feng Y, Sijie H, Zhong N, Valantin V, Leblanc S, Hinton A, Krishna SG. Accuracy and agreement of a large panel of endosonographers for endomicroscopy-guided virtual biopsy of pancreatic cystic lesions. Pancreatology 2022; 22:994-1002. [PMID: 36089484 PMCID: PMC10548449 DOI: 10.1016/j.pan.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/11/2022] [Accepted: 08/21/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although emerging data evidences that EUS-guided needle-based confocal laser endomicroscopy (nCLE) accurately diagnoses pancreatic cystic lesions (PCLs), there are a lack of interobserver agreement (IOA) studies utilizing reference histopathological diagnosis and for specific PCL subtypes. Hence, we sought to assess the IOA, intra-observer reliability (IOR), and diagnostic performance of EUS-nCLE using a large cohort of patients with histopathological diagnosis amongst a broad panel of international observers. METHODS EUS-nCLE videos (n = 76) of subjects with PCLs [intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystadenoma (SCA), pseudocyst, and cystic-neuroendocrine tumors/solid pseudopapillary neoplasm (cystic-NET/SPN)], simulating clinical prevalence rates were obtained from 3 prospective studies. An international panel of 13 endosonographers with nCLE experience, blinded to all PCL data, evaluated the video library twice with a two-week washout for PCL differentiation (mucinous vs. non-mucinous) and subtype diagnosis. RESULTS The IOA (κ = 0.82, 95% CI 0.77-0.87) and IOR (κ = 0.82, 95% CI 0.78-0.85) were "almost perfect" to differentiate mucinous vs. non-mucinous PCLs. For PCL subtype, IOA was highest for SCA (almost perfect; κ = 0.85), followed by IPMN (substantial, κ = 0.72), and cystic-NET/SPN (substantial, κ = 0.73). The IOA was moderate for MCN (κ = 0.47), and pseudocyst (κ = 0.57). Compared to histopathology, observers differentiated mucinous vs. non-mucinous PCLs with high accuracy (94.8%, 95% CI 93.3-96.1). For detecting specific PCLs subtypes, EUS-nCLE was highly accurate in diagnosing non-mucinous cysts (SCA: 98%; cystic-NET/SPN: 96%; pseudocyst: 96%) and slightly less accurate for mucinous lesions (IPMN: 86%; MCN: 84%). CONCLUSION Diagnosis of PCLs by EUS-nCLE guided virtual biopsy is very accurate and reliable for the most prevalent pancreatic cysts in clinical practice.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Pradermchai Kongkam
- Division of Hospital and Ambulatory Medicine, Department of Medicine, Chulalongkorn University, Thailand
| | - Helga Bertani
- Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Yunlu Feng
- Peking Union Medical College Hospital, Dongcheng-qu, Beijing, China
| | - Hao Sijie
- Huashan Hospital Fudan University, Shanghai, China
| | - Ning Zhong
- Qilu Hospital of Shandong University Qingdao, Qingdao, Shandong, China
| | | | - Sarah Leblanc
- Hopital Privé Jean Mermoz, Ramsay Generale de Sante, Lyon, France
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, United States
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15
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Pușcașu CI, Rimbaş M, Mateescu RB, Larghi A, Cauni V. Advances in the Diagnosis of Pancreatic Cystic Lesions. Diagnostics (Basel) 2022; 12:diagnostics12081779. [PMID: 35892490 PMCID: PMC9394320 DOI: 10.3390/diagnostics12081779] [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: 06/25/2022] [Revised: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
Pancreatic cystic lesions (PCLs) are a heterogenous group of lesions ranging from benign to malignant. There has been an increase in PCLs prevalence in recent years, mostly due to advances in imaging techniques, increased awareness of their existence and population aging. Reliable discrimination between neoplastic and non-neoplastic cystic lesions is paramount to ensuring adequate treatment and follow-up. Although conventional diagnostic techniques such as ultrasound (US), magnetic resonance imaging (MRI) and computer tomography (CT) can easily identify these lesions, assessing the risk of malignancy is limited. Endoscopic ultrasound (EUS) is superior to cross-sectional imaging in identifying potentially malignant lesions due to its high resolution and better imaging characteristics, and the advantage of allowing for cyst fluid sampling via fine-needle aspiration (FNA). More complex testing, such as cytological and histopathological analysis and biochemical and molecular testing of the aspirated fluid, can ensure an accurate diagnosis.
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Affiliation(s)
- Claudia Irina Pușcașu
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.I.P.); (R.B.M.)
| | - Mihai Rimbaş
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.I.P.); (R.B.M.)
- Department of Internal Medicine, Carol Davila University of Medicine, 050474 Bucharest, Romania
- Correspondence: ; Tel.: +40-723-232-052
| | - Radu Bogdan Mateescu
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.I.P.); (R.B.M.)
- Department of Internal Medicine, Carol Davila University of Medicine, 050474 Bucharest, Romania
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Victor Cauni
- Urology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania;
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16
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Brunner M, Häberle L, Esposito I, Grützmann R. [Pancreatic cystic space-occupying lesions-Diagnostics, treatment and follow-up care : Current recommendations taking the current German S3 guidelines on pancreatic cancer into account]. Chirurg 2022; 93:461-475. [PMID: 35316346 DOI: 10.1007/s00104-022-01616-9] [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] [Accepted: 02/14/2022] [Indexed: 11/03/2022]
Abstract
Due to their increased detection pancreatic cystic space-occupying lesions are becoming increasingly relevant in the clinical routine and represent a morphologically and biologically heterogeneous and thus clinically demanding as well as potentially (pre)malignant entity. As a result, recommendations for the diagnostics and treatment of pancreatic cystic tumors have now been incorporated into the current German S3 guidelines on pancreatic cancer. The diagnostics of pancreatic cystic space-occupying lesions are based on the following three elements: collection of relevant clinical information, performance of high-resolution imaging procedures and if diagnostic uncertainty persists, puncture diagnostics. Differentiated diagnostics are of essential importance as these represent the basis for an adequate treatment decision. Pancreatic cystic lesions with a relevant risk of malignant transformation, e.g., main duct intraductal papillary mucinous neoplasms (IPMN), followed by mucinous cystic neoplasms (MCN), solid pseudopapillary neoplasms (SPN) and generally pancreatic cystic lesions with risk factors independent of the entity, should be resected, whereas a differentiated and individualized approach is necessary, especially for branch-duct IPMNs. The serous cystic neoplasms (SCN) have no malignant potential and do not require any treatment if they are asymptomatic. Important principles in surgery of pancreatic cancer, such as adequate surgical resection taking oncological standards into account and standardized appropriate histopathological processing of the specimens as well as intraoperative frozen section analysis also play an important role in pancreatic cystic space-occupying lesions. An annual follow-up seems to be meaningful, especially for IPMNs.
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Affiliation(s)
- Maximilian Brunner
- Klink für Allgemein- und Viszeralchirurgie, Universitätsklinikum der Friedrich-Alexander-Universität Erlangen, Erlangen, Deutschland
| | - Lena Häberle
- Institut für Pathologie, Universitätsklinikum der Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
| | - Irene Esposito
- Institut für Pathologie, Universitätsklinikum der Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
| | - Robert Grützmann
- Klink für Allgemein- und Viszeralchirurgie, Universitätsklinikum der Friedrich-Alexander-Universität Erlangen, Erlangen, Deutschland.
- , Krankenhausstr. 12, 91054, Erlangen, Deutschland.
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