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Megibow AJ. Pancreatic Cysts: Radiology. Gastrointest Endosc Clin N Am 2023; 33:519-531. [PMID: 37245933 DOI: 10.1016/j.giec.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This article reviews the types of pancreatic cysts encountered in Radiologic practice. It summarizes the malignancy risk of each of the following: serous cystadenoma, mucinous cystic tumor, intraductal papillary mucinous neoplasm main duct and side branch, and some miscellaneous cysts such as neuroendocrine tumor and solid pseudopapillary epithelial neoplasm. Specific reporting recommendations are given. The choice between radiology follow-up versus endoscopic analysis is discussed.
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Affiliation(s)
- Alec J Megibow
- Department of Radiology, NYU-Langone Health, 550 1st Avenue, Room HCC 232, New York, NY 10016, USA.
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2
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Chen X, Yu Z, Wang J, Cui W, Cui C, Wang Y, Liu Y, Zhou H, Wang C, Wang Z, Chen X. Opportunistic Detection for Pancreatic Cystic Lesions During Chest Multidetector CT Scans for Lung Cancer Screening. Cancer Manag Res 2021; 13:7559-7568. [PMID: 34629902 PMCID: PMC8495141 DOI: 10.2147/cmar.s327022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/14/2021] [Indexed: 12/01/2022] Open
Abstract
Purpose The purpose of this study was to analyze the prevalence of and risk factors for incidental pancreatic cystic lesions (PCLs) in the Chinese general population. Furthermore, the association between baseline imaging findings and PCL progression was also investigated. Patients and Methods A total of 9826 individuals who underwent computed tomography (CT) examinations for lung cancer screening between January 1, 2018 and January 1, 2019 were included in this study. The participants’ CT imaging findings and biochemical biomarker levels were reviewed and analyzed. PCLs detected during the screening were followed up for 12 months. Associations between imaging findings and clinical factors with PCL progression were explored. Results PCLs were observed in 172 of the 9826 participants. The crude prevalence of PCLs in total population was 1.75%. In subjects aged >60 years, the prevalence of PCLs was 3.2% (102/3151). The occurrence of PCLs was significantly increased with an increase of age in both men and women (p < 0.001). High-risk PCLsL commonly located in pancreatic head showed extrapancreatic growth, and had high urea levels (p = 0.005, p = 0.015, p = 0.002, respectively) compared with low-risk PCLs. Location in the pancreatic head (odds ratio (OR) = 6.286, 95% confidence interval (CI): 1.842–21.452) and extrapancreatic growth (OR = 4.049, 95% CI: 1.235–13.333) were risk factors for PCL progression. Conclusion PCLs are not uncommon in the Chinese general population. Location in the pancreatic head and extrapancreatic growth are the independent predictors of high-risk of PCLs and PCL progression.
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Affiliation(s)
- Xin Chen
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210029, People's Republic of China.,Department of Radiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, 200233, People's Republic of China
| | - Zhicheng Yu
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210029, People's Republic of China.,Department of Radiology, Jiading Central Hospital, Shanghai University of Medicine & Health Sciences, Shanghai, 201800, People's Republic of China
| | - Jianhua Wang
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210029, People's Republic of China
| | - Wenjing Cui
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210029, People's Republic of China
| | - Can Cui
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210029, People's Republic of China
| | - Yajie Wang
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210029, People's Republic of China
| | - Yongkang Liu
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210029, People's Republic of China
| | - Hao Zhou
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210029, People's Republic of China
| | - Cheng Wang
- Department of Radiology, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, People's Republic of China
| | - Zhongqiu Wang
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210029, People's Republic of China
| | - Xiao Chen
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210029, People's Republic of China
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Park HW, Lee JS, Park SY, Kim TH, Lee JY, Koo JE, Bae SE, Choe J, Chang HS, Park DH, Bae I, Park S. Progression of pancreatic cystic lesions without any risk features is associated with initial cyst size and obesity. J Gastroenterol Hepatol 2020; 35:877-884. [PMID: 31758719 DOI: 10.1111/jgh.14940] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 11/07/2019] [Accepted: 11/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM The clinical significance of incidental pancreatic cystic lesions (PCLs) remains unclear in those that are not accompanied by worrisome features or high-risk stigmata. We aimed to investigate the natural course of PCLs without any risk features and examine the clinical factors associated with their progression. METHODS We conducted a retrospective cohort study of 427 patients with PCLs, which were incidentally detected by computed tomography between January 2003 and December 2012. Progression of PCLs without any risk features and the clinical factors associated with their progression were investigated. The length of time to significant growth was also evaluated. RESULTS Ninety-four (22.0%) of the 427 patients had asymptomatic PCLs that showed significant growth after a median surveillance period of 5.3 years; approximately 27.7% of the patients showed significant size changes in the first 5 years, while the remaining 72.3% showed significant changes after 5 years. The cumulative rate of patients with significant growth was associated with initial cyst size and high body mass index. In the growth group, additional treatments were required for 12 patients, one of whom developed malignancy. Four patients in the stable group underwent additional treatment and showed no malignant change. CONCLUSIONS One-fifth of the asymptomatic PCLs significantly increased in size after a long-term follow-up period, which was associated with initial cyst size and obesity. The size of PCLs mostly increased after 5 years; although the malignancy risk of PCLs was low, it was still a concern.
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Affiliation(s)
- Hye Won Park
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Soo Lee
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seo Young Park
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Hyup Kim
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Young Lee
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ja Eun Koo
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suh Eun Bae
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jaewon Choe
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Sook Chang
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Inyoung Bae
- Division of Radiology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sungwon Park
- Division of Radiology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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4
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Rosendahl J, Michl P. [Cystic lesions of the pancreas : Differential diagnostics and treatment]. Internist (Berl) 2019; 60:219-225. [PMID: 30617702 DOI: 10.1007/s00108-018-0547-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Cystic space-occupying lesions of the pancreas represent incidental findings in most cases. As there is a potential risk of malignant transformation further evaluation of the lesions as well as a follow-up of these patients is usually recommended. Before this work-up is initiated the clinical situation of the patient as a whole and comorbidities, age and personal preferences have to be taken into account. So far there are no biomarkers that reliably predict the risk of malignant transformation. Imaging by magnetic resonance tomography (MRI) in combination with magnetic resonance cholangiopancreatography (MRCP) is more accurate than computed tomography to identify worrisome features. During follow-up, endoscopic ultrasound (EUS) can be used as complementary method to MRI/MRCP. Using contrast enhancement or endoscopic fine needle aspiration (EUS-FNA) may influence the therapeutic strategy in some patients. Whereas for some cystic pancreatic lesions consensus has been reached, varying recommendations exist for intraductal papillary mucinous neoplasms (IPMN). There is consensus that in main-duct as well as in mixed-type IPMN surgery is recommended. The management of branch-duct type IPMN, however, remains controversial. A multidisciplinary expert panel including gastroenterologists, visceral surgeons, radiologists and pathologists is essential to discuss all cases of patients with cystic pancreatic lesions and to guarantee an optimal, patient-centered treatment recommendation.
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Affiliation(s)
- J Rosendahl
- Klinik für Innere Medizin I, Universitätsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland.
| | - P Michl
- Klinik für Innere Medizin I, Universitätsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland
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Abstract
Evidence-based guidelines on the management of pancreatic cystic neoplasms (PCN) are lacking. This guideline is a joint initiative of the European Study Group on Cystic Tumours of the Pancreas, United European Gastroenterology, European Pancreatic Club, European-African Hepato-Pancreato-Biliary Association, European Digestive Surgery, and the European Society of Gastrointestinal Endoscopy. It replaces the 2013 European consensus statement guidelines on PCN. European and non-European experts performed systematic reviews and used GRADE methodology to answer relevant clinical questions on nine topics (biomarkers, radiology, endoscopy, intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystic neoplasm, rare cysts, (neo)adjuvant treatment, and pathology). Recommendations include conservative management, relative and absolute indications for surgery. A conservative approach is recommended for asymptomatic MCN and IPMN measuring <40 mm without an enhancing nodule. Relative indications for surgery in IPMN include a main pancreatic duct (MPD) diameter between 5 and 9.9 mm or a cyst diameter ≥40 mm. Absolute indications for surgery in IPMN, due to the high-risk of malignant transformation, include jaundice, an enhancing mural nodule >5 mm, and MPD diameter >10 mm. Lifelong follow-up of IPMN is recommended in patients who are fit for surgery. The European evidence-based guidelines on PCN aim to improve the diagnosis and management of PCN.
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Tamura S, Yamamoto H, Ushida S, Suzuki K. Mucinous cystic neoplasms in male patients: two cases. Rare Tumors 2017; 9:7096. [PMID: 29081929 PMCID: PMC5643879 DOI: 10.4081/rt.2017.7096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/24/2017] [Accepted: 08/17/2017] [Indexed: 11/23/2022] Open
Abstract
Mucinous cystic neoplasms (MCNs) of the pancreas in male patients are very rare. Though few cases of MCNs in male patients have been reported, it is difficult to reveal them preoperatively. The first patient was a 50-year-old man and was incidentally found to have a cystic mass of 51 mm in the tail of the pancreas. We performed a distal pancreatectomy. The second patient was a 73-year-old man, incidentally found to have a cystic mass of 25 mm in diameter in the tail of the pancreas and a carcinoma of the bile duct. We performed a subtotal stomachpreserving pancreaticoduodenectomy and distal pancreatectomy. In both cases, the cystic lesion was diagnosed pathologically as MCNs. Since MCNs have the risk of malignancy, a resection is recommended. Cases of MCNs in male patients exhibit features that are similar to MCNs in women. We should recognize that MCNs of the pancreas in male patients exists.
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Affiliation(s)
| | | | | | - Kazufumi Suzuki
- Department of Gastrointestinal Surgery, Seirei Hamamatsu General Hospital, Shizuoka, Japan
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Megibow AJ, Baker ME, Morgan DE, Kamel IR, Sahani DV, Newman E, Brugge WR, Berland LL, Pandharipande PV. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2017; 14:911-923. [PMID: 28533111 DOI: 10.1016/j.jacr.2017.03.010] [Citation(s) in RCA: 191] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 02/27/2017] [Accepted: 03/13/2017] [Indexed: 12/12/2022]
Abstract
The ACR Incidental Findings Committee (IFC) presents recommendations for managing pancreatic cysts that are incidentally detected on CT or MRI. These recommendations represent an update from the pancreatic component of the JACR 2010 white paper on managing incidental findings in the adrenal glands, kidneys, liver, and pancreas. The Pancreas Subcommittee-which included abdominal radiologists, a gastroenterologist, and a pancreatic surgeon-developed this algorithm. The recommendations draw from published evidence and expert opinion, and were finalized by informal iterative consensus. Algorithm branches successively categorize pancreatic cysts based on patient characteristics and imaging features. They terminate with an ascertainment of benignity and/or indolence (sufficient to discontinue follow-up), or a management recommendation. The algorithm addresses most, but not all, pathologies and clinical scenarios. Our goal is to improve quality of care by providing guidance on how to manage incidentally detected pancreatic cysts.
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Affiliation(s)
- Alec J Megibow
- Department of Radiology, NYU-Langone Medical Center, New York, New York.
| | - Mark E Baker
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio
| | - Desiree E Morgan
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ihab R Kamel
- Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Dushyant V Sahani
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Elliot Newman
- Department of Surgery, NYU-Langone Medical Center, New York, New York
| | - William R Brugge
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lincoln L Berland
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Pari V Pandharipande
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
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Abstract
Pancreatic cytopathology, particularly through the use of endoscopic ultrasound-guided fine-needle aspiration (FNA), has excellent specificity and sensitivity for the diagnosis of pancreatic lesions. Such diagnoses can help guide preoperative management of patients, provide prognostic information, and confirm diagnoses in patients who are not surgical candidates. Furthermore, FNA can be used to obtain cyst fluid for ancillary tests that can improve the diagnosis of cystic lesions. In this article, we describe the cytomorphological features and differential diagnoses of the most commonly encountered pancreatic lesions on FNA.
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Affiliation(s)
- Jennifer A Collins
- Department of Pathology, The Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Syed Z Ali
- Department of Pathology, The Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Christopher J VandenBussche
- Department of Pathology, The Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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9
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You L, Xiao J, Cao Z, Zhang W, Liao Q, Dai M, Zhang T, Zhao Y. Analysis of clinical characteristics and treatment of pancreatic cystic tumors. Chin J Cancer Res 2016; 28:519-527. [PMID: 27877011 PMCID: PMC5101226 DOI: 10.21147/j.issn.1000-9604.2016.05.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective To summarize experience in the diagnosis and treatment of pancreatic cystic neoplasms. Methods This is a retrospective study of 207 patients who were diagnosed with pancreatic cystic tumors at Peking Union Medical College Hospital between Jan 2009 and Mar 2014. Clinical data, such as clinical manifestations, radiological and pathological images and surgical recordings, were collected. Results Of the 207 included patients, females accounted for 76.81%, and the mean patient age was 52.04 years. Malignancy was more common in older patients who presented with marasmus and jaundice. Other risk factors included solid components in the tumor, a large tumor size, and elevated levels of tumor markers. Surgical treatment was required when a malignant tumor was suspected. The operation approach was selected based on the location, size and characteristics of the tumor. The position of the tumor relative to the pancreatic duct also played a significant role. Conclusions No specific symptoms were observed for the patients with pancreatic cystic tumors. Imaging played an important role in making a differential diagnosis. Furthermore, surgical treatment should be proposed for patients with significant symptoms and potentially malignant tumors. The tumor resection rate is high, suggestive of good prognosis.
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Affiliation(s)
- Lei You
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jianchun Xiao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Zhe Cao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wanying Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Quan Liao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
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10
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Reames BN, Scally CP, Frankel TL, Dimick JB, Nathan H. National trends in resection of cystic lesions of the pancreas. HPB (Oxford) 2016; 18:375-82. [PMID: 27037208 PMCID: PMC4814594 DOI: 10.1016/j.hpb.2015.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 11/09/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Management of cystic lesions of the pancreas (CLP) is controversial. In this study, we sought to evaluate national changes in the resection of CLP over time, to better understand the impact of evolving guidelines on CLP management. METHODS We used Medicare data to examine CLP resection among patients undergoing pancreatic resection between 2001 and 2012. Patients with a diagnosis of CLP were identified and compared to patients with non-CLP indications. We then examined changes over time in patient and hospital characteristics and outcomes among patients with a CLP diagnosis. RESULTS We identified 56,419 Medicare patients undergoing pancreatic resection, of which 2129 had a CLP diagnosis. The annual number of CLP resections, and proportion of all resections performed for CLP increased significantly during the period, from 2.1% (65/3072) resections in 2001, to 4.5% (286/6348) in 2012 (p < 0.001). The proportion of CLP resections with a malignant diagnosis did not change (15.5% in 2001-2003 vs. 13.1% in 2010-2012, p = 0.4). Overall rates of 30-day mortality decreased significantly during the period (9.6% in 2001-2003 vs. 5.5% in 2010-2012, p < 0.001). DISCUSSION CLP resections were performed with increasing frequency in Medicare patients between 2001 and 2012, but this did not correspond to increased diagnosis of malignancy. Additional research is needed to understand the influence of recent guidelines on management of CLP.
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MESH Headings
- Aged
- Aged, 80 and over
- Female
- Humans
- Male
- Medicare/trends
- Neoplasms, Cystic, Mucinous, and Serous/diagnosis
- Neoplasms, Cystic, Mucinous, and Serous/mortality
- Neoplasms, Cystic, Mucinous, and Serous/surgery
- Pancreatectomy/adverse effects
- Pancreatectomy/mortality
- Pancreatectomy/standards
- Pancreatectomy/trends
- Pancreatic Cyst/diagnosis
- Pancreatic Cyst/mortality
- Pancreatic Cyst/surgery
- Pancreatic Neoplasms/diagnosis
- Pancreatic Neoplasms/mortality
- Pancreatic Neoplasms/surgery
- Pancreaticoduodenectomy/adverse effects
- Pancreaticoduodenectomy/mortality
- Pancreaticoduodenectomy/standards
- Pancreaticoduodenectomy/trends
- Practice Guidelines as Topic
- Practice Patterns, Physicians'/trends
- Process Assessment, Health Care/trends
- Time Factors
- Treatment Outcome
- United States
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Affiliation(s)
- Bradley N Reames
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Hari Nathan
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
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Scheiman JM, Hwang JH, Moayyedi P. American gastroenterological association technical review on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015; 148:824-48.e22. [PMID: 25805376 DOI: 10.1053/j.gastro.2015.01.014] [Citation(s) in RCA: 273] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- James M Scheiman
- Department of Internal Medicine and Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Joo Ha Hwang
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington
| | - Paul Moayyedi
- Division of Gastroenterology, Hamilton Health Sciences, Farncombe Family Digestive Health Research Institute, McMaster University Hamilton, Ontario, Canada
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12
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Freeny PC, Saunders MD. Moving beyond morphology: new insights into the characterization and management of cystic pancreatic lesions. Radiology 2014; 272:345-63. [PMID: 25058133 DOI: 10.1148/radiol.14131126] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The frequency of detection of cystic pancreatic lesions with cross-sectional imaging, particularly with multidetector computed tomography, magnetic resonance (MR) imaging, and MR cholangiopancreatography, is increasing, and many of these cystic pancreatic lesions are being detected incidentally in asymptomatic patients. Because there is considerable overlap in the cross-sectional imaging findings of cystic pancreatic lesions, and because many of these lesions being detected are smaller than 3 cm in diameter and lack any specific cross-sectional imaging features, it has become difficult to make informed decisions about patient management when the precise diagnosis remains uncertain. This article presents the limitations of cross-sectional imaging in patients with cystic pancreatic lesions, details advances in knowledge of the genomic and epigenomic changes that lead to progression of carcinogenesis, outlines the current understanding of the natural history of mucinous cystic lesions, and includes the current use and future potential of novel tumor markers and molecular analysis to characterize cystic pancreatic lesions more precisely. The need to move beyond cross-sectional imaging morphology and toward the use of new techniques to diagnose these lesions accurately is emphasized. An algorithm that uses these techniques is proposed and will hopefully lead to improved patient management.
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Affiliation(s)
- Patrick C Freeny
- From the Department of Radiology (P.C.F.) and Department of Medicine, Division of Gastroenterology (M.D.S.), University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195
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13
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Abstract
PURPOSE OF REVIEW Diagnosis of pancreatic cysts remains challenging due to limitations of currently available radiologic and endoscopic tools. The diagnostic approach should focus on identifying mucinous and malignant cysts. Mucinous cysts require further differentiation to allow appropriate management. RECENT FINDINGS Although the overall rate of malignant pancreatic cysts is low, it remains higher than the general population. MRI with magnetic resonance cholangiopancreatography is the preferred imaging modality for pancreatic cysts. Attempts to improve diagnostic yield of endoscopic ultrasound-guided fine needle aspiration include performing cyst wall cytology and DNA analysis. The 2012 international consensus guidelines for mucinous cystic neoplasm and intraductal papillary mucinous neoplasm are superior to the original 2006 guidelines, although issues include the relatively poor ability to diagnose malignant cysts leading to unnecessary surgeries and the de-emphasis of cyst size. Cyst size remains an important predictor of malignancy. Translational research involving genomics, microRNA, proteomics, and metabolomics holds promise for improved biomarkers. Endoscopic innovations may safely aid in cyst diagnosis. SUMMARY Incremental improvements in pancreatic cyst diagnosis have occurred with new biomarkers and endoscopic tools requiring validation in large-scale studies.
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Lee LS. Incidental Cystic Lesions in the Pancreas: Resect? EUS? Follow? CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2014; 12:333-49. [PMID: 24903582 DOI: 10.1007/s11938-014-0019-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pancreatic cysts challenge clinicians due to their increased incidental identification on radiology imaging, the limitations of currently available diagnostic tools, and potential for malignancy. Following initial identification of an incidental pancreatic cyst, a dedicated pancreatic protocol abdominal CT scan or MRI pancreas with MRCP should be performed. Surgical resection is recommended for all surgical candidates with MD-IPMN, mixed or combined type IPMN, mucinous cystic neoplasm, and solid pseudopapillary neoplasm. Serous cystadenoma may be followed with serial imaging unless the patient develops symptoms, the cyst is larger than 4 cm or rapidly growing, or diagnostic uncertainty remains despite thorough evaluation. Surveillance is also recommended for BD-IPMN without the following features concerning malignancy: obstructive jaundice with a cyst in the head of the pancreas; solid component; nodule; main pancreatic duct ≥10 mm; or cytology suspected or positive for malignancy. BD-IPMN ≥3 cm without concerning features may also be followed carefully, although surgical resection should be considered in surgically fit patients. EUS-FNA for cyst wall cytology, CEA, amylase, and occasionally k-ras mutation are also likely aids in the diagnosis of pancreatic cysts beyond radiologic imaging. This author typically recommends EUS-FNA to further evaluate cysts larger than 1 cm without definitive indication for resection. EUS is also appropriate in patients with solid component, nodule, or size ≥3 cm to aid in decision making, especially in older patients who may be less suitable surgical candidates. A multidisciplinary approach with a team of dedicated gastrointestinal radiologists, pancreatic surgeons, gastrointestinal pathologists, and gastroenterologists is essential for managing patients with pancreatic cysts.
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Affiliation(s)
- Linda S Lee
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA, 02115, USA,
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15
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Park JW, Jang JY, Kang MJ, Kwon W, Chang YR, Kim SW. Mucinous cystic neoplasm of the pancreas: is surgical resection recommended for all surgically fit patients? Pancreatology 2014; 14:131-6. [PMID: 24650968 DOI: 10.1016/j.pan.2013.12.006] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 12/24/2013] [Accepted: 12/27/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Surgical removal of mucinous cystic neoplasms (MCNs) is usually recommended because of the risk of malignancy. However, increased experience of MCNs suggests that the incidence of invasion is lower than had been thought. This study was designed to establish more reasonable surgical indications for MCN through re-assessment using strict pathologic diagnostic criteria. METHODS Ninety-four patients who underwent surgical removal of MCNs at Seoul National University Hospital from 1991 to 2012 were retrospectively analyzed. Pathologic results were re-evaluated by an experienced pathologist. Medical records and radiologic images were reviewed to determine factors predicting malignancy. RESULTS Of the 94 patients, 4 were found to have intraductal papillary mucinous neoplasms (IPMNs). Of the 90 MCNs, 60 (66.7%) were low-grade, 21 (23.3%) were intermediate-grade, and 5 (5.5%) were high-grade dysplasias; and 4 (4.4%) were invasive carcinoma. Mural nodules on CT scan (p = 0.005) and abnormal serum CA19-9 concentration (p = 0.029) were significant predictors of malignancy. All MCNs less than 3 cm in size with normal serum tumor markers were benign and all malignant MCNs had cyst fluid CA19-9 over 10,000 units/ml. The five year disease specific survival rates were 98.8% for all patients and 75.0% for those with invasive MCNs. CONCLUSION MCNs had a low prevalence of malignancy. Regardless of the histological grade, long-term outcome was excellent. Therefore, in the absence of specific symptoms, surgery may not be indicated for MCNs <3 cm without mural nodules or elevated serum tumor markers. Validation by a prospective study with very careful design is needed.
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Affiliation(s)
- Jae Woo Park
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Mee Joo Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ye Rim Chang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sun-Whe Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.
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