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Standardization of MRI Screening and Reporting in Individuals With Elevated Risk of Pancreatic Ductal Adenocarcinoma: Consensus Statement of the PRECEDE Consortium. AJR Am J Roentgenol 2022; 219:903-914. [PMID: 35856454 DOI: 10.2214/ajr.22.27859] [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: 12/14/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive malignancies, with a dismal survival rate. Screening the general population for early detection of PDAC is not recommended, but because early detection improves survival, high-risk individuals, defined as those meeting criteria based on a family history of PDAC and/or the presence of known pathogenic germline variant genes with PDAC risk, are recommended to undergo screening with MRI and/or endoscopic ultrasound at regular intervals. The Pancreatic Cancer Early Detection (PRECEDE) Consortium was formed in 2018 and is composed of gastroenterologists, geneticists, pancreatic surgeons, radiologists, statisticians, and researchers from 40 sites in North America, Europe, and Asia. The overarching goal of the PRECEDE Consortium is to facilitate earlier diagnosis of PDAC for high-risk individuals to increase survival of the disease. A standardized MRI protocol and reporting template are needed to enhance the quality of screening examinations, improve consistency of clinical management, and facilitate multiinstitutional research. We present a consensus statement to standardize MRI screening and reporting for individuals with elevated risk of pancreatic cancer.
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Khristenko E, Hank T, Gaida MM, Kauczor HU, Hackert T, Klauß M, Mayer P. Imaging features of intraductal tubulopapillary neoplasm of the pancreas and its differentiation from conventional pancreatic ductal adenocarcinoma. Sci Rep 2022; 12:15557. [PMID: 36114217 PMCID: PMC9481632 DOI: 10.1038/s41598-022-19517-6] [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: 12/17/2021] [Accepted: 08/30/2022] [Indexed: 11/19/2022] Open
Abstract
Intraductal tubulopapillary neoplasms (ITPN) are rare pancreatic tumors (< 1% of exocrine neoplasms) and are considered to have better prognosis than classical pancreatic ductal adenocarcinoma (PDAC). The present study aimed to evaluate imaging features of ITPN in computed tomography (CT) and magnetic resonance (MR) imaging. We performed monocentric retrospective analysis of 14 patients with histopathologically verified ITPN, operated in 2003–2018. Images were available for 12 patients and were analysed independently by two radiologists, blinded to reports. Imaging features were compared to a matched control group consisting of 43 patients with PDAC, matched for sex and age. Histopathologic analysis showed invasive carcinoma component in all ITPN patients. CT-attenuation values of ITPN were higher in arterial and venous phases (62.3 ± 14.6 HU and 68 ± 15.6 HU) than in unenhanced phase (39.2 ± 7.9 HU), compatible with solid lesion enhancement. Compared to PDAC, ITPN lesions had significantly higher HU-values in both arterial and venous phases (arterial and venous phases, p < 0.001). ITPN were significantly larger than PDAC (4.1 ± 2.0 cm versus 2.6 ± 0.84 cm, p = 0.021). ITPN lesions were more often well-circumscribed (p < 0.002). Employing a multiple logistic regression analysis with forward stepwise method, higher HU density in the arterial phase (p = 0.012) and well-circumscribed lesion margins (p = 0.047) were found to be significant predictors of ITPN versus PDAC. Our study identified key imaging features for differentiation of ITPN and PDAC. Isodensity or moderate hypodensity and well-circumscribed margins favor the diagnosis of ITPN over PDAC. Being familiar with CT-features of these rare pancreatic tumors is essential for radiologists to accelerate the diagnosis and narrow the differentials.
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Miller FH, Lopes Vendrami C, Recht HS, Wood CG, Mittal P, Keswani RN, Gabriel H, Borhani AA, Nikolaidis P, Hammond NA. Pancreatic Cystic Lesions and Malignancy: Assessment, Guidelines, and the Field Defect. Radiographics 2021; 42:87-105. [PMID: 34855543 DOI: 10.1148/rg.210056] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The widespread use of high-spatial-resolution cross-sectional imaging has led to an increase in detection of incidental pancreatic cystic lesions. These lesions are a diverse group, ranging from indolent and premalignant lesions to invasive cancers. The diagnosis of several of these lesions can be suggested on the basis of their imaging appearance, while many other lesions require follow-up imaging and/or aspiration. The smaller cystic lesions, often branch-duct intraductal papillary mucinous neoplasms, have overlapping imaging characteristics that make diagnostic assessment of the natural history and malignancy risk confusing. Expert panels have developed societal guidelines, based on a consensus, for surveillance of these lesions. However, these guidelines are often inconsistent and are constantly evolving as additional scientific data are accumulated. Identification of features associated with increased risk of malignancy is important for proper management. The concept of field defect, whereby pancreatic adenocarcinoma develops at a site different from the site of the pancreatic cyst, adds to the complexity of screening guidelines. As a result of the differences in guidelines, key stakeholders (eg, radiologists, gastroenterologists, and surgeons) must review and come to a consensus regarding which guideline, or combination of guidelines, to follow at their individual institutions. Standardized reporting and macros are helpful for ensuring the uniformity of interpretations. Radiologists play a critical role in the detection and characterization of pancreatic cystic lesions, in the follow-up recommendations for these lesions, and in the detection of associated cancer. An invited commentary by Zaheer is available online. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Frank H Miller
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Camila Lopes Vendrami
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Hannah S Recht
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Cecil G Wood
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Pardeep Mittal
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Rajesh N Keswani
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Helena Gabriel
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Amir A Borhani
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Paul Nikolaidis
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Nancy A Hammond
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
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Gong XH, Xu JR, Qian LJ. Atypical and uncommon CT and MR imaging presentations of pancreatic ductal adenocarcinoma. Abdom Radiol (NY) 2021; 46:4226-4237. [PMID: 33914139 DOI: 10.1007/s00261-021-03089-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/04/2021] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
Pancreatic ductal adenocarcinomas (PDACs) occasionally have atypical and uncommon imaging presentations that can present a diagnostic dilemma and result in false interpretation. This article aimed to illustrate these CT and MR imaging findings, including isoattenuating PDAC, coexisting acute pancreatitis, PDAC with a cystic feature, groove PDAC, diffuse PDAC, hypointensity on diffusion-weighted imaging (DWI), multifocal PDAC, intratumoral calcification, and extrapancreatic invasion with a barely discernable mass. A subset of PDACs with atypical features are occasionally encountered during routine clinical practice. Knowledge of and attention to these atypical and uncommon variable imaging features may allow radiologists to avoid misinterpretation and a delayed diagnosis.
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Halankar J, Jhaveri K, Metser U. Cystic lesions of the pancreatico-biliary tree: A schematic MRI approach. Indian J Radiol Imaging 2021; 27:167-176. [PMID: 28744077 PMCID: PMC5510314 DOI: 10.4103/ijri.ijri_226_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Although a common occurrence, cystic lesions of the pancreatico-biliary tree (PBT) may pose a diagnostic dilemma because they encompass a large number of neoplastic and benign processes with varied clinical symptoms. Knowledge of lesion classification and characterization are essential in making an accurate prospective diagnosis. This is necessary for identifying clinically significant cystic masses, which at times may require invasive intervention from indolent, nonneoplastic lesions, for which surveillance may suffice. Today, there is an arsenal of modalities for assessing the PBT, however, magnetic resonance imaging (MRI) remains at the forefront for characterizing cystic morphology and fluid content, internal septations, solid component, enhancement patterns, as well as assessing the surrounding normal structures. This pictorial review aims to review the spectrum of MRI features, which will aid in the differential diagnoses of cystic lesions of the PBT and mimickers, enabling the radiologist to reach a more confident diagnosis.
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Affiliation(s)
- Jaydeep Halankar
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital and Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kartik Jhaveri
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital and Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ur Metser
- Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital and Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
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Sagami R, Yamao K, Nakahodo J, Minami R, Tsurusaki M, Murakami K, Amano Y. Pre-Operative Imaging and Pathological Diagnosis of Localized High-Grade Pancreatic Intra-Epithelial Neoplasia without Invasive Carcinoma. Cancers (Basel) 2021; 13:cancers13050945. [PMID: 33668239 PMCID: PMC7956417 DOI: 10.3390/cancers13050945] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/08/2021] [Accepted: 02/19/2021] [Indexed: 12/11/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) arises from precursor lesions, such as pancreatic intra-epithelial neoplasia (PanIN) and intraductal papillary mucinous neoplasm (IPMN). The prognosis of high-grade precancerous lesions, including high-grade PanIN and high-grade IPMN, without invasive carcinoma is good, despite the overall poor prognosis of PDAC. High-grade PanIN, as a lesion preceding invasive PDAC, is therefore a primary target for intervention. However, detection of localized high-grade PanIN is difficult when using standard radiological approaches. Therefore, most studies of high-grade PanIN have been conducted using specimens that harbor invasive PDAC. Recently, imaging characteristics of high-grade PanIN have been revealed. Obstruction of the pancreatic duct due to high-grade PanIN may induce a loss of acinar cells replaced by fibrosis and lobular parenchymal atrophy. These changes and additional inflammation around the branch pancreatic ducts (BPDs) result in main pancreatic duct (MPD) stenosis, dilation, retention cysts (BPD dilation), focal pancreatic parenchymal atrophy, and/or hypoechoic changes around the MPD. These indirect imaging findings have become important clues for localized, high-grade PanIN detection. To obtain pre-operative histopathological confirmation of suspected cases, serial pancreatic-juice aspiration cytologic examination is effective. In this review, we outline current knowledge on imaging characteristics of high-grade PanIN.
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Affiliation(s)
- Ryota Sagami
- Department of Gastroenterology, Oita San-ai Medical Center, 1213 Oaza Ichi, Oita, Oita 870-1151, Japan
- Pancreatic Cancer Research for Secure Salvage Young Investigators (PASSYON), Osaka-Sayama, Osaka 589-8511, Japan; (K.Y.); (J.N.); (R.M.)
- Correspondence: ; Tel.: +81-97-541-1311; Fax: +81-97-541-5218
| | - Kentaro Yamao
- Pancreatic Cancer Research for Secure Salvage Young Investigators (PASSYON), Osaka-Sayama, Osaka 589-8511, Japan; (K.Y.); (J.N.); (R.M.)
- Department of Gastroenterology and Hepatology, Kindai University, Osaka-Sayama, Osaka 589-8511, Japan
| | - Jun Nakahodo
- Pancreatic Cancer Research for Secure Salvage Young Investigators (PASSYON), Osaka-Sayama, Osaka 589-8511, Japan; (K.Y.); (J.N.); (R.M.)
- Department of Gastroenterology Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan
| | - Ryuki Minami
- Pancreatic Cancer Research for Secure Salvage Young Investigators (PASSYON), Osaka-Sayama, Osaka 589-8511, Japan; (K.Y.); (J.N.); (R.M.)
- Department of Gastroenterology, Tenri Hospital, 200 Mishimacho, Tenri, Nara 632-0015, Japan
| | - Masakatsu Tsurusaki
- Department of Diagnostic Radiology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka 589-8511, Japan;
| | - Kazunari Murakami
- Department of Gastroenterology, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasamacho, Yufu, Oita 879-5593, Japan;
| | - Yuji Amano
- Department of Endoscopy, Urawa Kyosai Hospital, 3-15-31 Harayama, Midoriku, Saitama 336-0931, Japan;
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Yadav RK, Jiang X, Chen J. Differentiating benign from malignant pancreatic cysts on computed tomography. Eur J Radiol Open 2020; 7:100278. [PMID: 33163586 PMCID: PMC7607418 DOI: 10.1016/j.ejro.2020.100278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/11/2020] [Accepted: 09/23/2020] [Indexed: 12/19/2022] Open
Abstract
CT can distinguish between benign and premalignant or malignant pancreatic cysts. Solid component and septation were the only CT features that could differentiate benign from malignant cysts. Cyst wall enhancements on CT were more commonly observed in premalignant or malignant cysts than in benign cysts. CT is a necessary diagnostic modality to preoperatively detect and characterize pancreatic lesions.
Purpose It is important to identify features on computed tomography (CT) that can distinguish between benign and premalignant or malignant pancreatic cysts to avoid unnecessary surgeries. This study investigated the preoperative diagnostic evaluation of cystic pancreatic lesions to determine how advanced imaging and clinical factors should guide management. Methods In total, 53 patients with 27 benign and 26 premalignant or malignant cysts were enrolled. CT features of the cysts were compared using univariate and multivariate analyses. Results On univariate analysis, a solid component (p < 0.01), septation (p < 0.01), location (p < 0.01), border (p < 0.01), wall enhancement (p = 0.01), lesion margins (p < 0.01), pancreatic atrophy (p = 0.04), and a cystic wall (p < 0.01) were all significantly different between benign and premalignant or malignant cysts. On multivariate analysis, only a solid component (p < 0.01) and septation (p < 0.01) were significant. Conclusion A thin cystic wall, uniform homogeneity, a clear border, the presence of septation, pancreatic atrophy, and the absence of both wall enhancements and solid components were more frequently seen in benign cysts. A thick wall, lack of homogeneity, the presence of wall enhancements and solid components, absence of septation, only a small degree of pancreatic atrophy, and unclear borders were more frequent among premalignant or malignant cysts. The only CT features to differentiate benign from premalignant or malignant cysts were a solid component and septation.
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Key Words
- CEA, Carcinoembryonic antigen
- CPR, Curved planar reformation
- CTA, CT angiography
- DWI, Diffusion-weighted imaging
- ERCP, Endoscopic retrograde cholangiopancreatography
- FDG PET, Fluorodeoxyglucose PET
- FNA, Fine-needle aspiration
- HASTE, Half-Fourier acquisition single-shot turbo spin-echo
- IPMN, Intraductal papillary mucinous neoplasia
- MCA, Mucinous cystadenoma
- MCB, Mucinous cystic borderline tumor
- MCC, Mucinous cystadenocarcinoma
- MCN, Mucinous cystic neoplasm
- MPD, Main pancreatic duct
- MPR, Multi-planar reformation
- MRA, MR angiography
- MRCP, MR cholangiopancreatography
- MRI, Magnetic resonance imaging
- MSCT, Multi-slice helical computed tomography
- PACS, Picture archiving and communicating system
- PCN, Cystic neoplasms of the pancreas
- PDAC, Pancreatic ductal adenocarcinoma
- PET, Positron emission computed tomography
- Pancreatic cystic lesions
- Pancreatic ductal adenocarcinoma
- Pancreatic neoplasm
- ROI, Region of interest
- SCA, Serous cystadenoma
- SMA, Serous microcystic adenoma
- US, Ultrasonography
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Affiliation(s)
- Rajesh Kumar Yadav
- Second Affiliated Hospital, Department of Radiology, Sun Yat-sen University, Guangzhou 510000, China
- Corresponding author: Current Address: Novus Health Wellness, 4808 Munson St NW, OH 44718 USA.
| | - Xinhua Jiang
- Department of Radiology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Jianyu Chen
- Second Affiliated Hospital, Department of Radiology, Sun Yat-sen University, Guangzhou 510000, China
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Uribarri-González L, Pérez-Cuadrado-Robles E, López-López S, Lariño-Noia J, Martínez-Moneo E, Iglesias-García J, Fernández-Urién-Sanz I, Vila-Costas J. Development of a new risk score for invasive cancer in branch-duct intraductal papillary mucinous neoplasms according to morphological characterization by EUS. Endosc Ultrasound 2020; 9:193-199. [PMID: 32584315 PMCID: PMC7430908 DOI: 10.4103/eus.eus_11_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background and Objective The management of branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) is determined by a number of guidelines. The current weight of risk factors by EUS predicting invasive cancer is unknown. The aim of this study is to develop a risk score for early prediction of invasive cancer according to morphological characterization by EUS in a surgical cohort. Materials and Methods This is an observational, multicenter retrospective study. All consecutive patients with a histologically proven BD-IPMN who underwent previous EUS between 2005 and 2017 were included. Morphological features by EUS were evaluated. A score using a logistic regression model was performed to assess the risk of invasive cancer. Results Of 335 patients who underwent pancreatic surgery, 131 (median age: 66 years, 50.4% - male) were included. By multivariable analysis, lymph nodes (odds ratio [OR]: 17.7 [confidence interval (CI) 95%: 2.8-112.6], P = 0.002, 4 points), main pancreatic duct ≥10 mm (OR: 8.6 [CI 95%: 1.9-39.5], P = 0.006, 2 points), abrupt change of pancreatic duct (OR: 5.5 [CI 95%: 1.4-22.2], P = 0.016, 1.5 points), and solid component (OR: 4.2 [CI 95%: 1.3-13.6], P = 0.017, 1 point) were independent factors associated with invasive cancer and included in the model. The following categories of the score (0-8.5 points) - A (0-1), B (1.5-3), C (3.5-5), and D (5.5-8.5 points) - presented a positive predictive value of 8.5%, 38.9%, 62.5%, and 100%, respectively. The area under the curve was 0.857 (P < 0.001), with an overall sensitivity and specificity of 84% and 70% in the internal validation of the score. Conclusion This EUS predictive score for invasive cancer in BD-IPMN has a high accuracy and could be an additional tool to consider in patient management.
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Affiliation(s)
| | - Enrique Pérez-Cuadrado-Robles
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvaine, Brussels, Belgium; Department of Gastroenterology, Georges-Pompidou European Hospital, Paris, France
| | - Soraya López-López
- Department of Gastroenterology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - José Lariño-Noia
- Department of Gastroenterology, Hospital Universitario de Santiago de Compostela, Santiago de Compostela, Santiago, Spain
| | - Emma Martínez-Moneo
- Department of Gastroenterology, Hospital Universitario de Cruces, Bilbao, Spain
| | - Julio Iglesias-García
- Department of Gastroenterology, Hospital Universitario de Santiago de Compostela, Santiago de Compostela, Santiago, Spain
| | | | - Juan Vila-Costas
- Department of Gastroenterology, Complejo Hospitalario de Navarra, Pamplona, Spain
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Abstract
Multidetector computed tomography (MDCT) is a widely used cross-sectional imaging modality for initial evaluation of patients with suspected pancreatic ductal adenocarcinoma (PDAC). However, diagnosis of PDAC can be challenging due to numerous pitfalls associated with image acquisition and interpretation, including technical factors, imaging features, and cognitive errors. Accurate diagnosis requires familiarity with these pitfalls, as these can be minimized using systematic strategies. Suboptimal acquisition protocols and other technical errors such as motion artifacts and incomplete anatomical coverage increase the risk of misdiagnosis. Interpretation of images can be challenging due to intrinsic tumor features (including small and isoenhancing masses, exophytic masses, subtle pancreatic duct irregularities, and diffuse tumor infiltration), presence of coexisting pathology (including chronic pancreatitis and intraductal papillary mucinous neoplasm), mimickers of PDAC (including focal fatty infiltration and focal pancreatitis), distracting findings, and satisfaction of search. Awareness of pitfalls associated with the diagnosis of PDAC along with the strategies to avoid them will help radiologists to minimize technical and interpretation errors. Cognizance and mitigation of these errors can lead to earlier PDAC diagnosis and ultimately improve patient prognosis.
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Kuwatani M, Kawakami H, Kubota Y, Kawakubo K, Ito YM, Togo S, Ikeda T, Kusama K, Kobayashi Y, Murata T, Sakamoto N. Verification of the effectiveness of fucosylated haptoglobin as a pancreatic cancer marker in clinical diagnosis. Pancreatology 2019; 19:569-577. [PMID: 31031206 DOI: 10.1016/j.pan.2019.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 04/16/2019] [Accepted: 04/18/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Fucosylated haptoglobin detected by Pholiota squarrosa lectin (PhoSL) that had specificity for fucose α1-6 was reported as an effective biomarker for several gastrointestinal diseases. The aim of this study was to verify Fucosylated haptoglobin detected by Pholiota squarrosa lectin (PhoSL-HP) as a pancreatic cancer (PC) marker using a new method of PhoSL-ELISA. METHODS PhoSL-HP in sera from 98 PC patients and 158 non-PC samples including 32 intraductal papillary mucinous neoplasm (IPMN) patients, 21 chronic pancreatitis (CP) patients and 105 non-pancreatic disease controls (NPDC) were measured. We compared sensitivities, specificities and areas under the curves (AUC) of PhoSL-HP, CA19-9 and CEA as single markers. We also evaluated PhoSL-HP as combination marker by comparing AUC of CA19-9 combined with PhoSL-HP or CEA. RESULTS The sensitivities of PhoSL-HP, CA19-9 and CEA for PC were 58%, 76% and 42%, respectively. Although the specificity of PhoSL-HP for NPDC was inferior to both of CA19-9 and CEA, that for pancreatic diseases was higher than both of CA19-9 and CEA. Combined CA19-9 with PhoSL-HP, the AUC was significantly higher at 0.880 than single use of CA19-9 at 0.825 in case of distinguishing PC from other pancreatic diseases. In contrast, the AUC of CA19-9 was not elevated significantly when combined with CEA. CONCLUSION PhoSL-HP would be a useful marker for PC and have sufficient complementarity for CA19-9.
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Affiliation(s)
- Masaki Kuwatani
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yoshimasa Kubota
- Department of Gastroenterology and Hepatology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Kazumichi Kawakubo
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Yoichi M Ito
- Department of Biostatistics, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Shinji Togo
- Ishikawacho Medical Clinic, Yokohama, Kanagawa, Japan
| | - Takaaki Ikeda
- Yokosuka Mutual Aid Hospital, Yokosuka, Kanagawa, Japan
| | - Ken Kusama
- J-Oil Mills, Inc., Yokohama, Kanagawa, Japan
| | | | | | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Hokkaido, Japan; Department of Gastroenterology and Hepatology, Hokkaido University Faculty of Medicine and Graduate School of Medicine, Sapporo, Hokkaido, Japan.
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11
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Current concepts in molecular genetics and management guidelines for pancreatic cystic neoplasms: an essential update for radiologists. Abdom Radiol (NY) 2018; 43:2351-2368. [PMID: 29404638 DOI: 10.1007/s00261-017-1452-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Cystic neoplasms in the pancreas are encountered frequently on imaging, often detected incidentally during evaluation for other conditions. They can have a variety of clinical and imaging presentations, and similarly, wide-ranging prognostic and treatment implications. In the majority, imaging helps in diagnosis of pancreatic cystic neoplasms (PCNs) and guides management decisions. But, a significant minority of the PCNs remain indeterminate. There have been multiple recent advances in biomarkers and molecular genetics which will likely prove helpful in risk stratification of PCNs. Several prominent national and international societies, as well as consensus groups have put forth recommendations to help guide management of PCNs. The purpose of this article is to discuss the role of imaging in evaluation of PCNs, review the recent advances in molecular genetics and pancreatic cyst fluid analysis, and analyze the pros and cons of major evidence-based and consensus guidelines for management of PCNs.
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Chen M, Zhang H, Hu Y, Liu K, Deng Y, Yu Y, Wu Y, Qi A, Li Y, Wen G. Adult pancreatoblastoma: A case report and clinicopathological review of the literature. Clin Imaging 2018; 50:324-329. [PMID: 29753278 DOI: 10.1016/j.clinimag.2018.05.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/27/2018] [Accepted: 05/01/2018] [Indexed: 02/06/2023]
Abstract
PURPOSE Our purpose was to report a case of adult pancreatoblastoma, and review the literature in order to assist clinicians in the management of the disease. MATERIALS AND METHODS The demographic, clinical, and imaging findings of 41 patients with pathologically proven pancreatoblastoma from 1986 to 2017 identified in PubMed were reviewed. The key words used for searching PubMed were: "pancreatoblastoma", "pancreatic tumor", and "adult pancreatoblastoma." We also reported the details of a case of adult pancreatoblastoma treated at our institution. RESULTS We identified 41 cases of adult pancreatoblastomas, and the mean age at diagnosis was 41.4 ± 17.4 years. Pancreatoblastomas occurred in the pancreatic head in 48.4% of patients, and in 39.0% of cases the tumor was >8 cm in diameter at diagnosis. Patient age and tumor size were similar between males and females (P = 0.59; P = 0.32, respectively). Metastases was present in 17 of the 41 adult patients (41.5%). No significant difference in age, sex, tumor size, and tumor location was found between patients with and without metastases (P = 0.57, 0.58, 0.64, 0.39, respectively). CONCLUSION Preoperative diagnosis of adult pancreatoblastoma is difficult because of the heterogeneous, variable cellular differentiation and atypical clinical and imaging features. A pancreatoblastoma should be considered when tumors in the pancreas are solid and cystic.
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Affiliation(s)
- Menglin Chen
- Medical Imaging Teaching and Research Office, Southern Medical University, Guangzhou 510515, Guangdong, China
| | - Haijie Zhang
- Medical Imaging Teaching and Research Office, Southern Medical University, Guangzhou 510515, Guangdong, China
| | - Yixin Hu
- Medical Imaging Teaching and Research Office, Southern Medical University, Guangzhou 510515, Guangdong, China
| | - Kai Liu
- Medical Imaging Teaching and Research Office, Southern Medical University, Guangzhou 510515, Guangdong, China
| | - Yanjia Deng
- Medical Imaging Teaching and Research Office, Southern Medical University, Guangzhou 510515, Guangdong, China
| | - Yuanmeng Yu
- Department of Medical Imaging, Jinling Hospital, Nanjing University Medical School, Nanjing 210002, Jiangsu, China
| | - Yulan Wu
- Medical Imaging Teaching and Research Office, Southern Medical University, Guangzhou 510515, Guangdong, China
| | - Anqi Qi
- Medical Imaging Teaching and Research Office, Southern Medical University, Guangzhou 510515, Guangdong, China
| | - Yingjia Li
- Department of Ultrasound, Nanfang Hospital, Southern Medical University, Guangzhou 510515, Guangdong, China.
| | - Ge Wen
- Medical Imaging Teaching and Research Office, Southern Medical University, Guangzhou 510515, Guangdong, China.
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Hoshi H, Zaheer A, El Abiad RG, Maxwell JE, Chu LC, Gerke H, Chan CH. Management of pancreatic intraductal papillary mucinous neoplasm. Curr Probl Surg 2018; 55:126-152. [DOI: 10.1067/j.cpsurg.2018.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/11/2018] [Indexed: 12/16/2022]
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Hoffman DH, Ream JM, Hajdu CH, Rosenkrantz AB. Utility of whole-lesion ADC histogram metrics for assessing the malignant potential of pancreatic intraductal papillary mucinous neoplasms (IPMNs). Abdom Radiol (NY) 2017; 42:1222-1228. [PMID: 27900458 DOI: 10.1007/s00261-016-1001-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To evaluate whole-lesion ADC histogram metrics for assessing the malignant potential of pancreatic intraductal papillary mucinous neoplasms (IPMNs), including in comparison with conventional MRI features. METHODS Eighteen branch-duct IPMNs underwent MRI with DWI prior to resection (n = 16) or FNA (n = 2). A blinded radiologist placed 3D volumes-of-interest on the entire IPMN on the ADC map, from which whole-lesion histogram metrics were generated. The reader also assessed IPMN size, mural nodularity, and adjacent main-duct dilation. Benign (low-to-intermediate grade dysplasia; n = 10) and malignant (high-grade dysplasia or invasive adenocarcinoma; n = 8) IPMNs were compared. RESULTS Whole-lesion ADC histogram metrics demonstrating significant differences between benign and malignant IPMNs were: entropy (5.1 ± 0.2 vs. 5.4 ± 0.2; p = 0.01, AUC = 86%); mean of the bottom 10th percentile (2.2 ± 0.4 vs. 1.6 ± 0.7; p = 0.03; AUC = 81%); and mean of the 10-25th percentile (2.8 ± 0.4 vs. 2.3 ± 0.6; p = 0.04; AUC = 79%). The overall mean ADC, skewness, and kurtosis were not significantly different between groups (p ≥ 0.06; AUC = 50-78%). For entropy (highest performing histogram metric), an optimal threshold of >5.3 achieved a sensitivity of 100%, a specificity of 70%, and an accuracy of 83% for predicting malignancy. No significant difference (p = 0.18-0.64) was observed between benign and malignant IPMNs for cyst size ≥3 cm, adjacent main-duct dilatation, or mural nodule. At multivariable analysis of entropy in combination with all other ADC histogram and conventional MRI features, entropy was the only significant independent predictor of malignancy (p = 0.004). CONCLUSION Although requiring larger studies, ADC entropy obtained from 3D whole-lesion histogram analysis may serve as a biomarker for identifying the malignant potential of IPMNs, independent of conventional MRI features.
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Choi SH, Kim HJ, Kim KW, An S, Hong SM, Kim SC, Kim MH. DPC4 gene expression in primary pancreatic ductal adenocarcinoma: relationship with CT characteristics. Br J Radiol 2017; 90:20160403. [PMID: 28339284 DOI: 10.1259/bjr.20160403] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To investigate the relationship between CT imaging findings and DPC4 gene expression and to determine the prognostic value of DPC4 gene expression to predict overall survival in patients with pancreatic ductal adenocarcinoma. METHODS Between January and December 2011, we retrospectively analyzed 163 pancreatic ductal adenocarcinomas in 163 patients who had undergone surgical resection (mean age = 61.8 years; range = 35-81 years). We divided the study patients into two groups according to DPC4 gene expression: DPC4-expression or DPC4-non-expression group. The CT findings were analyzed by two reviewers. The associations between the CT imaging findings and DPC4 gene expression were evaluated using univariate analysis and multivariate logistic regression analysis. Overall survival was compared according to the DPC4 gene expression (DPC4-expression vs DPC4-non-expression) using Kaplan-Meier analysis and log-rank testing. To avoid bias, subgroup analyses of CT findings in T3 tumour and overall survival in patients with T3 tumour and R0 resection were performed. RESULTS Between DPC4-expression group (n = 75) and DPC4-non-expression group (n = 88), three CT findings (i.e., tumour margin, peripancreatic infiltration, and the presence of background intraductal pancreatic mucinous neoplasm) were significantly different in univariate analysis. Of these, a well-defined tumour margin was significantly associated with DPC4-expression tumour (adjusted odds ratio = 2.06; p = 0.032) in multivariate analysis. Of the total 163 patients, the mean overall survival of the DPC4-expression group was significantly longer than that of the DPC4-non-expression group (30.0 vs 22.0 months; p = 0.049). Of the 150 T3 tumours, the presence of well-defined tumour margins was also a significant CT finding (adjusted odd ratio = 2.00; p = 0.044) in multivariate analysis. However, of 131 patients with T3 tumour and R0 resection, the overall survival period of the DPC4-expression group was not significantly different from that of the DPC4-non-expression group (24.0 vs 22.0 months; p = 0.240). CONCLUSION The presence of well-defined tumour margins on CT was significantly linked with DPC4-expression tumour. Advances in knowledge: A well-defined tumour margin is an independent CT finding associated with DPC4-expression pancreatic ductal adenocarcinoma.
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Affiliation(s)
- Sang Hyun Choi
- 1 Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hyoung Jung Kim
- 1 Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Kyung Won Kim
- 1 Department of Radiology and the Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Soyeon An
- 2 Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Seung-Mo Hong
- 2 Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Song Cheol Kim
- 3 Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Myung-Hwan Kim
- 4 Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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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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Nougaret S, Mannelli L, Pierredon MA, Schembri V, Guiu B. Cystic pancreatic lesions: From increased diagnosis rate to new dilemmas. Diagn Interv Imaging 2016; 97:1275-1285. [PMID: 27840080 DOI: 10.1016/j.diii.2016.08.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 08/24/2016] [Indexed: 12/18/2022]
Abstract
Cystic pancreatic lesions vary from benign to malignant entities and are increasingly detected on cross-sectional imaging. Knowledge of the imaging appearances of cystic pancreatic lesions may help radiologists in their diagnostic reporting and management. In this review, we discuss the morphologic classification of these lesions based on a diagnostic algorithm as well as the management of these lesions.
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Affiliation(s)
- S Nougaret
- Department of Radiology, institut régional du cancer de Montpellier (IRCM), institut de recherche en cancérologie de Montpellier, Inserm, U1194, 371, avenue du Doyen-G.-Giraud, 34295 Montpellier, France.
| | - L Mannelli
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 10075 New York, NY, USA
| | - M-A Pierredon
- Department of Radiology, hôpital Saint-Éloi, CHU de Monptellier, 34000 Montpellier, France
| | - V Schembri
- Department of Radiology, hôpital Saint-Éloi, CHU de Monptellier, 34000 Montpellier, France
| | - B Guiu
- Department of Radiology, hôpital Saint-Éloi, CHU de Monptellier, 34000 Montpellier, France
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Abstract
In this article, we aimed to review the literature on the clinics and management of intraductal papillary mucinous neoplasm (IPMN). Intraductal papillary mucinous neoplasm of the pancreas is a mucin-producing cystic mass originating from the pancreatic ductal system. Approximately 25% of the pancreatic neoplasms resected surgically and 50% of pancreatic cysts detected incidentally are IPMNs. They can be benign or malignant in character, while malignant transformation of benign forms can be encountered. It is important to determine IPMNs in the early stages, implementation of appropriate treatment approaches, and follow-up to provide better prognosis. We reviewed the studies published in the English medical literature through PubMed and summarized the clinical features and current approaches to the treatment and follow-up of the IPMN. Due to the recent advances and widespread implementation of radiological imaging techniques, the incidental detection rate of IPMNs has increased significantly. The effective treatment of the disease is possible via the detailed diagnosis of the disease, determination of the prognostic factors, and a multidisciplinary approach. Recent literature also emphasized the molecular profile determination approaches for assessment of prognosis of patients with IPMN. Current knowledge on IPMN, a clinically important epidemiologic problem, shows that the treatment should be personalized considering the prognostic features and life expectancy of the patient.
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Seo N, Byun JH. Evaluation of malignant intraductal papillary mucinous neoplasms of the pancreas on computed tomography and magnetic resonance imaging. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Nieun Seo
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Ho Byun
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Adsay V, Mino-Kenudson M, Furukawa T, Basturk O, Zamboni G, Marchegiani G, Bassi C, Salvia R, Malleo G, Paiella S, Wolfgang CL, Matthaei H, Offerhaus GJ, Adham M, Bruno MJ, Reid M, Krasinskas A, Klöppel G, Ohike N, Tajiri T, Jang KT, Roa JC, Allen P, Castillo CFD, Jang JY, Klimstra DS, Hruban RH. Pathologic Evaluation and Reporting of Intraductal Papillary Mucinous Neoplasms of the Pancreas and Other Tumoral Intraepithelial Neoplasms of Pancreatobiliary Tract: Recommendations of Verona Consensus Meeting. Ann Surg 2016; 263:162-77. [PMID: 25775066 PMCID: PMC4568174 DOI: 10.1097/sla.0000000000001173] [Citation(s) in RCA: 167] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND There are no established guidelines for pathologic diagnosis/reporting of intraductal papillary mucinous neoplasms (IPMNs). DESIGN An international multidisciplinary group, brought together by the Verona Pancreas Group in Italy-2013, was tasked to devise recommendations. RESULTS (1) Crucial to rule out invasive carcinoma with extensive (if not complete) sampling. (2) Invasive component is to be documented in a full synoptic report including its size, type, grade, and stage. (3) The term "minimally invasive" should be avoided; instead, invasion size with stage and substaging of T1 (1a, b, c; ≤ 0.5, > 0.5-≤ 1, > 1 cm) is to be documented. (4) Largest diameter of the invasion, not the distance from the nearest duct, is to be used. (5) A category of "indeterminate/(suspicious) for invasion" is acceptable for rare cases. (6) The term "malignant" IPMN should be avoided. (7) The highest grade of dysplasia in the non-invasive component is to be documented separately. (8) Lesion size is to be correlated with imaging findings in cysts with rupture. (9) The main duct diameter and, if possible, its involvement are to be documented; however, it is not required to provide main versus branch duct classification in the resected tumor. (10) Subtyping as gastric/intestinal/pancreatobiliary/oncocytic/mixed is of value. (11) Frozen section is to be performed highly selectively, with appreciation of its shortcomings. (12) These principles also apply to other similar tumoral intraepithelial neoplasms (mucinous cystic neoplasms, intra-ampullary, and intra-biliary/cholecystic). CONCLUSIONS These recommendations will ensure proper communication of salient tumor characteristics to the management teams, accurate comparison of data between analyses, and development of more effective management algorithms.
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Affiliation(s)
- Volkan Adsay
- Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Toru Furukawa
- Department of Pathology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Olca Basturk
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | - Claudio Bassi
- Department of Surgery, University of Verona, Verona, Italy
| | - Roberto Salvia
- Department of Surgery, University of Verona, Verona, Italy
| | | | | | - Christopher L. Wolfgang
- Department of Surgery, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Hanno Matthaei
- Department of Surgery, University of Bonn, Bonn, Germany
| | - G. Johan Offerhaus
- Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Mustapha Adham
- Department of Surgery, Edouard Herriot Hospital, HCL, Lyon, France
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Michelle Reid
- Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Alyssa Krasinskas
- Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Günter Klöppel
- Department of Pathology, Technical University, München, Germany
| | - Nobuyuki Ohike
- Department of Pathology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Takuma Tajiri
- Department of Pathology, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Kee-Taek Jang
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Juan Carlos Roa
- Department of Pathology, Pontificia Universidad Católica de Chile, Chile
| | - Peter Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - David S. Klimstra
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Ralph H. Hruban
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, USA
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Basturk O, Hong SM, Wood LD, Adsay NV, Albores-Saavedra J, Biankin AV, Brosens LA, Fukushima N, Goggins M, Hruban RH, Kato Y, Klimstra DS, Klöppel G, Krasinskas A, Longnecker DS, Matthaei H, Offerhaus GJA, Shimizu M, Takaori K, Terris B, Yachida S, Esposito I, Furukawa T. A Revised Classification System and Recommendations From the Baltimore Consensus Meeting for Neoplastic Precursor Lesions in the Pancreas. Am J Surg Pathol 2015; 39:1730-41. [PMID: 26559377 PMCID: PMC4646710 DOI: 10.1097/pas.0000000000000533] [Citation(s) in RCA: 505] [Impact Index Per Article: 56.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
International experts met to discuss recent advances and to revise the 2004 recommendations for assessing and reporting precursor lesions to invasive carcinomas of the pancreas, including pancreatic intraepithelial neoplasia (PanIN), intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm, and other lesions. Consensus recommendations include the following: (1) To improve concordance and to align with practical consequences, a 2-tiered system (low vs. high grade) is proposed for all precursor lesions, with the provision that the current PanIN-2 and neoplasms with intermediate-grade dysplasia now be categorized as low grade. Thus, "high-grade dysplasia" is to be reserved for only the uppermost end of the spectrum ("carcinoma in situ"-type lesions). (2) Current data indicate that PanIN of any grade at a margin of a resected pancreas with invasive carcinoma does not have prognostic implications; the clinical significance of dysplasia at a margin in a resected pancreas with IPMN lacking invasive carcinoma remains to be determined. (3) Intraductal lesions 0.5 to 1 cm can be either large PanINs or small IPMNs. The term "incipient IPMN" should be reserved for lesions in this size with intestinal or oncocytic papillae or GNAS mutations. (4) Measurement of the distance between an IPMN and invasive carcinoma and sampling of intervening tissue are recommended to assess concomitant versus associated status. Conceptually, concomitant invasive carcinoma (in contrast with the "associated" group) ought to be genetically distinct from an IPMN elsewhere in the gland. (5) "Intraductal spread of invasive carcinoma" (aka, "colonization") is recommended to describe lesions of invasive carcinoma invading back into and extending along the ductal system, which may morphologically mimic high-grade PanIN or even IPMN. (6) "Simple mucinous cyst" is recommended to describe cysts >1 cm having gastric-type flat mucinous lining at most minimal atypia without ovarian-type stroma to distinguish them from IPMN. (7) Human lesions resembling the acinar to ductal metaplasia and atypical flat lesions of genetically engineered mouse models exist and may reflect an alternate pathway of carcinogenesis; however, their biological significance requires further study. These revised recommendations are expected to improve our management and understanding of precursor lesions in the pancreas.
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Affiliation(s)
| | - Seung-Mo Hong
- Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Laura D. Wood
- The Sol Goldman Pancreatic Cancer Research Center, Department of Pathology, Johns Hopkins University School of Medicine, MD
| | | | | | | | | | | | - Michael Goggins
- The Sol Goldman Pancreatic Cancer Research Center, Department of Pathology, Johns Hopkins University School of Medicine, MD
| | - Ralph H. Hruban
- The Sol Goldman Pancreatic Cancer Research Center, Department of Pathology, Johns Hopkins University School of Medicine, MD
| | - Yo Kato
- Cancer Institute, Japanese Foundation for Cancer Research, Japan
| | | | | | | | | | | | | | | | | | | | | | - Irene Esposito
- Heinrich-Heine University and University Hospital of Düsseldorf, Germany
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Permuth JB, Georgeades C, Malafa M. MiRNAs as biomarkers of high-risk pancreatic cysts: a possible holy grail for the early detection of pancreatic cancer. Future Oncol 2015; 11:3105-8. [PMID: 26549701 DOI: 10.2217/fon.15.230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jennifer B Permuth
- Department of Cancer Epidemiology, H Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.,Department of Gastrointestinal Oncology, H Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | | | - Mokenge Malafa
- Department of Gastrointestinal Oncology, H Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
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23
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Kang HJ, Lee JM, Joo I, Hur BY, Jeon JH, Jang JY, Lee K, Ryu JK, Han JK, Choi BI. Assessment of Malignant Potential in Intraductal Papillary Mucinous Neoplasms of the Pancreas: Comparison between Multidetector CT and MR Imaging with MR Cholangiopancreatography. Radiology 2015; 279:128-39. [PMID: 26517448 DOI: 10.1148/radiol.2015150217] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To compare the diagnostic performance of multidetector computed tomography (CT) and magnetic resonance (MR) imaging with MR cholangiopancreatography (MRCP) in identifying the malignant potential of pancreatic intraductal papillary neoplasms (IPMNs) and evaluate their intermodality agreement. MATERIALS AND METHODS Institutional review board approval was obtained, and the requirement for informed consent was waived for this retrospective study. In 129 patients with pathologically proved pancreatic IPMNs, three reviewers independently evaluated their preoperative CT and MR imaging with MRCP findings. Intermodality agreement between multidetector CT and MR imaging with MRCP, as well as interobserver agreement of each imaging modality, for depicting high-risk stigmata and worrisome features were assessed. Diagnostic values of other signs of overt malignancy, including the presence of a parenchymal mass and local-regional extension, were analyzed. Diagnostic performance and intermodality agreement were assessed by using receiver operating characteristics (ROC) curve analysis and weighted κ statistics. RESULTS Overall, multidetector CT and MR imaging with MRCP were similar in their ability to depict signs suspicious or indicative of malignancy in patients with IPMN (area under the ROC curve [AUC] = 0.82 for both), with good intermodality agreement (κ = 0.75) and moderate interobserver agreement (κ = 0.47-0.59) when high-grade dysplasia was used as the cutoff for malignancy. When parenchymal masses and local-regional extensions were also considered as overt signs of malignancy, the ability to identify invasive IPMNs significantly increased (AUC = 0.87 for CT and AUC = 0.88 for MR imaging), with high sensitivity (94.3%), while maintaining specificity (69.1%). CONCLUSION The diagnostic performance of multidetector CT and MR imaging with MRCP for identifying the malignant potential of pancreatic IPMNs was similar and showed good intermodality agreement, suggesting that follow-up with either modality may be used.
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Affiliation(s)
- Hyo-Jin Kang
- From the Departments of Radiology (H.J.K., J.M.L., I.J., J.H.J., J.K.H.), Surgery (J.Y.J.), Pathology (K.B.L.), and Internal Medicine (J.K.R.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea; Institute of Radiation Medicine, Seoul National University College Medical Research Center, Seoul, Korea (J.M.L., I.J., J.K.H.); Department of Radiology, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.H.J., J.K.H.); Department of Radiology, National Cancer Center, Seoul, Korea (B.Y.H.); and Department of Radiology, Chung-Ang University Hospital, Seoul, Korea (B.I.C.)
| | - Jeong Min Lee
- From the Departments of Radiology (H.J.K., J.M.L., I.J., J.H.J., J.K.H.), Surgery (J.Y.J.), Pathology (K.B.L.), and Internal Medicine (J.K.R.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea; Institute of Radiation Medicine, Seoul National University College Medical Research Center, Seoul, Korea (J.M.L., I.J., J.K.H.); Department of Radiology, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.H.J., J.K.H.); Department of Radiology, National Cancer Center, Seoul, Korea (B.Y.H.); and Department of Radiology, Chung-Ang University Hospital, Seoul, Korea (B.I.C.)
| | - Ijin Joo
- From the Departments of Radiology (H.J.K., J.M.L., I.J., J.H.J., J.K.H.), Surgery (J.Y.J.), Pathology (K.B.L.), and Internal Medicine (J.K.R.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea; Institute of Radiation Medicine, Seoul National University College Medical Research Center, Seoul, Korea (J.M.L., I.J., J.K.H.); Department of Radiology, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.H.J., J.K.H.); Department of Radiology, National Cancer Center, Seoul, Korea (B.Y.H.); and Department of Radiology, Chung-Ang University Hospital, Seoul, Korea (B.I.C.)
| | - Bo Yun Hur
- From the Departments of Radiology (H.J.K., J.M.L., I.J., J.H.J., J.K.H.), Surgery (J.Y.J.), Pathology (K.B.L.), and Internal Medicine (J.K.R.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea; Institute of Radiation Medicine, Seoul National University College Medical Research Center, Seoul, Korea (J.M.L., I.J., J.K.H.); Department of Radiology, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.H.J., J.K.H.); Department of Radiology, National Cancer Center, Seoul, Korea (B.Y.H.); and Department of Radiology, Chung-Ang University Hospital, Seoul, Korea (B.I.C.)
| | - Ju Hyeon Jeon
- From the Departments of Radiology (H.J.K., J.M.L., I.J., J.H.J., J.K.H.), Surgery (J.Y.J.), Pathology (K.B.L.), and Internal Medicine (J.K.R.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea; Institute of Radiation Medicine, Seoul National University College Medical Research Center, Seoul, Korea (J.M.L., I.J., J.K.H.); Department of Radiology, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.H.J., J.K.H.); Department of Radiology, National Cancer Center, Seoul, Korea (B.Y.H.); and Department of Radiology, Chung-Ang University Hospital, Seoul, Korea (B.I.C.)
| | - Jin-Young Jang
- From the Departments of Radiology (H.J.K., J.M.L., I.J., J.H.J., J.K.H.), Surgery (J.Y.J.), Pathology (K.B.L.), and Internal Medicine (J.K.R.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea; Institute of Radiation Medicine, Seoul National University College Medical Research Center, Seoul, Korea (J.M.L., I.J., J.K.H.); Department of Radiology, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.H.J., J.K.H.); Department of Radiology, National Cancer Center, Seoul, Korea (B.Y.H.); and Department of Radiology, Chung-Ang University Hospital, Seoul, Korea (B.I.C.)
| | - Kyoungbun Lee
- From the Departments of Radiology (H.J.K., J.M.L., I.J., J.H.J., J.K.H.), Surgery (J.Y.J.), Pathology (K.B.L.), and Internal Medicine (J.K.R.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea; Institute of Radiation Medicine, Seoul National University College Medical Research Center, Seoul, Korea (J.M.L., I.J., J.K.H.); Department of Radiology, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.H.J., J.K.H.); Department of Radiology, National Cancer Center, Seoul, Korea (B.Y.H.); and Department of Radiology, Chung-Ang University Hospital, Seoul, Korea (B.I.C.)
| | - Ji Kon Ryu
- From the Departments of Radiology (H.J.K., J.M.L., I.J., J.H.J., J.K.H.), Surgery (J.Y.J.), Pathology (K.B.L.), and Internal Medicine (J.K.R.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea; Institute of Radiation Medicine, Seoul National University College Medical Research Center, Seoul, Korea (J.M.L., I.J., J.K.H.); Department of Radiology, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.H.J., J.K.H.); Department of Radiology, National Cancer Center, Seoul, Korea (B.Y.H.); and Department of Radiology, Chung-Ang University Hospital, Seoul, Korea (B.I.C.)
| | - Joon Koo Han
- From the Departments of Radiology (H.J.K., J.M.L., I.J., J.H.J., J.K.H.), Surgery (J.Y.J.), Pathology (K.B.L.), and Internal Medicine (J.K.R.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea; Institute of Radiation Medicine, Seoul National University College Medical Research Center, Seoul, Korea (J.M.L., I.J., J.K.H.); Department of Radiology, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.H.J., J.K.H.); Department of Radiology, National Cancer Center, Seoul, Korea (B.Y.H.); and Department of Radiology, Chung-Ang University Hospital, Seoul, Korea (B.I.C.)
| | - Byung Ihn Choi
- From the Departments of Radiology (H.J.K., J.M.L., I.J., J.H.J., J.K.H.), Surgery (J.Y.J.), Pathology (K.B.L.), and Internal Medicine (J.K.R.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea; Institute of Radiation Medicine, Seoul National University College Medical Research Center, Seoul, Korea (J.M.L., I.J., J.K.H.); Department of Radiology, Seoul National University College of Medicine, Seoul, Korea (J.M.L., J.H.J., J.K.H.); Department of Radiology, National Cancer Center, Seoul, Korea (B.Y.H.); and Department of Radiology, Chung-Ang University Hospital, Seoul, Korea (B.I.C.)
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Alessandrino F, Souza D, Ivanovic AM, Radulovic D, Yee EU, Mortele KJ. MDCT and MRI of the ampulla of Vater (part II): non-epithelial neoplasms, benign ampullary disorders, and pitfalls. ACTA ACUST UNITED AC 2015; 40:3292-312. [DOI: 10.1007/s00261-015-0529-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Machado NO, Al Qadhi H, Al Wahibi K. Intraductal Papillary Mucinous Neoplasm of Pancreas. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2015; 7:160-75. [PMID: 26110127 PMCID: PMC4462811 DOI: 10.4103/1947-2714.157477] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are neoplasms that are characterized by ductal dilation, intraductal papillary growth, and thick mucus secretion. This relatively recently defined pathology is evolving in terms of its etiopathogenesis, clinical features, diagnosis, management, and treatment guidelines. A PubMed database search was performed. All the relevant abstracts in English language were reviewed and the articles in which cases of IPMN could be identified were further scrutinized. Information of IPMN was derived, and duplication of information in several articles and those with areas of persisting uncertainties were excluded. The recent consensus guidelines were examined. The reported incidence of malignancy varies from 57% to 92% in the main duct-IPMN (MD-IPMN) and from 6% to 46% in the branch duct-IPMN (BD-IPMN). The features of high-risk malignant lesions that raise concern include obstructive jaundice in a patient with a cystic lesion in the pancreatic head, the findings on radiological imaging of a mass lesion of >30 mm, enhanced solid component, and the main pancreatic duct (MPD) of size ≥10 mm; while duct size 5-9 mm and cyst size <3 mm are considered as “worrisome features.” Magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS) are primary investigations in diagnosing and following up on these patients. The role of pancreatoscopy and the analysis of aspirated cystic fluid for cytology and DNA analysis is still to be established. In general, resection is recommended for most MD-IPMN, mixed variant, and symptomatic BD-IPMN. The 5-year survival of patients after surgical resection for noninvasive IPMN is reported to be at 77-100%, while for those with invasive carcinoma, it is significantly lower at 27-60%. The follow-up of these patients could vary from 6 months to 1 year and would depend on the risk stratification for invasive malignancy and the pathology of the resected specimen. The understanding of IPMN has evolved over the years. The recent guidelines have played a role in this regard.
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Affiliation(s)
| | - Hani Al Qadhi
- Department of Surgery, Sultan Qaboos University Hospital, Muscat, Oman
| | - Khalifa Al Wahibi
- Department of Surgery, Sultan Qaboos University Hospital, Muscat, Oman
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Kim SH, Lee JM, Lee ES, Baek JH, Kim JH, Han JK, Choi BI. Intraductal papillary mucinous neoplasms of the pancreas: evaluation of malignant potential and surgical resectability by using MR imaging with MR cholangiography. Radiology 2014; 274:723-33. [PMID: 25302831 DOI: 10.1148/radiol.14132960] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To evaluate the diagnostic performance of magnetic resonance (MR) imaging with MR cholangiopancreatography (MRCP) in determining the malignant potential and surgical resectability of pancreas intraductal papillary mucinous neoplasms (IPMNs). MATERIALS AND METHODS Institutional review board approval was obtained, and the requirement for informed consent was waived. Ninety-eight patients with pathologically proved pancreas IPMNs who underwent MR imaging with MRCP comprised the study population. MR images were analyzed for findings suggestive of high-risk stigmata or worrisome features, as proposed by the international consensus guidelines 2012. Interobserver agreement between two experienced observers (observers 1 and 2) and one inexperienced observer (observer 3) was assessed. Diagnostic performance of MR imaging in the evaluation of the malignant potential and surgical resectability of IPMNs was analyzed in these three observers by using receiver operating curve analysis. RESULTS MR imaging with MRCP showed sensitivity of 83% (35/42), 79% (33/42), and 90% (38/42); specificity of 80% (41/51), 51% (26/51), and 24% (12/51); and accuracy of 82% (76/93), 63% (59/93), and 54% (50/93) for observers 1, 2, and 3, respectively, in the evaluation of the malignant potential of pancreas IPMNs when at least one worrisome feature was present. Interobserver agreement in the detection of intramural nodules (κ = 0.349-0.574), enhanced solid components (κ = 0.318-0.574), and measurement of main pancreatic duct diameter (intraclass correlation coefficient = 0.9477) was fair to high. The respective sensitivity, specificity, and accuracy in determination of surgical resectability were 95% (81/85), 99% (84/85), and 88% (75/85); 69% (9/13), 69% (9/13), and 54% (7/13); and 92% (90/98), 95% (93/98), and 84% (82/98) for observers 1, 2, and 3. CONCLUSION MR imaging with MRCP is a useful modality in the evaluation of the malignant potential and resectability of IPMNs, with high sensitivity and moderate specificity in the experienced radiologists but relatively low specificity in the inexperienced radiology trainee.
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Affiliation(s)
- Seong Ho Kim
- From the Department of Radiology (S.H.K., J.M.L., J.H.B., J.H.K., J.K.H., B.I.C.) and Institute of Radiation Medicine (J.M.L., J.H.K., J.K.H., B.I.C.), Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea; and Department of Radiology, Research Institute and Hospital of National Cancer Center, Goyang, Republic of Korea (E.S.L.)
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27
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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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28
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Santa LGDL, Retortillo JAP, Miguel AC, Klein LM. Radiology of pancreatic neoplasms: An update. World J Gastrointest Oncol 2014; 6:330-343. [PMID: 25232458 PMCID: PMC4163731 DOI: 10.4251/wjgo.v6.i9.330] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 12/13/2013] [Indexed: 02/05/2023] Open
Abstract
Diagnostic imaging is an important tool to evaluate pancreatic neoplasms. We describe the imaging features of pancreatic malignancies and their benign mimics. Accurate detection and staging are essential for ensuring appropriate selection of patients who will benefit from surgery and for preventing unnecessary surgeries in patients with unresectable disease. Ultrasound, multidetector computed tomography with multiplanar reconstruction and magnetic resonance imaging can help to do a correct diagnosis. Radiologists should be aware of the wide variety of anatomic variants and pathologic conditions that may mimic pancreatic neoplasms. The knowledge of the most important characteristic key findings may facilitate the right diagnosis.
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Bai XL, Zhang Q, Masood N, Masood W, Zhang Y, Liang TB. Pancreatic cystic neoplasms: a review of preoperative diagnosis and management. J Zhejiang Univ Sci B 2013; 14:185-94. [PMID: 23463761 DOI: 10.1631/jzus.b1200283] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Pancreatic cystic neoplasms (PCNs) are a diverse group of neoplasms in the pancreas, and are more increasingly encountered with widespread abdominal screening and improved imaging techniques. The most common types of PCNs are serous cystic neoplasms (SCNs), mucinous cystic neoplasms (MCNs), and intraductal papillary mucinous neoplasms (IPMNs). Clinicians frequently feel bewildered in the differential diagnosis and subsequent management among the various types of lesions in the pancreas, which may lead to overtreatment or delayed treatment. The current review provides recent developments in the understanding of the three most common types of PCNs, the latest modalities used in preoperative diagnosis and differential diagnosis, as well as the most up to date management. Suggestions for diagnosis and differential diagnosis of SCNs, MCNs, and IPMNs are also provided for young surgeons. Better understanding of these neoplasms is essential for clinicians to make accurate diagnosis and to provide the best management for patients.
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Affiliation(s)
- Xue-li Bai
- Department of Hepatobiliary-Pancreatic Surgery, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Mortelé KJ. Cystic Pancreatic Neoplasms: Imaging Features and Management Strategy. Semin Roentgenol 2013; 48:253-63. [DOI: 10.1053/j.ro.2013.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Emuron D, Senadhi V, Teagarden S, Parasher VK. Pancreatic cysts: a systematic approach and second look. J Gastrointest Cancer 2013; 43:526-31. [PMID: 22735974 DOI: 10.1007/s12029-012-9390-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pancreatic cysts are relatively rare, but constitute an important disease entity that poses a challenge with clinical, radiological, and pathological differential diagnosis. METHODS New attention has been drawn to pancreatic cysts given their potential cure rates with resection. However, preoperative distinction between neoplastic and benign lesions needs further study for effective strategies in identification and management. The role and safety of cystic fluid analysis remains to be clarified in this context. RESULTS The presence of mural nodules is a significant indicator for malignancy; however, size as a reliable predictor remains controversial. Specific criteria are required with particular focus on the histologic subtype of pancreatic lesions. CONCLUSION We review recent developments in the understanding and management of cystic lesions of the pancreas.
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Affiliation(s)
- Dennis Emuron
- Johns Hopkins University/Sinai Hospital, Baltimore, MD, USA
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Abstract
OBJECTIVE The purpose of this review is to outline the management guidelines for the care of patients with cystic pancreatic lesions. CONCLUSION The guidelines are as follows: Annual imaging surveillance is generally sufficient for benign serous cystadenomas smaller than 4 cm and for asymptomatic lesions. Asymptomatic thin-walled unilocular cystic lesions smaller than 3 cm or side-branch intraductal papillary mucinous neoplasms should be followed up with CT or MRI at 6 and 12 months interval after detection. Cystic lesions with more complex features or with growth rates greater than 1 cm/year should be followed more closely or recommended for resection if the patient's condition allows surgery. Symptomatic cystic lesions, neoplasms with high malignant potential, and lesions larger than 3 cm should be referred for surgical evaluation. Endoscopic ultrasound with fine-needle aspiration (FNA) biopsy can be used preoperatively to assess the risk of malignancy.
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Solución del caso 43. Tumor mucinoso papilar intraductal de páncreas. RADIOLOGIA 2012; 54:473-5. [DOI: 10.1016/j.rx.2011.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 02/04/2011] [Indexed: 11/22/2022]
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Abstract
Cystic tumors of the pancreas are a subset of rare pancreatic tumors that vary from benign to malignant. Many have specific imaging findings that allow them to be differentiated from each other. This article (1) reviews the imaging features of the common cystic pancreatic lesions, including serous microcystic adenoma, mucinous cystic tumor, intraductal papillary mucinous tumor, and solid pseudopapillary tumor, and including the less common lesions such as cystic endocrine tumors, cystic metastases, cystic teratomas, and lymphangiomas; and (2) provides comprehensive algorithms on how to manage the individual lesions, with recommendations on when to reimage patients.
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MESH Headings
- Adenocarcinoma, Mucinous/diagnosis
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/surgery
- Biopsy, Fine-Needle
- Cystadenocarcinoma/diagnosis
- Cystadenocarcinoma/pathology
- Cystadenocarcinoma/surgery
- Cystadenoma/diagnosis
- Cystadenoma/pathology
- Cystadenoma/surgery
- Cystadenoma, Serous/diagnosis
- Cystadenoma, Serous/pathology
- Cystadenoma, Serous/surgery
- Diagnosis, Differential
- Female
- Humans
- Magnetic Resonance Imaging/methods
- Middle Aged
- Neoplasms, Cystic, Mucinous, and Serous/diagnosis
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/surgery
- Pancreas/diagnostic imaging
- Pancreas/pathology
- Pancreatic Neoplasms/diagnosis
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/surgery
- Tomography, X-Ray Computed/methods
- Ultrasonography
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Affiliation(s)
- Catherine E Dewhurst
- Division of Abdominal Imaging and MRI, Department of Radiology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA
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35
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Cho HW, Choi JY, Kim MJ, Park MS, Lim JS, Chung YE, Kim KW. Pancreatic tumors: emphasis on CT findings and pathologic classification. Korean J Radiol 2011; 12:731-9. [PMID: 22043156 PMCID: PMC3194778 DOI: 10.3348/kjr.2011.12.6.731] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 07/11/2011] [Indexed: 12/13/2022] Open
Abstract
Pancreatic tumors can be classified by their morphologic features on CT. The subtypes include solid tumors, mixed cystic and solid lesions, unilocular cysts, multilocular cystic lesions, and microcystic lesions. Endoscopic US and MRI can provide detailed information for classifying pancreatic lesions. Each subtype has different kinds of tumors and malignant potential, thus the classification can be useful for a better differential diagnosis and treatment planning. For this purpose, we suggest an appropriate modified classification system by using the imaging features of pancreatic tumors with an emphasis on CT findings and illustrate various findings of typical and atypical manifestations.
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Affiliation(s)
- Hee-Woo Cho
- Department of Radiology and the Research Institute of Radiological Sciences, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, Korea
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Prospective evaluation of reader performance on MDCT in characterization of cystic pancreatic lesions and prediction of cyst biologic aggressiveness. AJR Am J Roentgenol 2011; 197:W53-61. [PMID: 21700995 DOI: 10.2214/ajr.10.5866] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Our objective was to evaluate the accuracy of MDCT features of pancreatic cystic lesions in cyst characterization and in predicting cyst biologic aggressiveness. SUBJECTS AND METHODS In this prospective study, 114 patients (40 men and 74 women; age range, 23-89 years) with 130 cystic lesions (size range, 31-160 mm) in the pancreas underwent contrast-enhanced dual-phase (n = 92) and portal phase (n = 22) examinations with 16- or 64-MDCT scanners. Using defined morphologic features of cystic lesions on MDCT, two readers performed blinded evaluations for cystic characterization and predicting biologic aggressiveness (invasive lesions, carcinoma in situ, and moderate grade dysplasias) before pancreatic surgery. Receiver operating characteristic analysis was performed to assess the accuracy of MDCT using pathologic evaluation of the surgical specimen as a reference standard. RESULTS On the basis of MDCT features, the radiologic accuracy (reader 1 and reader 2) for stratifying lesions into mucinous and nonmucinous subtypes was 85% and 82% and for recognizing cysts with aggressive biology was 86% and 85%, respectively. Predictive values of MDCT were superior for lesions > 30 mm and nonmucinous lesions. Features favoring aggressive biology were main pancreatic duct dilation > 10 mm (p < 0.0001), biliary obstruction (p=0.01), mural nodule (p < 0.0001), main-duct intraductal papillary mucinous neoplasm (p < 0.0001), and advanced age (p = 0.0001). Sensitivity of detecting morphologic features was higher with the dual-phase pancreatic protocol CT. CONCLUSION Morphologic features of pancreatic cystic lesions on MDCT allow reliable characterization into mucinous and nonmucinous subtypes and enable prediction of biologic aggressiveness.
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Prasad S, Wilson J, Kalade A, Desmond P, Chen R. Endoscopic ultrasound of pancreatic cystic lesions. ANZ J Surg 2010; 80:600-4. [PMID: 20840401 DOI: 10.1111/j.1445-2197.2010.05336.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The impact of endoscopic ultrasonography (EUS) on the management of pancreatic cystic lesions remains unclear, and there are no published studies of the Australian experience in this area. The aim of this study was to review the experience of EUS for such lesions within our institution. METHODS A retrospective review was undertaken of data collected prospectively over a two-year period within the EUS database of St. Vincent's Hospital. Patients who underwent EUS for suspected pancreatic cystic lesions were identified. Data were collected on demographic variables, EUS findings, the results of EUS-guided fine-needle aspiration (FNA) and the findings on clinical and radiological follow-up. RESULTS Fifty-nine patients were identified. Two thirds were female. Most lesions were located at the pancreatic head. Median diameter was 25 mm. FNA was performed in 36 cases (61%). On cytology, six (17%) showed features of mucinous tumours and five (14%) showed adenocarcinoma. The remainder contained either non-specific benign cells or insufficient epithelial tissue. Follow-up data on 48 cases (83%), after a median duration of 15 months, revealed that 15 lesions (31%) had been resected, including six serous and six mucinous tumours. The level of carcinoembryonic antigen in FNA specimens appeared to be higher in mucinous than in serous neoplasms. Twenty-four lesions had undergone repeat radiological imaging: only three had grown in size. CONCLUSIONS EUS and FNA are useful procedures for assessing pancreatic cystic lesions. Malignant features are demonstrated in only a small minority. The majority of the remainder show no signs of progression during follow-up.
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Affiliation(s)
- Shyam Prasad
- Department of Gastroenterology, St. Vincent's Hospital (Melbourne), Fitzroy, Victoria, Australia
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Abstract
Intraductal papillary mucinous neoplasms (IPMN) are mucinous cystic tumors of the pancreas, which were first classified into a unified diagnosis by the World Health Organization in 1996. These lesions originate from the cells of the pancreatic ductal system and may grossly or microscopically involve the pancreatic ducts in a diffuse or multifocal fashion. As experience with IPMN increases, it is becoming more evident that this process presents as a spectrum of neoplasia with significant variation regarding the clinical and radiologic presentation, malignant potential, and disease-specific outcome. IPMN encompasses a spectrum of precursor lesions, from adenoma to intraductal carcinoma to invasive cancer, with molecular data supporting the premise that this dysplastic process has the potential to progress from low-grade dysplasia to invasive carcinoma. Controversy over the management of IPMN exists because of the difficulty in obtaining a preoperative histologic diagnosis, the broad spectrum of neoplasia, the lack of understanding as to the frequency and time to malignant progression. This article describes the radiologic and histopathologic classification system of IPMN; the biologic behavior of these lesions, and the diagnostic testing most commonly used, and discusses the current treatment controversies.
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Weinberg BM, Spiegel BM, Tomlinson JS, Farrell JJ. Asymptomatic pancreatic cystic neoplasms: maximizing survival and quality of life using Markov-based clinical nomograms. Gastroenterology 2010; 138:531-40. [PMID: 19818780 PMCID: PMC2949077 DOI: 10.1053/j.gastro.2009.10.001] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2008] [Revised: 09/19/2009] [Accepted: 10/01/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The natural history and management of pancreatic cysts, especially for branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), remain uncertain. We developed evidence-based nomograms to assist with clinical decision making. METHODS We used decision analysis with Markov modeling to compare competing management strategies in a patient with a pancreatic head cyst radiographically suggestive of BD-IPMN, including the following: (1) initial pancreaticoduodenectomy (PD), (2) yearly noninvasive radiographic surveillance, (3) yearly invasive surveillance with endoscopic ultrasound, and (4) "do nothing." We derived probability estimates from a systematic literature review. The primary outcomes were overall and quality-adjusted survival. We depicted the results in a series of nomograms accounting for age, comorbidities, and cyst size. RESULTS Initial PD was the dominant strategy to maximize overall survival for any cyst greater than 2 cm, regardless of age or comorbidities. In contrast, surveillance was the dominant strategy for any lesion less than 1 cm. However, when measuring quality-adjusted survival, the do-nothing approach maximized quality of life for all cysts less than 3 cm in patients younger than age 75. Once age exceeded 85 years, noninvasive surveillance dominated. Initial PD did not maximize quality of life in any age group or cyst size. CONCLUSIONS Management of pancreatic cysts can be guided using novel Markov-based clinical nomograms, and depends on age, cyst size, comorbidities, and whether patients value overall survival vs quality-adjusted survival. For patients focused on overall survival, regardless of quality of life, surgery is optimal for lesions greater than 2 cm. For patients focused on quality-adjusted survival, a 3-cm threshold is more appropriate for surgery except for the extreme elderly.
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Affiliation(s)
- Benjamin M. Weinberg
- Department of Gastroenterology, VA Greater Los Angeles Healthcare System,Division of Digestive Diseases, David Geffen School of Medicine at UCLA
| | - Brennan M.R. Spiegel
- Department of Gastroenterology, VA Greater Los Angeles Healthcare System,Division of Digestive Diseases, David Geffen School of Medicine at UCLA,Department of Health Services, UCLA School of Public Health,UCLA/VA Center for Outcomes Research and Education
| | - James S. Tomlinson
- Department of Surgery, David Geffen School of Medicine at UCLA,Department of Surgery, VA Greater Los Angeles Healthcare System
| | - James J. Farrell
- Department of Gastroenterology, VA Greater Los Angeles Healthcare System,Division of Digestive Diseases, David Geffen School of Medicine at UCLA
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Pancreatic and extrapancreatic lesions in patients with intraductal papillary mucinous neoplasms of the pancreas: a single-centre experience. Radiol Med 2010; 115:442-52. [PMID: 20082228 DOI: 10.1007/s11547-010-0502-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Accepted: 07/19/2009] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was performed to describe the possible presence of extrapancreatic neoplasms in patients with intraductal papillary mucinous neoplasm (IPMN) and to evaluate whether the extrapancreatic tumours were synchronous or metachronous to IPMNs. MATERIALS AND METHODS One hundred and forty-two patients (56 men and 86 women; mean age 69.5 years, range 37-98) with IPMN diagnosed using the Sendai criteria were enrolled. Six patients (4.2%) had type I, 103 (72.5%) type II and 33 (23.2%) type III IPMN. All patients were studied using the following imaging techniques: ultrasonography (US), multidetector computed tomography (MDCT) and magnetic resonance cholangiopancreatography (MRCP). RESULTS Pancreatic IPMN was localised in the head in 43 patients (30.3%), in the body in 13 (9.2%), in the tail in ten (7.0%), in the head-body in 17 (12.0%), in the body-tail in 15 (10.6%) diffuse throughout the gland in 44 (31.0%). The mean size of the cystic lesions was [(mean+/-standard deviation (SD)] 1.9+/-1.9 cm (range 0.5-8.0 cm). Twenty patients (14.1%) had associated pancreatic or extrapancreatic diseases. In evaluating the distribution of pancreatic or extrapancreatic diseases according to IPMN type, we found that this was not significantly different among types I, II and III (p=0.776). CONCLUSIONS The majority of pancreatic and extrapancreatic cancers occur before the diagnosis of IPMNs is made and is not related to the type of IPMN.
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Comparative performance of MDCT and MRI with MR cholangiopancreatography in characterizing small pancreatic cysts. AJR Am J Roentgenol 2009; 193:722-31. [PMID: 19696285 DOI: 10.2214/ajr.08.1253] [Citation(s) in RCA: 136] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The objective of our study was to compare MDCT with MRI-MR cholangiopancreatography (MRCP) in characterizing small pancreatic cysts (< or = 3 cm) and predicting aggressiveness. MATERIALS AND METHODS In a retrospective analysis, contrast-enhanced MDCT and MRI examinations of 30 patients with 38 pathologically confirmed small pancreatic cysts were reviewed. MDCT and MRCP studies were independently evaluated by two readers for cyst morphology, cyst characterization, and prediction of lesion aggressiveness, which included lesions with moderate-grade dysplasia, high-grade dysplasia (carcinoma in situ), and invasive carcinomas. The sensitivity of MDCT and MRI for the detection of each morphologic feature, accuracy for cyst characterization, and predictive values for aggressiveness were calculated. RESULTS Of 38 lesions, 14 were side-branch intraductal papillary mucinous neoplasms (IPMNs), 12 mixed IPMNs, six mucinous cystic neoplasms, and six nonneoplastic cysts. On histopathology, 26 lesions were nonaggressive (six nonneoplastic cysts, six benign mucinous cystic neoplasms, 14 low-grade dysplasias in IPMNs), whereas 12 lesions revealed aggressive biology (eight moderate-grade dysplasias, four high-grade dysplasias in IPMNs). The sensitivity of MRCP for the detection of morphologic features was better than that of MDCT, but the differences were not statistically significant (p = 0.25-1). Interreader agreement and MDCT-MRI agreement for morphologic features were good to perfect (kappa = 0.7-1). The accuracy of MDCT and MRI was higher in classifying cysts as mucinous or nonmucinous than in determining a specific diagnosis (71-84.2% vs 39.5-44.7%, respectively), whereas the accuracy of the two techniques in characterizing cysts into nonaggressive and aggressive categories was similar (MDCT vs MRI, 75-78% vs 78-86%, respectively; p > 0.05). CONCLUSION MRI enables more confident assessment of the morphology of small cysts than MDCT, but the accuracy of the two imaging techniques for cyst characterization is comparable. MDCT and MRI have high accuracy in classifying cysts into mucinous and nonmucinous categories and perform similarly in estimating histologic aggressiveness.
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Itou Y, Kataoka TR, Takashima S. A case of intraductal tubular adenocarcinoma of the pancreas that developed extensive intratumoral calcification. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/j.ejrex.2009.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Sahani DV, Lin DJ, Venkatesan AM, Sainani N, Mino-Kenudson M, Brugge WR, Fernandez-Del-Castillo C. Multidisciplinary approach to diagnosis and management of intraductal papillary mucinous neoplasms of the pancreas. Clin Gastroenterol Hepatol 2009; 7:259-69. [PMID: 19121413 DOI: 10.1016/j.cgh.2008.11.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Revised: 10/28/2008] [Accepted: 11/02/2008] [Indexed: 02/07/2023]
Abstract
Intraductal papillary mucinous neoplasms have gained recognition in recent years as premalignant precursors to pancreatic cancer that enable early detection and often are found incidentally at imaging. Accurate diagnosis and optimal, finely tuned management of these lesions are important and require collaboration across various disciplines, including radiology, endoscopy, surgery, and pathology. Several imaging modalities can visualize these lesions adequately, each with specific advantages and disadvantages. Multidetector computed tomography and magnetic resonance cholangiopancreatography are generally the first-line imaging modalities; endoscopic imaging such as endoscopic ultrasound and endoscopic retrograde cholangiopancreatography are beneficial when the former 2 modalities are equivocal. Surgical candidates generally include patients with main duct lesions or branch duct lesions greater than 3 cm or any possessing a solid component. A management algorithm indicating when surgery should be pursued is proposed. For nonsurgical and postsurgical patients, follow-up management is important to monitor growth and recurrence, and risks from repeated radiation exposure should be taken into account. Furthermore, issues of multifocality and increased predisposition of the pancreas to ductal adenocarcinoma must be addressed at follow-up evaluation. A follow-up management algorithm also is proposed in this review.
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Affiliation(s)
- Dushyant V Sahani
- Department of Radiology, Division of Abdominal Imaging and Intervention, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
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Abstract
Cystic lesions of the pancreas encompass a broad spectrum of benign, premalignant, and malignant tumors which are primarily cystic or result from cystic necroses of solid neoplasms. Because of the wide use of cross-sectional imaging techniques they are increasingly being identified in asymptomatic patients as well as in patients presenting with abdominal pain, jaundice or pancreatitis. Among these lesions, intraductal papillary mucinous neoplasms, serous cystic neoplasms and mucinous cystic neoplasms represent the majority of cases. With increasing experience with these tumors, a refinement of our understanding of their morphology and of their natural course has emerged. It is important to be familiar with the CT and MR imaging features of these lesions to differentiate these tumors and to orient the diagnosis towards benign or malignant forms. Because characterization of cystic tumors of the pancreas can sometimes be difficult due to overlapping imaging features, additional criteria such as clinical symptoms, localization, age and gender have to be taken into account. If appropriately treated, these tumors can usually be cured by resection and the decreasing risk of pancreatic surgery has led to an increasing number of resections of pancreatic tumors. The management of cystic tumors of the pancreas has not yet been standardized and the correct evaluation and subsequent management of the disease in asymptomatic patients have not been fully defined.
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Affiliation(s)
- H-J Brambs
- Abteilung für diagnostische und interventionelle Radiologie, Universitätsklinikum Ulm, Steinhövelstr. 9, 89075, Ulm, Deutschland.
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Pancreatic intraductal papillary mucinous neoplasms: role of CT in predicting pathologic subtypes. AJR Am J Roentgenol 2008; 191:1458-64. [PMID: 18941085 DOI: 10.2214/ajr.07.3302] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of our study was to evaluate whether CT can be used to predict the pathologic subtypes of pancreatic intraductal papillary mucinous neoplasms (IPMNs). MATERIALS AND METHODS Three radiologists, blinded to the pathologic IPMN subtype, retrospectively and independently reviewed the preoperative CT scans of 38 patients with surgically resected pancreatic IPMN: 11 intraductal papillary mucinous adenomas, 11 intraductal papillary mucinous carcinomas, and 16 intraductal papillary mucinous carcinomas with invasion. The patients, 16 women and 22 men, ranged in age from 38 to 80 years (mean age, 64.3 years). CT findings were correlated with each pathologic subtype using the chi-square (two-sided) test and analysis of variance. Interobserver agreement of the CT diagnosis of pathologic subtype and agreement between the CT diagnosis and pathologic subtype were also studied (kappa statistic). RESULTS Predominant main pancreatic duct (MPD) involvement (p = 0.04) and a wide (> 1 cm) connection of a side-branch lesion with the MPD (p = 0.03) correlated with intraductal papillary mucinous carcinoma with invasion. Tumor size, MPD diameter, number of tumors per patient, number of pseudoseptations per tumor, common bile duct dilatation, enlarged lymph nodes, intraductal calcifications, papillary bulging, and presence and size of a solid mass yielded no statistically significant relationship with pathologic subtype. Both interobserver agreement of CT diagnosis (range, 0.004-0.359) and agreement between CT diagnosis and pathologic subtype (range, 0.046-0.317) ranged from slight to fair. CONCLUSION Prediction of the pathologic subtypes of pancreatic IPMNs by CT is limited. Predominant MPD involvement and a wide connection of a side-branch lesion with the MPD are the only CT findings that can be used to predict the pathologic subtype of pancreatic IPMN.
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Nair RM, Barthel JS, Centeno BA, Choi J, Klapman JB, Malafa MP. Interdisciplinary management of an intraductal papillary mucinous neoplasm of the pancreas. Cancer Control 2008; 15:322-33. [PMID: 18813200 DOI: 10.1177/107327480801500407] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is less common than classic invasive ductal adenocarcinoma of the pancreas but is being diagnosed with greater frequency since its clinicopathologic features are now clearly defined. Often multifocal in its existence along the pancreatic duct, IPMN is associated with a significant risk for recurrence and warrants vigilant surveillance, even after a margin-negative resection. METHODS The authors present a case highlighting important features in the diagnosis, workup, and management of IPMN. They also review existing literature highlighting epidemiology, findings of molecular studies, and current treatment recommendations. RESULTS Physicians and patients must carefully weigh the risks and benefits associated with treatment options. Limited resection in a patient with a high likelihood of multifocal disease preserves pancreatic parenchyma and reduces the risk of developing pancreatic endocrine and exocrine insufficiency. Though the risk of developing invasive cancer in the remnant is small, the prognosis is worse if it does develop. Conversely, total pancreatectomy eliminates the risk of future malignancy but involves life-long insulin and exogenous pancreatic enzyme dependence and significant associated morbidity. CONCLUSIONS Decision making for effective treatment of IPMN is complex and requires attention to detail by an interdisciplinary team with experience in the diagnosis and management of these tumors. Treatment must be individualized based on patient life expectancy in terms of remaining years and overall quality. Molecular profiling of these lesions may allow for more precise tailoring of treatment in the future.
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Affiliation(s)
- Rajesh M Nair
- Gastrointestinal Tumor Program, H Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
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de Juan C, Sanchez M, Miquel R, Pages M, Ayuso JR, Ayuso C. Uncommon tumors and pseudotumoral lesions of the pancreas. Curr Probl Diagn Radiol 2008; 37:145-64. [PMID: 18502323 DOI: 10.1067/j.cpradiol.2007.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Ductal adenocarcinoma is the most common tumor of the pancreas, accounting for about 80% of all pancreatic tumors. The other 20% of pancreatic tumors is represented by a heterogeneous group of pancreatic neoplasms that includes cystic pancreatic neoplasms, islet cell tumors, and the so-called rare pancreatic tumors. In addition, the pancreatic gland may present a variety of inflammatory and pseudotumoral lesions that may mimic a primary pancreatic neoplasm. These uncommon tumors and pseudotumoral lesions present a wide spectrum of imaging findings and they are often poorly understood by the radiologist, becoming a diagnostic challenge. Some of these lesions may show an appearance similar to ductal adenocarcinoma being radiologically indistinguishable. However, some of these lesions sometimes may present specific features on imaging studies that may help to characterize the mass and to suggest a correct diagnosis. Many of these uncommon tumors and pseudotumoral lesions have a different approach, therapy, and prognosis than ductal adenocarcinoma. Therefore, it is important for the radiologist to be familiar with these entities to include them in the differential diagnosis to initiate an appropriate lesion-specific workup and treatment. In the present article, we review the radiological features of uncommon pancreatic tumors, atypical manifestations of ductal adenocarcinoma, and pseudotumoral masses, focusing on those features that can be helpful for the differential diagnosis.
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Affiliation(s)
- Carmen de Juan
- Department of Radiology, Hospital Clinic, University of Barcelona, Barcelona, Spain.
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Manfredi R, Mehrabi S, Motton M, Graziani R, Ferrari M, Salvia R, Pozzi Mucelli R. MR imaging and MR cholangiopancreatography of multifocal intraductal papillary mucinous neoplasms of the side branches: MR pattern and its evolution. Radiol Med 2008; 113:414-28. [PMID: 18493777 DOI: 10.1007/s11547-008-0260-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2007] [Accepted: 07/04/2007] [Indexed: 12/29/2022]
Abstract
PURPOSE This paper describes the magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) pattern of multifocal intraductal papillary mucinous tumours (IPMT) of the pancreatic side branches and its evolution during followup. MATERIALS AND METHODS Twenty-six patients with multifocal IPMT of the side branches were included in this retrospective study. Inclusion criteria were > or =2 ectasic side branches, presence of communication with the main pancreatic duct, and > or =2 MRI/MRCP examinations after > or = 6-12 months. Exclusion criteria were IPMT involving both the main pancreatic duct and its branch ducts, previous surgery and lack of follow-up MRI examinations. Median follow-up was 27 (range 6-59) months. Images were assessed qualitatively and quantitatively. Qualitative assessment considered: the number of cystic lesions of the branch ducts, morphology of the communication between the cystic lesion and the main duct (direct or neck), presence of intraluminal filling defects within the cystic lesions, presence of mural nodules and mural enhancement of the cystic lesion. quantitative assessment considered mean maximal diameter of the cystic lesions and mean length of the communication neck. RESULTS At diagnosis, the mean number of cystic lesions of the side branches was 7.5. a communication neck was detected in 16/26 patients (60%). Intraluminal filling defects in the side branches were present in 6/26 patients (23%). Mural nodules were seen in 1/26 patients (4%). The mean diameter of the cystic lesions was 18.8 mm. The mean length of the communication neck was 6.9 mm. At follow-up, the mean number of cystic lesions of the side branches was 8.4. A communication neck was detected in 20/26 patients (77%). Intraluminal filling defects in the side branches were detected in 7/26 patients (27%); mural nodules were seen in 2/26 patients (8%). Mural enhancement of the branch duct was detected in 2/26 patients (8%). The mean diameter of the cystic lesions increased to 22.3 mm (p < 0.05), and the mean length of the communication neck was 8.6 mm. CONCLUSIONS MultifocaL IPMT of the side branches shows a constant but very slow progression over time. In our series, only 2/26 patients showed mural nodules.
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Affiliation(s)
- R Manfredi
- Istituto di Radiologia, Università di Verona, Policlinico G.B. Rossi, Piazzale L.A. Scuro 10, Verona, Italy.
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Abstract
Intraductal papillary mucinous neoplasms (IPMNs) are a well-characterized group of intraductal mucin-producing cystic neoplasms of pancreas with clear malignant potential. It has a favorable prognosis and distinct molecular or clicinopathologic features compared with other types of pancreatic tumors. In addition, IPMNs can be divided into several subtypes in accordance with the papillary structure and mucin expression profile. Importantly, as IPMNs are acknowledged as key stages during pancreatic carcinogenesis, it can better reveal the mechanism and biological characteristics of IPMNs through further investigation of the pathologic features and the molecular aberrations harbored in different subtypes of IPMNs. This paper reviewed relevant literatures and elucidated its progression in terms of the molecular and clicinopathologic characteristics, diagnosis, treatment and prognosis of IPMNs.
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Schick V, Franzius C, Beyna T, Oei ML, Schnekenburger J, Weckesser M, Domschke W, Schober O, Heindel W, Pohle T, Juergens KU. Diagnostic impact of 18F-FDG PET-CT evaluating solid pancreatic lesions versus endosonography, endoscopic retrograde cholangio-pancreatography with intraductal ultrasonography and abdominal ultrasound. Eur J Nucl Med Mol Imaging 2008; 35:1775-85. [PMID: 18481063 DOI: 10.1007/s00259-008-0818-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2008] [Accepted: 04/22/2008] [Indexed: 12/15/2022]
Abstract
PURPOSE This prospective single-centre phase II trial assessed the diagnostic impact of (18)F-FDG PET-CT in the evaluation of solid pancreatic lesions (phi >or= 10 mm) compared to endosonography (EUS), endoscopic retrograde cholangio-pancreatography (ERCP) with intraductal ultrasound (IDUS), abdominal ultrasound (US) and histopathological reference. METHODS Forty-six patients (32 men/14 women, phi 61.7 years) with suspected pancreatic neoplasms underwent PET-CT with contrast-enhanced biphasic multi-detector CT of the upper abdomen followed by a diagnostic work-up with EUS, ERCP with IDUS and US within 3 weeks. PET-CT data sets were analysed by two expert readers in a consensus reading. Histology from surgery, biopsy/fine-needle aspiration and/or clinical follow-up >or=12 months served as standard of reference. RESULTS Twenty-seven pancreatic malignancies were histopathologically proven; 19 patients had benign diseases: 36/46 lesions (78%) were detected in the head of the pancreas, 7/46 and 3/46 in the body and tail region, respectively. Sensitivity and specificity of PET-CT were 89% and 74%, respectively; positive predictive value (PPV) and negative predictive value (NPV) were 83% and 82%, respectively. Sensitivity (81-89%), specificity (74-88%), PPV (83-90%) and NPV (77-82%) achieved by EUS, ERCP and US were not significantly different. PET analysis revealed significantly higher maximum mean standardised uptake values (SUV(max) 6.5+/-4.6) in patients with pancreatic malignancy (benign lesions: SUV(max) 4.2+/-1.5; p<0.05). PET-CT revealed cervical lymphonodal metastasis from occult bronchogenic carcinoma and a tubular colon adenoma with intermediate dysplasia on polypectomy, respectively. CONCLUSIONS (18)F-FDG PET-CT achieves a comparably high diagnostic impact evaluating small solid pancreatic lesions versus conventional reference imaging modalities. Additional clinical diagnoses are derived from concomitant whole-body PET-CT imaging.
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Affiliation(s)
- Verena Schick
- Department of Medicine B, Muenster University Hospital, Albert-Schweitzer-Strasse 33, 48149 Muenster, Germany
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