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D'Onofrio M, Geraci L, De Robertis RL, Cardobi N, Balduzzi A, Tomaiuolo L, Bardhi E, Faccioli N, Aluffi G, Marchegiani G, Salvia R. Magnetic resonance imaging short protocols for intraductal papillary mucinous neoplasm (IPMN) surveillance: The time has come. Dig Liver Dis 2024; 56:1551-1556. [PMID: 38614923 DOI: 10.1016/j.dld.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/19/2024] [Accepted: 03/06/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND/OBJECTIVES To analyze the diagnostic performance of three short magnetic resonance imaging (MRI) protocols for the follow-up of pancratic intraductal papillary mucinous neoplasms (IPMN). METHODS Follow-up MRI examinations of 287 patients with IPMN performed in two centers were retrospectively retrieved. Four MRI protocols were identified as follows: T1-weighted (T1w), T2-weighted (T2w), and MRCP sequences (protocol 1); T1w, T2w, MRCP, and diffusion-weighted (DWI) sequences (protocol 2); T1w, T2w, MRCP, and post-contrast T1w-sequences (protocol 3); and a comprehensive protocol including all previous sequences (protocol 4). Three radiologists with different experience in abdominal imaging expressed their opinion upon the optimal patient's management upon the evaluation of each protocol. Intra-and inter-observer agreement and concordance with the clinical decision expressed by a pancreatic surgeon were calculated with Cohen's kappa test. RESULTS 223 patients were included (66±10 years; 92 men, 131 women). 143 patients had branch-duct-IPMNs, 25 main-duct-IPMNs and 55 mixed-type-IPMNs. 79 patients underwent surgery, resulting in 52 high-grade dysplasia (HGD) and 27 low-grade dysplasia (LGD). Concordance for the expert reader between protocols 1, 2 and 3 and the actual clinical decision were 0.63, 0.72, and 0.74 respectively (95% CI, 0.53-0.73, 0.63-0.81, and 0.65-0.83). Inter-observer agreement between reader 1 and reader 2, reader 1 and reader 3, and reader 2 and reader 3 were: 0.71, 0.50, and 0.75 for protocol 1 (95% CI, 0.63-0.81, 0.40-0.60, and 0.66-0.84);0.68, 0.54, and 0.84 for protocol 2 (95% CI, 0.59-0.77, 0.44-0.64, and 0.76-0.91); and 0.77, 0.65, and 0.86 for protocol 3 (95% CI, 0.69-0.86, 0.55-0.74, and 0.80-0.93). CONCLUSIONS Short MRI protocol is suitable for IPMN surveillance.
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Affiliation(s)
- Mirko D'Onofrio
- Department of Radiology - G.B. Rossi University Hospital, AOUI Verona, Department of Diagnostics and Public Health, University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy.
| | - Luca Geraci
- Department of Radiology - G.B. Rossi University Hospital, AOUI Verona, Department of Diagnostics and Public Health, University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Riccardo Lombardi De Robertis
- Department of Radiology - G.B. Rossi University Hospital, AOUI Verona, Department of Diagnostics and Public Health, University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Nicolò Cardobi
- Department of Radiology, Ospedale Civile Maggiore, AOUI Verona, 37134 Verona, Italy
| | - Alberto Balduzzi
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luisa Tomaiuolo
- Department of Radiology - G.B. Rossi University Hospital, AOUI Verona, Department of Diagnostics and Public Health, University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Eda Bardhi
- Department of Radiology - G.B. Rossi University Hospital, AOUI Verona, Department of Diagnostics and Public Health, University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Niccolò Faccioli
- Department of Radiology - G.B. Rossi University Hospital, AOUI Verona, Department of Diagnostics and Public Health, University of Verona, Piazzale L.A. Scuro 10, 37134, Verona, Italy
| | - Gregorio Aluffi
- Department of Radiology, Hospital "Casa di Cura Pederzoli," Peschiera del Garda (VR), Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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de Jesus VHF, Donadio MDS, de Brito ÂBC, Gentilli AC. A narrative review on rare types of pancreatic cancer: should they be treated as pancreatic ductal adenocarcinomas? Ther Adv Med Oncol 2024; 16:17588359241265213. [PMID: 39072242 PMCID: PMC11282540 DOI: 10.1177/17588359241265213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 06/13/2024] [Indexed: 07/30/2024] Open
Abstract
Pancreatic cancer is one of the deadliest malignancies in humans and it is expected to play a bigger part in cancer burden in the years to come. Pancreatic ductal adenocarcinoma (PDAC) represents 85% of all primary pancreatic malignancies. Recently, much attention has been given to PDAC, with significant advances in the understanding of the mechanisms underpinning disease initiation and progression, along with noticeable improvements in overall survival in both localized and metastatic settings. However, given their rarity, rare histological subtypes of pancreatic cancer have been underappreciated and are frequently treated as PDAC, even though they might present non-overlapping molecular alterations and clinical behavior. While some of these rare histological subtypes are true variants of PDAC that should be treated likewise, others represent separate clinicopathological entities, warranting a different therapeutic approach. In this review, we highlight clinical, pathological, and molecular aspects of rare histological types of pancreatic cancer, along with the currently available data to guide treatment decisions.
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Affiliation(s)
- Victor Hugo Fonseca de Jesus
- Oncoclínicas, Department of Gastrointestinal Medical Oncology, Santos Dumont St. 182, 4 floor, Florianópolis, Santa Catarina 88015-020, Brazil
- Department of Medical Oncology, Centro de Pesquisas Oncológicas, Florianópolis, Santa Catarina, Brazil
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Crippa S, Marchegiani G, Belfiori G, Rancoita PVM, Pollini T, Burelli A, Apadula L, Scarale MG, Socci D, Biancotto M, Vanella G, Arcidiacono PG, Capurso G, Salvia R, Falconi M. Impact of age, comorbidities and relevant changes on surveillance strategy of intraductal papillary mucinous neoplasms: a competing risk analysis. Gut 2024; 73:1336-1342. [PMID: 38653539 DOI: 10.1136/gutjnl-2023-329961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 04/14/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Cost-effectiveness of surveillance for branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) is debated. We combined different categories of risks of IPMN progression and of IPMN-unrelated mortality to improve surveillance strategies. DESIGN Retrospective analysis of 926 presumed BD-IPMNs lacking worrisome features (WFs)/high-risk stigmata (HRS) under surveillance. Charlson Comorbidity Index (CACI) defined the severity of comorbidities. IPMN relevant changes included development of WF/HRS, pancreatectomy or death for IPMN or pancreatic cancer. Pancreatic malignancy-unrelated death was recorded. Cumulative incidence of IPMN relevant changes were estimated using the competing risk approach. RESULTS 5-year cumulative incidence of relevant changes was 17.83% and 1.6% developed pancreatic malignancy. 5-year cumulative incidences for IPMN relevant changes were 13.73%, 19.93% and 25.04% in low-risk, intermediate-risk and high-risk groups, respectively. Age ≥75 (HR: 4.15) and CACI >3 (HR: 3.61) were independent predictors of pancreatic malignancy-unrelated death. 5-year cumulative incidence for death for other causes was 15.93% for age ≥75+CACI >3 group and 1.49% for age <75+CACI ≤3. 5-year cumulative incidence of IPMN relevant changes were 13.94% in patients with age <75+CACI ≤3 compared with 29.60% in those with age ≥75+CACI >3. In this group 5-year rate of malignancy-free patients was 95.56% with a 5-year survival of 79.51%. CONCLUSION Although it is not uncommon the occurrence of changes considered by current guidelines as relevant during surveillance of low risk BD-IPMNs, malignancy rate is low and survival is significantly affected by competing patients' age and comorbidities. IPMN surveillance strategy should be tailored based on these features and modulated over time.
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Affiliation(s)
- Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Giovanni Marchegiani
- Division of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, GB Rossi Hospital, Verona, Italy
| | - Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | | | - Tommaso Pollini
- Division of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, GB Rossi Hospital, Verona, Italy
| | - Anna Burelli
- Division of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, GB Rossi Hospital, Verona, Italy
| | - Laura Apadula
- Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Maria Giovanna Scarale
- University Center of Statistics in the Biomedical Sciences, Vita Salute San Raffaele University, Milan, Italy
| | - Davide Socci
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Marco Biancotto
- Division of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, GB Rossi Hospital, Verona, Italy
| | - Giuseppe Vanella
- Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Gabriele Capurso
- Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Roberto Salvia
- Division of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, GB Rossi Hospital, Verona, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
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Tzadok R, Kessner R, Ritter E, Aizic A, Yashar H, Lazar S, Katz Y, Ronen-Amsalem Z, Chernomorets A, Shibolet O, Ben-Ami Shor D. Utility of Radiological Follow Up of Main-Duct Intraductal Papillary Mucinous Neoplasms and Mixed-Type Intraductal Papillary Mucinous Neoplasms. Biomedicines 2024; 12:1437. [PMID: 39062014 PMCID: PMC11274131 DOI: 10.3390/biomedicines12071437] [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: 06/02/2024] [Revised: 06/19/2024] [Accepted: 06/25/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMNs) have the potential to evolve into pancreatic adenocarcinoma (PDAC). While main-duct IPMNs (MD-IPMNs), involving the main pancreatic duct (MPD), are less common than side-branch IPMNs (SB-IPMNs) or mixed-type IPMNs (mixed-IPMNs), their malignant transformation potential is far greater. Controversy exists between different guidelines in terms of recommended management strategies. This study was aimed at assessing the utility of the radiological follow up of MD-IPMNs and mixed-type IPMNs, including prevalence of worrisome radiological findings as well as clinical and laboratory parameters, and their correlation with the development of progression or pancreatic adenocarcinoma. METHODS Eighty-four patients with MD-IPMNs or mixed-type IPMNs who underwent at least one magnetic resonance cholangiopancreatography (MRCP) were included. Clinical and laboratory data were obtained retrospectively. A cross-sectional analysis was carried out to establish clinical and laboratory parameters associated with development of PDAC. A retrospective cohort analysis was performed on 44 patients who had at least six months of follow up, trying to identify factors correlating with worrisome radiological features. RESULTS Nine cases (10.7%) of PDAC were recorded in this cohort. The laboratory and imaging factors associated with cyst size progression greater than 5 mm during follow up were elevated alanine transaminase (ALT) levels, the maximal cyst size, and the MPD diameter. Cross-sectional analysis indicated that PDAC was associated with nausea (p = 0.01), as well as increased levels of aspartate aminotransferase (AST) (p = 0.05), gamma glutamyl transpeptidase (GGT) (p = 0.01), and alkaline phosphatase (ALP) (p = 0.01). CONCLUSIONS Elevated levels of liver enzymes were associated with IPMN progression and, subsequently, the development of PDAC. ALT levels, maximal cyst size, and MPD diameter are associated with the progression of cyst size. These data may aid in risk-stratifying patients when determining the follow up approach for IPMNs.
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Affiliation(s)
- Roie Tzadok
- Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (R.T.); (E.R.)
| | - Rivka Kessner
- Department of Radiology, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Einat Ritter
- Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (R.T.); (E.R.)
| | - Asaf Aizic
- Department of Pathology, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Hila Yashar
- Department of Radiology, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Sapir Lazar
- Department of Radiology, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Yuval Katz
- Department of Radiology, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Zur Ronen-Amsalem
- Department of Radiology, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Arthur Chernomorets
- Department of Radiology, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Oren Shibolet
- Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (R.T.); (E.R.)
| | - Dana Ben-Ami Shor
- Department of Gastroenterology and Liver Diseases, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel; (R.T.); (E.R.)
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Beger HG. [Premalignant cystic neoplasms and neuroendocrine tumors of the pancreatic head-Is the Kausch-Whipple resection an adequate treatment?]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:461-465. [PMID: 38568302 PMCID: PMC11096214 DOI: 10.1007/s00104-024-02070-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 05/16/2024]
Abstract
Currently, the most frequently used surgical treatment for symptomatic, benign, premalignant cystic and neuroendocrine neoplasms of the pancreatic head is the Whipple procedure or pylorus-preserving pancreatoduodenectomy (PD). However, when performed for treatment of benign tumors, PD is a multiorgan resection involving loss of pancreatic and extrapancreatic tissue and functions. PD for benign neoplasm is associated with the risk of considerable early postoperative complications and an in-hospital mortality of up to 5%. Following the Whipple procedure a new onset of diabetes mellitus is observed in 14-20% and new exocrine insufficiency in 25-45%, leading to metabolic dysfunction and impairment of quality of life persisting after resection of benign tumors. Symptomatic neoplasms are indication for surgery. Patients with asymptomatic pancreatic tumors are treated according to the criteria of surveillance protocols. The goal of surgical treatment for asymptomatic patients is, according to the guideline criteria, interruption of the surveillance program before the development of an advanced stage cancer associated with the neoplasm. Tumor enucleation and duodenum-preserving pancreatic head resection, either total or partial, are parenchyma-sparing resections for benign neoplasms of the pancreatic head. The first choice for small tumors is enucleation; however, enucleation is associated with an increased risk of pancreatic fistula B + C following pancreatic main duct injury. Duodenum-preserving total or partial pancreatic head resection has the advantage of low postoperative surgery-related complications, a mortality of < 0.5% and maintenance of the endocrine and exocrine pancreatic functions. Parenchyma-sparing pancreatic head resections should replace classical Whipple procedures for neoplasms of the pancreatic head.
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Affiliation(s)
- Hans G Beger
- c/o Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland.
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Kruse DE, Paulson EK. The Incidental Pancreatic Cyst: When to Worry About Cancer. Korean J Radiol 2024; 25:559-564. [PMID: 38807337 PMCID: PMC11136942 DOI: 10.3348/kjr.2024.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/05/2024] [Accepted: 04/02/2024] [Indexed: 05/30/2024] Open
Abstract
Incidental pancreatic cystic lesions are a common challenge encountered by diagnostic radiologists. Specifically, given the prevalence of benign pancreatic cystic lesions, determining when to recommend aggressive actions such as surgical resection or endoscopic ultrasound with sampling is difficult. In this article, we review the common types of cystic pancreatic lesions including serous cystadenoma, intraductal papillary mucinous neoplasm, and mucinous cystic neoplasm with imaging examples of each. We also discuss high-risk or worrisome imaging features that warrant a referral to a surgeon or endoscopist and provid several examples of these features. These imaging features adhere to the latest guidelines from the International Consensus Guidelines, American Gastroenterological Association (2015), American College of Gastroenterology (2018), American College of Radiology (2010, 2017), and European Guidelines (2013, 2018). Our focused article addresses the imaging dilemma of managing incidental cystic pancreatic lesions, weighing the options between imaging follow-up and aggressive interventions.
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Yoon DW, Kim DK, Kim T, Lee KC. Detection Rate of Small Pancreas Cysts and Intrareader Reliability of the Cysts Size Measurements on Transabdominal Ultrasonography. Ultrasound Q 2024; 40:132-135. [PMID: 38470608 DOI: 10.1097/ruq.0000000000000657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
ABSTRACT This study aimed to assess the detection rate of small (<10 mm) pancreas cyst and intrareader reliability for cyst size measurements on transabdominal ultrasonography (US). From 2020 to 2022, 194 pancreas cysts in 173 patients, incidentally detected on computed tomography or magnetic resonance imaging, were evaluated on US by 1 of 2 radiologists (readers 1 and 2). Intrareader agreements of cyst size measurements on US were assessed by intraclass correlation coefficient (ICC). Bland-Altman plot was used to visualize the differences between the first and second size measurements in each reader. In this study, readers 1 and 2 evaluated 86 cysts in 76 patients and 108 cysts in 97 patients, respectively. Most of the cysts (191 of 194) were located in the nontail portion of the pancreas. Overall detection rate of pancreas cysts by US was 92.3% (179 of 194). The mean size of measured 179 pancreas cysts was 4.7 ± 1.5 mm. The readers showed excellent intrareader agreements (ICC = 0.925 and 0.960) for cyst size measurements, except for the cysts with size ≤5 mm, where both readers showed good intrareader agreements (ICC = 0.848 and 0.873). The 95% limits of agreement of readers 1 and 2 were 13.8% and 14.9% of the mean, respectively. Therefore, transabdominal US could be a reliable follow-up imaging modality for small (<10 mm) nontail pancreas cysts incidentally detected on computed tomography or magnetic resonance imaging, especially for the cysts with size between 5 and 10 mm. Size changes of the pancreas cysts approximately less than 15% may be within the measurement error.
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Affiliation(s)
- Do Won Yoon
- Department of Radiology, the Armed Forces Capital Hospital, Seongnam
| | - Dong Kyu Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
| | - Taeho Kim
- Department of Radiology, the Armed Forces Capital Hospital, Seongnam
| | - Kyu-Chong Lee
- Department of Radiology, the Armed Forces Capital Hospital, Seongnam
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Balaban DV, Coman LI, Balaban M, Costache RS, Jinga M. Novel Insights into Postoperative Surveillance in Resected Pancreatic Cystic Neoplasms-A Review. Diagnostics (Basel) 2024; 14:1056. [PMID: 38786354 PMCID: PMC11119521 DOI: 10.3390/diagnostics14101056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/11/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
Pancreatic cystic lesions (PCL) are frequently encountered in clinical practice and some are referred to surgery due to their neoplastic risk or malignant transformation. The management of PCL involves complex decision-making, with postoperative surveillance being a key component for long-term outcomes, due to the potential for recurrence and postoperative morbidity. Unfortunately, the follow-up of resected patients is far from being optimal and there is a lack of consensus on recommendations with regard to timing and methods of surveillance. Here, we summarize the current knowledge on the postoperative surveillance of neoplastic pancreatic cysts, focusing on the mechanisms and risk factors for recurrence, the recurrence rates according to the initial indication for surgery, the final result of the surgical specimen and neoplastic risk in the remaining pancreas, as well as the postsurgical morbidity comprising pancreatic exocrine insufficiency, metabolic dysfunction and diabetes after resection, according to the type of surgery performed. We analyze postsurgical recurrence rates and morbidity profiles, as influenced by different surgical techniques, to better delineate at-risk patients, and highlight the need for tailored surveillance strategies adapted to preoperative and operative factors with an impact on outcomes.
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Affiliation(s)
- Daniel Vasile Balaban
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Laura-Ioana Coman
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Marina Balaban
- Doctoral School, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Raluca Simona Costache
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Mariana Jinga
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
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Fogliati A, Truty MJ. ASO Author Reflections: The Role of Neoadjuvant Chemotherapy in Invasive Intraductal Mucinous Neoplasms of the Pancreas. Ann Surg Oncol 2024; 31:2967-2968. [PMID: 38485866 PMCID: PMC10997528 DOI: 10.1245/s10434-024-15002-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 04/08/2024]
Affiliation(s)
- A Fogliati
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Medicine and Surgery, University of Milano Bicocca, Milano, Italy
| | - Mark J Truty
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN, USA.
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Ohtsuka T, Fernandez-Del Castillo C, Furukawa T, Hijioka S, Jang JY, Lennon AM, Miyasaka Y, Ohno E, Salvia R, Wolfgang CL, Wood LD. International evidence-based Kyoto guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas. Pancreatology 2024; 24:255-270. [PMID: 38182527 DOI: 10.1016/j.pan.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/14/2023] [Accepted: 12/22/2023] [Indexed: 01/07/2024]
Abstract
This study group aimed to revise the 2017 international consensus guidelines for the management of intraductal papillary mucinous neoplasm (IPMN) of the pancreas, and mainly focused on five topics; the revision of high-risk stigmata (HRS) and worrisome features (WF), surveillance of non-resected IPMN, surveillance after resection of IPMN, revision of pathological aspects, and investigation of molecular markers in cyst fluid. A new development from the prior guidelines is that systematic reviews were performed for each one of these topics, and published separately to provide evidence-based recommendations. One of the highlights of these new "evidence-based guidelines" is to propose a new management algorithm, and one major revision is to include into the assessment of HRS and WF the imaging findings from endoscopic ultrasound (EUS) and the results of cytological analysis from EUS-guided fine needle aspiration technique, when this is performed. Another key element of the current guidelines is to clarify whether lifetime surveillance for small IPMNs is required, and recommends two options, "stop surveillance" or "continue surveillance for possible development of concomitant pancreatic ductal adenocarcinoma", for small unchanged BD-IPMN after 5 years surveillance. Several other points are also discussed, including identifying high-risk features for recurrence in patients who underwent resection of non-invasive IPMN with negative surgical margin, summaries of the recent observations in the pathology of IPMN. In addition, the emerging role of cyst fluid markers that can aid in distinguishing IPMN from other pancreatic cysts and identify those IPMNs that harbor high-grade dysplasia or invasive carcinoma is discussed.
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Affiliation(s)
- Takao Ohtsuka
- Department of Digestive Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.
| | | | - Toru Furukawa
- Department of Investigative Pathology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Jin-Young Jang
- Division of Hepatobiliary-Pancreatic Surgery, Departments of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Anne Marie Lennon
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Yoshihiro Miyasaka
- Department of Surgery, Fukuoka University Chikushi Hospital, and Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Fujita Health University, Toyoake, Aichi, Japan
| | - Roberto Salvia
- Department of Surgery, Dentistry, Paediatrics and Gynaecology University of Verona, Verona, Italy
| | | | - Laura D Wood
- Departments of Pathology and Oncology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Basturk O, Adsay NV. Early Cancerous Lesions of the Pancreas and Ampulla: Current Concepts and Challenges. Gastroenterol Clin North Am 2024; 53:57-84. [PMID: 38280751 PMCID: PMC10823180 DOI: 10.1016/j.gtc.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Owing to the increased use of advanced imaging techniques, mass-forming (cystic/intraductal) preinvasive neoplasms are being detected much more frequently and they have rapidly become one of the main focuses of interests in medical field. These neoplasms have very distinctive clinical and radiographic findings, exhibit a spectrum of dysplastic transformation, from low-grade dysplasia to high-grade dysplasia, and may be associated with an invasive carcinoma. Accounting for about 5% to 10% of pancreatic ductal adenocarcinomas, they provide a curable target subset in an otherwise biologically dismal pancreas cancer category.
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Affiliation(s)
- Olca Basturk
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - N Volkan Adsay
- Department of Pathology, Koc University School of Medicine, Davutpaşa Cd. No:4, Zeytinburnu, Istanbul 34010, Turkey.
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Brandi N, Renzulli M. Towards a Simplified and Cost-Effective Diagnostic Algorithm for the Surveillance of Intraductal Papillary Mucinous Neoplasms (IPMNs): Can We Save Contrast for Later? Cancers (Basel) 2024; 16:905. [PMID: 38473267 DOI: 10.3390/cancers16050905] [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: 02/08/2024] [Revised: 02/20/2024] [Accepted: 02/21/2024] [Indexed: 03/14/2024] Open
Abstract
The increased detection of pancreatic cysts in recent years has triggered extensive diagnostic investigations to clarify their potential risk of malignancy, resulting in a large number of patients undergoing numerous imaging follow-up studies for many years. Therefore, there is a growing need for optimization of the current surveillance protocol to reduce both healthcare costs and waiting lists, while still maintaining appropriate sensibility and specificity. Imaging is an essential tool for evaluating patients with intraductal papillary mucinous neoplasms (IPMNs) since it can assess several predictors for malignancy and thus guide further management recommendations. Although contrast-enhanced magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) has been widely recommended by most international guidelines, recent results support the use of unenhanced abbreviated-MRI (A-MRI) protocols as a surveillance tool in patients with IPMN. In fact, A-MRI has shown high diagnostic performance in malignant detection, with high sensitivity and specificity as well as excellent interobserver agreement. The aim of this paper is, therefore, to discuss the current available evidence on whether the implementation of an abbreviated-MRI (A-MRI) protocol for cystic pancreatic lesion surveillance could improve healthcare economics and reduce waiting lists in clinical practice without significantly reducing diagnostic accuracy.
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Affiliation(s)
- Nicolò Brandi
- Department of Radiology, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy
- Department of Radiology, AUSL Romagna, 48018 Faenza, Italy
| | - Matteo Renzulli
- Department of Radiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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13
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Yoshioka T, Shigekawa M, Ikezawa K, Hirao M, Ishii S, Suda T, Kegasawa T, Matsumoto K, Iwahashi K, Murata J, Kaneko A, Nakazuru S, Yamamoto S, Matsumae T, Kozumi K, Sato Y, Okabe J, Sato K, Hikita H, Sakamori R, Tatsumi T, Takehara T. The relationship between observation interval and prognosis in pancreatic cancer concomitant with intraductal papillary mucinous neoplasia. Pancreatology 2024; 24:73-77. [PMID: 37996267 DOI: 10.1016/j.pan.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/24/2023] [Accepted: 11/08/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasia (IPMN) is a risk factor for pancreatic cancer (PC). PC concomitant with IPMN shows rapid progression similar to de novo PC, therefore, the appropriate observation interval (OI) is not yet clear. PATIENTS AND METHOD This was a multicenter retrospective observational study, and patients with PC concomitant with IPMN were analyzed. OI was defined as the interval between the date of imaging at PC diagnosis and just before the diagnosis. Clinical factors of PC and prognosis were assessed according to OI. RESULTS From January 2010 to December 2018, 73 patients from 11 institutions were enrolled. The images performed just before PC diagnosis were contrast-enhanced CT/magnetic resonance imaging/endoscopic ultrasonography in 44/27/2 patients, respectively. The median cyst size was 14.0 mm, and the median main pancreatic duct diameter was 3.0 mm. The median OI was 6.8 months. In OI 6 months or less (OI ≤ 6 M)/OI more than 6 months (OI > 6 M), the mean tumor size, the frequencies of metastatic PC, resectable PC and early-stage PC were 20.1/21.5 mm (P = 0.91), 12.1 %/32.5 % (P = 0.05), 72.7 %/52.5 % (P = 0.09) and 27.3 %/25.0 % (P = 1.00), respectively. The median overall survival was 35.5 months in OI ≤ 6 M and 16.2 months in OI > 6 M (P = 0.05). CONCLUSION In OI 6 months or less, the rate of resectable PC was high, however, the rate of early PC was almost the same as that of OI more than 6 months. Approximately 10 % of cases found in the advanced stage with metastasis even if OI 6 months or less.
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Affiliation(s)
- Teppei Yoshioka
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Minoru Shigekawa
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kenji Ikezawa
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Motohiro Hirao
- Department of Gastroenterology and Hepatology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Shuji Ishii
- Department of Gastroenterology and Hepatology, Osaka General Medical Center, Osaka, Japan
| | - Takahiro Suda
- Department of Gastroenterology and Hepatology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Tadashi Kegasawa
- Department of Gastroenterology and Hepatology, Ikeda Municipal Hospital, Ikeda, Osaka, Japan
| | - Kengo Matsumoto
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Kiyoshi Iwahashi
- Department of Gastroenterology and Hepatology, Osaka Police Hospital, Osaka, Osaka, Japan
| | - Jun Murata
- Department of Gastroenterology, Higashiosaka City Medical Center, Higashiosaka, Osaka, Japan
| | - Akira Kaneko
- Department of Gastroenterology and Hepatology, Minoh City Hospital, Minoh, Osaka, Japan
| | - Shoichi Nakazuru
- Department of Gastroenterology and Hepatology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Shuhei Yamamoto
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takayuki Matsumae
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kazuhiro Kozumi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yu Sato
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Junya Okabe
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Katsuhiko Sato
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hayato Hikita
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Ryotaro Sakamori
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tomohide Tatsumi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
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14
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Ohno E, Balduzzi A, Hijioka S, De Pastena M, Marchegiani G, Kato H, Takenaka M, Haba S, Salvia R. Association of high-risk stigmata and worrisome features with advanced neoplasia in intraductal papillary mucinous neoplasms (IPMN): A systematic review. Pancreatology 2024; 24:48-61. [PMID: 38161091 DOI: 10.1016/j.pan.2023.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/24/2023] [Accepted: 12/03/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND This systematic review aimed to assess the diagnostic accuracy of the International Consensus Fukuoka Guidelines (ICG2017) in identifying high-risk lesions of Intraductal Papillary Mucinous Neoplasms (IPMNs). METHODS The ICG2017 revision committee conducted a comprehensive literature review to establish evidence-based statements on IPMNs. The review focused on articles examining the diagnostic value of imaging features (e.g., cyst or main pancreatic duct diameter), clinical symptoms associated with IPMN, and serum biomarkers. Five clinical questions regarding high-risk stigmata (HRS) and worrisome features (WF) in the ICG2017 guidelines were addressed. RESULTS A total of 210 articles were reviewed. The findings revealed a significant association between the presence of mural nodules ≥5 mm in diameter or solid components with contrast enhancement and the diagnosis of high-grade dysplasia or invasive carcinoma. Contrast-enhanced diagnostic tools, such as CT, MRI, or EUS, demonstrated the highest prediction rate and were recommended. Positive cytology was identified as an HRS, while symptoms like acute pancreatitis and cyst diameter growth ≥2.5 mm per year were considered WFs. The use of nomograms and multiple diagnostic factors was recommended for optimal IPMN management. CONCLUSIONS This systematic review provides evidence supporting the improved diagnostic accuracy of ICG2017 in identifying high-risk lesions of IPMN. The multidisciplinary incorporation of HRS and WF based on imaging findings and clinical symptoms is crucial. These findings should inform the revision of ICG2017, enhancing the evaluation and management of IPMN patients. By implementing these recommendations, clinicians can make more informed decisions, leading to better diagnosis and treatment outcomes for high-risk IPMN cases.
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Affiliation(s)
- Eizaburo Ohno
- Fujita Health University, Department of Gastroenterology and Hepatology, Japan; Nagoya University Hospital, Department of Gastroenterology and Hepatology, Japan
| | - Alberto Balduzzi
- The Pancreas Institute Verona, Unit of General and Pancreatic Surgery Department of Surgery, Dentistry, Paediatrics and Gynaecology University of Verona, Italy
| | - Susumu Hijioka
- National Cancer Center Hospital, Department of Hepatobiliary and Pancreatic Oncology, Japan
| | - Matteo De Pastena
- The Pancreas Institute Verona, Unit of General and Pancreatic Surgery Department of Surgery, Dentistry, Paediatrics and Gynaecology University of Verona, Italy
| | - Giovanni Marchegiani
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences (DISCOG), University of Padua, Padua, Italy
| | - Hironari Kato
- Okayama University Hospital, Department of Gastroenterology and Hepatology, Japan
| | - Mamoru Takenaka
- Kindai University, Department of Gastroenterology and Hepatology, Japan
| | - Shin Haba
- Aichi Cancer Center Hospital, Department of Gastroenterology, Japan
| | - Roberto Salvia
- The Pancreas Institute Verona, Unit of General and Pancreatic Surgery Department of Surgery, Dentistry, Paediatrics and Gynaecology University of Verona, Italy.
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15
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Ding C, Yang JF, Yang B, Lu W, Wang X, Zhou YF, Zhang XF. A pancreaticogastric fistula related to intraductal papillary mucinous neoplasm of the pancreas developed during follow-up: A case report and literature review. J Dig Dis 2024; 25:140-146. [PMID: 38433115 DOI: 10.1111/1751-2980.13255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Cong Ding
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province Hangzhou, Hangzhou, Zhejiang Province, China
| | - Jian Feng Yang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province Hangzhou, Hangzhou, Zhejiang Province, China
| | - Bin Yang
- Department of Radiology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
| | - Wen Lu
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province Hangzhou, Hangzhou, Zhejiang Province, China
| | - Xia Wang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province Hangzhou, Hangzhou, Zhejiang Province, China
| | - Yi Feng Zhou
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province Hangzhou, Hangzhou, Zhejiang Province, China
| | - Xiao Feng Zhang
- Department of Gastroenterology, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang Province, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province Hangzhou, Hangzhou, Zhejiang Province, China
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16
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Schroder PM, Biesterveld BE, Al-Adra DP. Premalignant Lesions in the Kidney Transplant Candidate. Semin Nephrol 2024; 44:151495. [PMID: 38490902 DOI: 10.1016/j.semnephrol.2024.151495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
End-stage kidney disease patients who are referred for transplant undergo an extensive evaluation process to ensure their health prior to transplant due in part to the shortage of available organs. Although management and surveillance guidelines exist for malignancies identified in the transplant and waitlist populations, less is written about the management of premalignant lesions in this population. This review covers the less common premalignant lesions (intraductal papillary mucinous neoplasm, gastrointestinal stromal tumor, thymoma, and pancreatic neuroendocrine tumor) that can be found in the transplant candidate population. High-level evidence for the management of these rarer premalignant lesions in the transplant population is lacking, and this review extrapolates evidence from the general population and should not be a substitute for a multidisciplinary discussion with medical and surgical oncologists.
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Affiliation(s)
- Paul M Schroder
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ben E Biesterveld
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - David P Al-Adra
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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17
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Davis CH, Choubey AP, Langan RC, Grandhi MS, Kennedy TJ, August DA, Alexander HR, Pitt HA. Pancreatectomy for intraductal papillary mucinous neoplasm: has anything changed in North America? HPB (Oxford) 2024; 26:109-116. [PMID: 37805363 DOI: 10.1016/j.hpb.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/02/2023] [Accepted: 09/04/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND Multiple guidelines on the management of intraductal papillary mucinous neoplasm (IPMN) have been published over the past decade. However, practice data are lacking. This study aims to determine whether pancreatectomy procedures, IPMN pathology, or outcomes have changed. METHODS ACS-NSQIP Procedure Targeted Pancreatectomy database was queried for patients with IPMN from 2014 to 2019. Cases were stratified by pathology, tumor stage/cyst size and procedure. Pancreatectomies for IPMN by year, 30-day morbidity, and clinically relevant postoperative pancreatic fistula (CR-POPF) were quantified. Mann-Kendall trend tests were performed to assess surgical trends and associated outcomes over time. RESULTS 3912 patients underwent pancreatectomy for IPMN. 21% demonstrated malignancy and 79% were benign. Morbidity and mortality occurred in 29.7% and 1.5% of cases, respectively. Over time, no change was observed in use of pancreatectomy for IPMN (10%) or in benign/malignant pathology, or cyst size. Robotic approach increased from 9.1% to 16.5% with decreases in laparoscopic (19.5%-15.0%) and open interventions (71.5%-68.1%, p = 0.016). No change was observed over time in morbidity or mortality; however, rates of CR-POPF decreased (18.8%-13.8%, p < 0.001). CONCLUSIONS Practice patterns in treatment of IPMN have not changed significantly in North America. More patients are undergoing robotic pancreatectomy, and postoperative pancreatic fistula rates are improving.
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Affiliation(s)
- Catherine H Davis
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA; Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Ankur P Choubey
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Russell C Langan
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA; Department of Surgery, Cooperman Barnabas Medical Center, Livingston, NJ, USA
| | - Miral S Grandhi
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA; Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Timothy J Kennedy
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA; Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - David A August
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA; Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - H Richard Alexander
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA; Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Henry A Pitt
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA; Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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18
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Lai T, Bull N, Goonawardena J, Bradshaw L, Fox A, Hassen S. Are the screening guidelines for branch duct intraductal papillary mucinous neoplasms cost-effective in an Australian setting? ANZ J Surg 2023; 93:2885-2891. [PMID: 37727043 DOI: 10.1111/ans.18697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUNDS Intraductal papillary mucinous neoplasms (IPMN) are cystic neoplasms of the pancreatic ductal system. These incidental cystic lesions are increasingly found on radiological imaging and screened for malignant transformation. The Fukuoka consensus guidelines recommend screening with computed tomography, magnetic resonance imaging or endoscopic ultrasound. Branch duct IPMN (BD-IPMN) have significantly lower malignancy and mortality rates compared to main duct IPMN. Our aim was to assess the cost-effectiveness of guideline's recommendations for BD-IPMN screening of cysts between 2 and 3 cm in an Australian context. METHODS Markov model decision analysis was used to calculate the incremental cost-effectiveness ratio (ICER) of screening. The ICER was compared to a willingness to pay (WTP) threshold of $50 000. We performed scenario analysis to examine the effect of cyst size and non-linearity of malignancy rate on ICER. Probabilistic sensitivity analyses (PSA) were performed on our input parameters. RESULTS Screening resulted in 586 quality adjusted life years gained and a net present value of $20 379 939, resulting in a base-case ICER of $34 758. After scenario analysis for non-linearity of malignancy rate the ICER increases to $64 555, which is above the WTP threshold. PSA indicates that ICER is most susceptible to the pre-test malignancy rate. CONCLUSION This cost analysis demonstrates that screening of 2-3 cm BD-IPMN according to current guidelines is unlikely to be cost-effective in an Australian context. To determine the true ICER, a cost analysis on real-world data is required.
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Affiliation(s)
- Timothy Lai
- Department of Upper GI and HPB Surgery, Eastern Health, Box Hill, Victoria, Australia
| | - Nicholas Bull
- Department of Upper GI and HPB Surgery, Eastern Health, Box Hill, Victoria, Australia
| | - Janindu Goonawardena
- Department of Upper GI and HPB Surgery, Eastern Health, Box Hill, Victoria, Australia
| | - Luke Bradshaw
- Department of Upper GI and HPB Surgery, Eastern Health, Box Hill, Victoria, Australia
| | - Adrian Fox
- Department of Upper GI and HPB Surgery, Eastern Health, Box Hill, Victoria, Australia
| | - Sayed Hassen
- Department of Upper GI and HPB Surgery, Eastern Health, Box Hill, Victoria, Australia
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Minelli C, Balducci F, Cavalleri C, Milanetto AC, Ferrara F, Crimì F, Quaia E, Vernuccio F. Intraductal papillary mucinous neoplasms of the pancreas: Uncommon imaging presentation, evolution and comparison of guidelines. Eur J Radiol Open 2023; 11:100531. [PMID: 37920680 PMCID: PMC10618428 DOI: 10.1016/j.ejro.2023.100531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/29/2023] [Accepted: 10/10/2023] [Indexed: 11/04/2023] Open
Abstract
Pancreatic cystic lesions are often asymptomatic, incidentally detected and include a range of entities with varying degrees of concern for malignancy. Among these, intraductal papillary mucinous neoplasms (IPMN) are considered premalignant pancreatic lesions, with a broad pathological spectrum ranging from lesions without dysplasia, which can be managed conservatively, to malignant lesions that require surgical resection. The increasing use of CT and MRI has led to increased recognition of this entity incidentally, with branch-duct IPMN representing the most common subtype and the most challenging lesions in terms of patient management. The main imaging modality involved in diagnosis and surveillance of IPMN is MRI. Radiologists play an important role in the management of patients with IPMN, including lesion detection, characterization, follow-up and prognostication, allowing early MRI identification of features that are concerning for malignancy. The main aim of this pictorial review is to illustrate MRI features of IPMN and to discuss risk stratification scores based on different guidelines, with a main focus on branch-duct IPMN. The secondary aims include the presentation of common and uncommon imaging evolution of BD-IPMN as well as the discussion on current controversies on the appropriate management of IPMN.
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Affiliation(s)
- Chiara Minelli
- Institute of Radiology, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Federico Balducci
- Institute of Radiology, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Cristina Cavalleri
- Institute of Radiology, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Anna Caterina Milanetto
- Chirurgia Generale 3, Department of Surgery, Oncology and Gastroenterology - University of Padova, 35128, Padova, Italy
| | - Francesco Ferrara
- Gastroenterology Unit - University Hospital of Padova, 35128 Padova, Italy
| | - Filippo Crimì
- Institute of Radiology, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Emilio Quaia
- Institute of Radiology, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Federica Vernuccio
- Department of Radiology, University Hospital of Padova, 35128 Padova, Italy
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20
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Ciprani D, Frampton A, Amar H, Oppong K, Pandanaboyana S, Aroori S. The role of intraoperative pancreatoscopy in the surgical management of intraductal papillary mucinous neoplasms of the pancreas: a systematic scoping review. Surg Endosc 2023; 37:9043-9051. [PMID: 37907657 DOI: 10.1007/s00464-023-10518-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/08/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND The type and the extent of surgery is still debatable for intraductal papillary mucinous neoplasm (IPMN). Intraoperative pancreatoscopy (IOP) allows the visualization of the main pancreatic duct (MPD) in its entire length and could help determine the extent of MPD involvement and the type and extent of pancreatic resection. However, current guidelines do not advise its routine use as there is a lack of evidence supporting its safety and feasibility. The present study aims to perform a scoping review of published evidence on the safety and feasibility of IOP in IPMN surgical management. METHODS We systematically searched PubMed, Cochrane, Medline and EMbase to identify studies reporting the use of IOP in IPMN surgical management. The research was completed in June 2023. Data extracted included patient selection criteria, demographics, safety of the procedure, intraoperative findings, impact on surgical strategy, histology results and postoperative outcomes. RESULTS Four retrospective and one prospective study were included in this scoping review. A total of 142 patients had IOP. The selection criteria for inclusion were heterogenous, with one out of five studies including branch duct (BD), main duct (MD) and mixed type IPMN. Indications for IOP and surgical resection were only reported in two studies. A median of seven outcomes (range 5-8) was described, including the type of surgical resection, additional lesions and change of surgical plan, and complications after IOP. IOP showed additional lesions in 48 patients (34%) and a change of surgical plan in 48(34%). No IOP-related complications were reported. CONCLUSIONS This scoping review suggests IOP is safe and identifies additional lesions impacting the surgical strategy for IPMN. However, the included studies were small and heterogeneous regarding IPMN definition and indications for surgery and IOP. There is a need for a large multi-centre prospective study to determine the role of IOP and its impact on surgical strategy for IPMN.
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Affiliation(s)
- Debora Ciprani
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Adam Frampton
- Department of HPB Surgery, Royal Surrey County NHS Foundation Trust, Guildford, UK
| | - Hoda Amar
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Kofi Oppong
- HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | | | - Somaiah Aroori
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK.
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21
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Lattimore CM, Kane WJ, Subbarao S, Venitti C, Cramer CL, Turkheimer LM, Bauer TW, Turrentine FE, Zaydfudim VM. Long-term surveillance of branch-duct intraductal papillary mucinous neoplasms without worrisome or high-risk features. J Surg Oncol 2023; 128:1087-1094. [PMID: 37530526 PMCID: PMC10592219 DOI: 10.1002/jso.27414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Long-term data evaluating clinical outcomes in patients with branch-duct Intraductal papillary mucinous neoplasms (BD-IPMN) without high-risk stigmata (HRS) or worrisome features (WF) remain limited. METHODS This observational cohort study included all patients diagnosed with BD-IPMN without HRS or WF between 2003 and 2019 who were enrolled in a prospective surveillance program. Time-to-progression analysis was performed using a cumulative incidence function plot and survival analysis was conducted using Kaplan-Meier. RESULTS The median follow-up time for the 267 patient cohort was 44.5 months (interquartile range [IQR]: 24.1-72.2). Radiographic cyst growth was observed in 123 (46.1%) patients; 65 (24.3%) patients progressed to WF/HRS. Twenty-six (9.7%) patients were selected for resection during surveillance: 21 (80.8%) WF, 4 (15.4%) HRS; 1 (3.9%) transformed to mixed-duct. Of all the patients who underwent resection, 5 (19.2%) had adenocarcinoma, and 1 (3.8%) had carcinoma-in-situ. The probability of any radiographic progression was 21.3% (5-year) and 51.3% (10-year). For the entire cohort, there was 1.1% mortality secondary to pancreatic adenocarcinoma and 8.2% all-cause mortality. The 5-year overall survival rate was 91.5%, and at 10 years, 81.5%. CONCLUSION Approximately one in four patients with nonworrisome BD-IPMN have progression to WF/HRS stigmata during surveillance. However, the risk of malignant transformation remains low. Surveillance strategy remains prudent in this patient population.
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Affiliation(s)
- Courtney M. Lattimore
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - William J. Kane
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | | | | | - Christopher L. Cramer
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - Lena M. Turkheimer
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | | | - Florence E. Turrentine
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
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22
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Omori Y, Furukawa T, Scarpa A, Luchini C. Co-occurring IPMN and pancreatic cancer: the same or different? An overview from histology to molecular pathology. J Clin Pathol 2023; 76:734-739. [PMID: 37500498 DOI: 10.1136/jcp-2023-209012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is one of the most well-established precursors of pancreatic cancer. Its progression to acquire invasiveness is a complex process, based on the accumulation of morphological and genetic alterations. Recent advances in DNA sequencing also showed that co-occurring IPMNs and pancreatic cancers could be totally independent, further complicating our understanding of this complex scenario. The distinction between IPMN and related pancreatic cancer vs IPMN and co-occurring-but not related-pancreatic cancer is a challenging task in routine diagnostic activity, but may have important implications for precision oncology. Of note, recent multiregional sequencing-based studies focused not only on IPMN multi-step tumourigenesis, but also on the divergent intratumoural heterogeneity of this neoplasm. Globally considered, there are three different situations in which co-occurring IPMNs and invasive carcinomas can be found in the same pancreata, indicated with different terminologies: (1) IPMN-associated carcinoma: this definition indicates a carcinoma arising from an IPMN and can be also defined as IPMN-derived carcinoma, sequential or likely related; (2) independent IPMN and invasive carcinoma: the two lesions are not related, and this situation is defined as concomitant, de novo or likely independent; (3) branch-off pathway, where an invasive carcinoma and an adjacent IPMN develop divergently in a forked fashion from a common ancestral clone. In this review, we aim at clarifying the most important nomenclature/definitions of these different situations, also providing an overview of the molecular state-of-the-art and of the clinical implications of this complex landscape.
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Affiliation(s)
- Yuko Omori
- Department of Investigative Patholgy, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
| | - Toru Furukawa
- Department of Investigative Patholgy, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
- ARC-Net Research Center, University and Hospital Trust, Verona, Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
- ARC-Net Research Center, University and Hospital Trust, Verona, Italy
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23
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Sacks GD, Shin P, Braithwaite RS, Soares KC, Kingham TP, D'Angelica MI, Drebin JA, Jarnagin WR, Wei AC. The Influence of Patient Preference on Surgeons' Treatment Recommendations in the Management of Intraductal Papillary Mucinous Neoplasms. Ann Surg 2023; 278:e1068-e1072. [PMID: 36804447 DOI: 10.1097/sla.0000000000005829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
OBJECTIVE We aimed to determine whether surgeon variation in management of intraductal papillary mucinous neoplasms (IPMN) is driven by differences in risk perception and quantify surgeons' risk threshold for changing their recommendations. BACKGROUND Surgeons vary widely in management of IPMN. METHODS We conducted a survey of members of the Americas HepatoPancreatoBiliary Association, presented participants with 2 detailed clinical vignettes and asked them to choose between surgical resection and surveillance. We also asked them to judge the likelihood that the IPMN harbors cancer and that the patient would have a serious complication if surgery was performed. Finally, we asked surgeons to rate the level of cancer risk at which they would change their treatment recommendation. We examined the association between surgeons' treatment recommendations and their risk perception and risk threshold. RESULTS One hundred and fifty surgeons participated in the study. Surgeons varied in their recommendations for surgery [19% for vignette 1 (V1) and 12% for V2] and in their perception of the cancer risk (interquartile range: 2%-10% for V1 and V2) and risk of surgical complications (V1 interquartile range: 10%-20%, V2 20%-30%). After adjusting for surgeon characteristics, surgeons who were above the median in cancer risk perception were 22 percentage points (27% vs. 5%) more likely to recommend resection than those who were below the median (95% CI: 11.34%; P <0.001). The median risk threshold at which surgeons would change their recommendation was 15% (V1 and V2). Surgeons who recommended surgery had a lower risk threshold for changing their recommendation than those who recommended surveillance (V1: 10.0 vs. 15.0, P =0.06; V2: 7.0 vs. 15.0, P =0.05). CONCLUSIONS The treatment that patients receive for IPMNs depends greatly on how their surgeons perceive the risk of cancer in the lesion. Efforts to improve cancer risk prediction for IPMNs may lead to decreased variations in care.
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Affiliation(s)
- Greg D Sacks
- Department of Surgery, New York University Grossman School of Medicine and NYU-Langone Health, New York, NY
- VA New York Harbor Healthcare System, New York, NY
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Paul Shin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - R Scott Braithwaite
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Kevin C Soares
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - T Peter Kingham
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Michael I D'Angelica
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Jeffrey A Drebin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - William R Jarnagin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Alice C Wei
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
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24
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Sacks GD, Shin P, Braithwaite RS, Soares KC, Kingham TP, D'Angelica MI, Drebin JA, Jarnagin WR, Wei AC. Risk Perceptions and Risk Thresholds Among Surgeons in the Management of Intraductal Papillary Mucinous Neoplasms. Ann Surg 2023; 278:e1073-e1079. [PMID: 37796751 PMCID: PMC11265933 DOI: 10.1097/sla.0000000000005827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVES We aimed to determine whether surgeon variation in management of intraductal papillary mucinous neoplasm (IPMN) is driven by differences in risk perception and quantify surgeons' risk threshold for changing their recommendations. BACKGROUND Surgeons vary widely in management of IPMN. METHODS We conducted a survey of members of the Americas HepatoPancreatoBiliary Association, presented participants with 2 detailed clinical vignettes and asked them to choose between surgical resection and surveillance. We also asked them to judge the likelihood that the IPMN harbors cancer and that the patient would have a serious complication if surgery was performed. Finally, we asked surgeons to rate the level of cancer risk at which they would change their treatment recommendation. We examined the association between surgeons' treatment recommendations and their risk perception and risk threshold. RESULTS One hundred fifty surgeons participated in the study. Surgeons varied in their recommendations for surgery [19% for vignette 1 (V1) and 12% for V2] and in their perception of the cancer risk (interquartile range: 2%-10% for V1 and V2) and risk of surgical complications (V1 interquartile range: 10%-20%, V2 20-30%). After adjusting for surgeon characteristics, surgeons who were above the median in cancer risk perception were 22 percentage points (27% vs 5%) more likely to recommend resection than those who were below the median (95% CI: 11%-4%; P <0.001). The median risk threshold at which surgeons would change their recommendation was 15% (V1 and V2). Surgeons who recommended surgery had a lower risk threshold for changing their recommendation than those who recommended surveillance (V1: 10.0 vs 15.0, P =0.06; V2: 7.0 vs 15.0, P =0.05). CONCLUSIONS The treatment that patients receive for IPMNs depends greatly on how their surgeons perceive the risk of cancer in the lesion. Efforts to improve cancer risk prediction for IPMNs may lead to decreased variations in care.
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Affiliation(s)
- Greg D Sacks
- Department of Surgery, New York University Grossman School of Medicine and NYU-Langone Health, New York, NY
- VA New York Harbor Healthcare System, New York, NY
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Paul Shin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - R Scott Braithwaite
- Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Kevin C Soares
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - T Peter Kingham
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Michael I D'Angelica
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Jeffrey A Drebin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - William R Jarnagin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
| | - Alice C Wei
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Medical College at Cornell University, New York, NY
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25
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Zhang CL, Shen Q, Liu FD, Yang F, Gao MQ, Jiang XC, Li Y, Zhang XY, En GE, Pan X, Pang B. SDC1 and ITGA2 as novel prognostic biomarkers for PDAC related to IPMN. Sci Rep 2023; 13:18727. [PMID: 37907515 PMCID: PMC10618477 DOI: 10.1038/s41598-023-44646-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 10/11/2023] [Indexed: 11/02/2023] Open
Abstract
The existing biomarkers are insufficient for predicting the prognosis of pancreatic ductal adenocarcinoma (PDAC). Intraductal papillary mucinous neoplasm (IPMN) is a precursor to PDAC; therefore, identifying biomarkers from differentially expressed genes (DEGs) of PDAC and IPMN is a new and reliable strategy for predicting the prognosis of PDAC. In this study, four datasets were downloaded from the Gene Expression Omnibus database and standardized using the R package 'limma.' A total of 51 IPMN and 81 PDAC samples were analyzed, and 341 DEGs in PDAC and IPMN were identified; DEGs were involved in the extracellular matrix and tumor microenvironment. An acceptable survival prognosis was demonstrated by SDC1 and ITGA2, which were highly expressed during in vitro PDAC cell proliferation, apoptosis, and migration. SDC1high was enriched in interferon alpha (IFN-α) response and ITGA2high was primarily detected in epithelial-mesenchymal transition (EMT), which was verified using western blotting. We concluded that SDC1 and ITGA2 are potential prognostic biomarkers for PDAC associated with IPMN. Downregulation of SDC1 and ITGA2 expression in PDAC occurs via a mechanism involving possible regulation of IFN-α response, EMT, and immunity, which may act as new targets for PDAC therapy.
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Affiliation(s)
- Chuan-Long Zhang
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Qian Shen
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Fu-Dong Liu
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Fan Yang
- Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Meng-Qi Gao
- Wangjing Hospital, China Academy of Chinese Medical Sciences, Beijing, 100102, China
| | - Xiao-Chen Jiang
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Yi Li
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China
| | - Xi-Yuan Zhang
- Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Ge-Er En
- Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Xue Pan
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, 100053, China.
- Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, 100029, China.
| | - Bo Pang
- International Medical Department of Guang'anmen Hospital China Academy of Chinese Medical Sciences, Beijing, 100053, China.
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26
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Ciers P, Vanderhaeghe D, Vansteenkiste F, Moubax K, Vanooteghem S, Vanneste A, Van Moerkercke W. Lymphoepithelial cysts of the pancreas: case report and review of the literature. Acta Chir Belg 2023; 123:550-554. [PMID: 35249466 DOI: 10.1080/00015458.2022.2050032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/02/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Lymphoepithelial cysts (LECs) of the pancreas are a rare type of true pancreatic cysts and represent an estimated 0.5% of all pancreatic cystic lesions. They are benign lesions and have no malignant potential. However, they are hard to differentiate from malignant lesions because their imaging and clinical presentation vary greatly. Seeing as these are benign lesions which are increasingly found incidentally during imaging for other indications, correct diagnosis is important to prevent unnecessary intervention and morbidity. CASE REPORT We report the case of a 41-year-old female who presented with abdominal discomfort, bloating and dyspepsia. An abdominal computed tomography (CT) showed a large mass in the left fossa. We describe the diagnostic and therapeutic measures taken in this case. METHODS We reviewed the literature for common features of the LEC. We grouped common imaging and histological features of the LEC of the pancreas to provide easily identifiable characteristics to facilitate diagnosis. For the review, we focused on papers, mostly case reports, presenting these common characteristics. We also reviewed the literature for key topics that should be taken into account when considering therapeutic interventions in a patient with a possible diagnosis of a LEC. CONCLUSION Cysts of the pancreas are increasingly identified due to widespread use and improved resolution of cross-sectional imaging. To obtain the correct diagnosis, it is sometimes necessary to combine advanced imaging, i.e. CT and MRI-imaging, and endoscopic ultrasound with fine needle aspiration (EUS/FNA), while CA 19-9 also has diagnostic value. We summarize all diagnostic characteristics in a table for ease of use. Furthermore we summarized possible therapeutic interventions.
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Affiliation(s)
- Philippe Ciers
- Department of Vascular Surgery, Klinikum Westmunsterland GmbH, Bocholt, Germany
| | | | | | - Kim Moubax
- Department of Gastroenterology, AZ Groeninge, Kortrijk, Belgium
| | - Sofie Vanooteghem
- Department of Gastroenterology, OLV van Lourdes Hospital, Waregem, Belgium
| | - Alain Vanneste
- Department of Pathological Anatomy, AZ Groeninge, Kortrijk, Belgium
| | - Wouter Van Moerkercke
- Department of Gastroenterology, AZ Groeninge, Kortrijk, Belgium
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, UZ Leuven, Leuven, Belgium
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27
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Marchegiani G, Pollini T, Burelli A, Han Y, Jung HS, Kwon W, Rocha Castellanos DM, Crippa S, Belfiori G, Arcidiacono PG, Capurso G, Apadula L, Zaccari P, Noia JL, Gorris M, Busch O, Ponweera A, Mann K, Demir IE, Phillip V, Ahmad N, Hackert T, Heckler M, Lennon AM, Afghani E, Vallicella D, Dall'Olio T, Nepi A, Vollmer CM, Friess H, Ghaneh P, Besselink M, Falconi M, Bassi C, Goh BKP, Jang JY, Fernández-Del Castillo C, Salvia R. Surveillance for Presumed BD-IPMN of the Pancreas: Stability, Size, and Age Identify Targets for Discontinuation. Gastroenterology 2023; 165:1016-1024.e5. [PMID: 37406887 PMCID: PMC10548445 DOI: 10.1053/j.gastro.2023.06.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 06/11/2023] [Accepted: 06/14/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND & AIMS Currently, most patients with branch duct intraductal papillary mucinous neoplasms (BD-IPMN) are offered indefinite surveillance, resulting in health care costs with questionable benefits regarding cancer prevention. This study sought to identify patients in whom the risk of cancer is equivalent to an age-matched population, thereby justifying discontinuation of surveillance. METHODS International multicenter study involving presumed BD-IPMN without worrisome features (WFs) or high-risk stigmata (HRS) at diagnosis who underwent surveillance. Clusters of individuals at risk for cancer development were defined according to cyst size and stability for at least 5 years, and age-matched controls were used for comparison using standardized incidence ratios (SIRs) for pancreatic cancer. RESULTS Of 3844 patients with presumed BD-IPMN, 775 (20.2%) developed WFs and 68 (1.8%) HRS after a median surveillance of 53 (interquartile range 53) months. Some 164 patients (4.3%) underwent surgery. Of the overall cohort, 1617 patients (42%) remained stable without developing WFs or HRS for at least 5 years. In patients 75 years or older, the SIR was 1.12 (95% CI, 0.23-3.39), and in patients 65 years or older with stable lesions smaller than 15 mm in diameter after 5 years, the SIR was 0.95 (95% CI, 0.11-3.42). The all-cause mortality for patients who did not develop WFs or HRS for at least 5 years was 4.9% (n = 79), and the disease-specific mortality was 0.3% (n = 5). CONCLUSIONS The risk of developing pancreatic malignancy in presumed BD-IPMN without WFs or HRS after 5 years of surveillance is comparable to that of the general population depending on cyst size and patient age. Surveillance discontinuation could be justified after 5 years of stability in patients older than 75 years with cysts <30 mm, and in patients 65 years or older who have cysts ≤15 mm.
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Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy; Hepatopancreatobiliary and Liver Transplant Surgery, Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Padua, Italy
| | - Tommaso Pollini
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Anna Burelli
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hye-Sol Jung
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | | | - Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Laura Apadula
- Pancreato-Biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Piera Zaccari
- Pancreato-Biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - José Lariño Noia
- Endoscopy and Pancreatic Unit, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Myrte Gorris
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Olivier Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Kulbir Mann
- Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar School of Medicine, Technical University Munich, Munich, Germany
| | - Veit Phillip
- Department of Gastroenterology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Nuzhat Ahmad
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Max Heckler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Anne Marie Lennon
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elham Afghani
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Davide Vallicella
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Tommaso Dall'Olio
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Angelica Nepi
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Charles M Vollmer
- Department of Surgery, Division of General Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar School of Medicine, Technical University Munich, Munich, Germany
| | - Paula Ghaneh
- University of Liverpool, Liverpool, United Kingdom
| | - Marc Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Brian Kim-Poh Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | | | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy.
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Choi M, Wang SE, Park JS, Kim HS, Choi SH, Lee JH, Chong JU, Nagakawa Y, Wada K, Nakamura Y, Sunagawa H, Dasari BVM, Peng CM, Seng LL, Wolters H, Gurbadam U, Park BUK, Winslow E, Fishbein T, Hawksworth J, Radkani P, Kang CM. Impact of adjuvant therapy in patients with invasive intraductal papillary mucinous neoplasms of the pancreas: an international multicenter cohort study. Int J Surg 2023; 109:2906-2913. [PMID: 37300881 PMCID: PMC10583921 DOI: 10.1097/js9.0000000000000537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Adjuvant therapy prolongs survival in patients with pancreatic ductal adenocarcinoma. However, no clear guidelines are available regarding the oncologic effects of adjuvant therapy (AT) in resected invasive intraductal papillary mucinous neoplasms (IPMN). The aim was to investigate the potential role of AT in patients with resected invasive IPMN. MATERIALS AND METHODS From 2001 to 2020, 332 patients with invasive pancreatic IPMN were retrospectively reviewed in 15 centres in eight countries. Propensity score-matched and stage-matched survival analyses were conducted. RESULTS A total of 289 patients were enroled in the study after exclusion (neoadjuvant therapy, unresectable disease, uncertain AT status, and stage IV). A total of 170 patients were enroled in a 1:1 propensity score-matched analysis according to the covariates. In the overall cohort, disease-free survival was significantly better in the surgery alone group than in the AT group ( P =0.003), but overall survival (OS) was not ( P =0.579). There were no significant differences in OS in the stage-matched analysis between the surgery alone and AT groups (stage I, P =0.402; stage II, P =0.179). AT did not show a survival benefit in the subgroup analysis according to nodal metastasis (N0, P =0.481; N+, P =0.705). In multivariate analysis, node metastasis (hazard ratio, 4.083; 95% CI, 2.408-6.772, P <0.001), and cancer antigen 19-9 greater than or equal to 100 (hazard ratio, 2.058; 95% CI, 1.247-3.395, P =0.005) were identified as adverse prognostic factors in resected invasive IPMN. CONCLUSION The current AT strategy may not be recommended to be performed with resected invasive IPMN in stage I and II groups, unlike pancreatic ductal adenocarcinoma. Further investigations of the potential role of AT in invasive IPMN are recommended.
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Affiliation(s)
- Munseok Choi
- Department of Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si, Korea
| | - Shin-E Wang
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | | | | | - Sung Hoon Choi
- Department of Surgery, CHA Bundang Medical Center, CHA University, Seongam-si, Korea
| | - Jin Ho Lee
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jae Uk Chong
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Keita Wada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yoshiharu Nakamura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan
| | - Hiroki Sunagawa
- Department of Gastrointestinal Surgery, Nakagami Hospital, Okinawa, Japan
| | - Bobby VM Dasari
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK
| | - Cheng-Ming Peng
- Department of General Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Lee Lip Seng
- Hepatopancreatobiliary Unit, Department of General Surgery, Changi General Hospital, Singapore
| | - Heiner Wolters
- Department of Visceral and General Surgery, St. Josefs-Hospital, Dortmund, Germany
| | - Unenbat Gurbadam
- Department of Surgery, National Cancer Center Hospital, Ulan Bator, Mongolia
| | - Byoung UK Park
- Department of Pathology, The University of California, San Francisco, CA
| | - Emily Winslow
- Department of Pathology, The University of California, San Francisco, CA
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Thomas Fishbein
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jason Hawksworth
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Pejman Radkani
- MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Ryoo DY, Koehler B, Rath J, Shah ZK, Chen W, Esnakula AK, Hart PA, Krishna SG. A Comparison of Single Dimension and Volume Measurements in the Risk Stratification of Pancreatic Cystic Lesions. J Clin Med 2023; 12:5871. [PMID: 37762812 PMCID: PMC10531933 DOI: 10.3390/jcm12185871] [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: 07/24/2023] [Revised: 08/25/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
The incidence of pancreatic cystic lesions (PCLs) has been rising due to improvements in imaging. Of these, intraductal papillary mucinous neoplasms (IPMNs) are the most common and are thought to contribute to almost 20% of pancreatic adenocarcinomas. All major society guidelines for the management of IPMNs use size defined by maximum diameter as the primary determinant of whether surveillance or surgical resection is recommended. However, there is no consensus on how these measurements should be obtained or whether a single imaging modality is superior. Furthermore, the largest diameter may fail to capture the complexity of PCLs, as most are not perfectly spherical. This article reviews current PCL measurement techniques in CT, MRI, and EUS and posits volume as a possible alternative to the largest diameter.
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Affiliation(s)
- Da Yeon Ryoo
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.Y.R.); (B.K.)
| | - Bryn Koehler
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (D.Y.R.); (B.K.)
| | - Jennifer Rath
- Department of Radiology, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (J.R.); (Z.K.S.)
| | - Zarine K. Shah
- Department of Radiology, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (J.R.); (Z.K.S.)
| | - Wei Chen
- Department of Pathology, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (W.C.); (A.K.E.)
| | - Ashwini K. Esnakula
- Department of Pathology, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; (W.C.); (A.K.E.)
| | - Phil A. Hart
- Division of Gastroenterology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA;
| | - Somashekar G. Krishna
- Division of Gastroenterology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA;
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30
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Honselmann KC, Elser Y, Boeckmann T, Bolm L, Winkel MT, Deichmann S, Braun R, Wellner UF, Keck T, Lapshyn H. Recent onset diabetes is associated with better survival in pancreatic ductal adenocarcinoma-An analysis of preoperative symptoms within the DGAV StuDoQ|Pancreas Registry. Surgery 2023; 174:674-683. [PMID: 37349251 DOI: 10.1016/j.surg.2023.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 03/21/2023] [Accepted: 04/27/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND This multicenter study analyzed the relationship between preoperative symptoms and postsurgical outcomes utilizing the German national DGAV StuDoQ|Pancreas database. METHODS This retrospective study included 2,643 pancreatic ductal adenocarcinoma patients undergoing pancreatic head resection from 2013-2017 within the German pancreatic surgery registry (DGAV StuDoQ|Pancreas). The association of preoperative symptoms with overall survival was analyzed using Kaplan-Meier and Cox regression analysis. RESULTS Preoperative symptoms were common, with 2,380 of 2,643 (90%) patients presenting with any one or more of the following symptoms: jaundice (40%), biliary obstruction treated with biliary stent (41%), pain (37%), weight loss (29%), nausea (18%), diabetes (31%), emesis (6%), and recent onset diabetes (5%). Patients were separated into 3 groups: no symptoms (n = 293), symptoms (n = 2,229), and recent onset diabetes (n = 121). The 3 groups differed in body mass index and nodal staging, where patients with recent onset diabetes had the highest values (body mass index: no symptoms: 24.5 kg/m2, symptoms: 25.1 kg/m2; recent-onset diabetes: 26.3 kg/m2, P = .007), (no symptoms: N1: 55%, N2: 10%; symptoms: N1: 53%, N2: 17%; recent-onset diabetes: N1: 56%, N2: 16%, P = .023). Other pathological characteristics, carbohydrate antigen 19-9 levels, and adjuvant chemotherapy receival did not differ between the groups. Interestingly, recent-onset diabetes was associated with better survival compared with the other groups (Median overall survival: 28 months [no symptoms at all], 22 months [symptoms] versus not reached [recent onset diabetes group], and 5-year overall survival rates of 28%, 11%, and 57%, respectively [log rank, P = .013]). Multivariable analysis revealed that recent-onset diabetes and preoperative symptoms were independently associated with overall survival (recent-onset diabetes, relative risk 0.052 P = .027, >5 symptoms relative risk 3.66, P < .001). CONCLUSION Pancreatic ductal adenocarcinoma symptoms occured in up to 90% of patients with resectable pancreatic ductal adenocarcinoma. In addition, PDAC symptoms were associated with overall survival and might identify unique pancreatic ductal adenocarcinoma subtypes.
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Affiliation(s)
- Kim C Honselmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany. http://www.twitter.com/KimCHonselmann
| | - Yannic Elser
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Tabea Boeckmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Meike Ten Winkel
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Steffen Deichmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ruediger Braun
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ulrich F Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
| | - Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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31
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Fong ZV, Hernandez-Barco YG, Castillo CFD. A Clinical Guide to the Management of Intraductal Papillary Mucinous Neoplasms: the Need for a More Graded Approach in Clinical Decision-making. J Gastrointest Surg 2023; 27:1988-1998. [PMID: 37495820 DOI: 10.1007/s11605-022-05536-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/30/2022] [Indexed: 07/28/2023]
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) have become a very common diagnosis and represent a spectrum of disease that ranges from benign to malignant lesions. Presently, clinical and radiographic features are used to predict the presence of high-grade dysplasia and invasive cancer to inform treatment decisions of whether to pursuit surgical resection or continued surveillance. However, the natural history of IPMNs is still not completely understood, with guidelines from different societies providing contradictory recommendations. This underscores the challenge in balancing the risk of missing cancer with long-term surveillance and the morbidity associated with surgical resection. In this review, we aim to reconcile the differences in the guidelines' recommendations and provide a clinical framework to the management of IPMNs with hopes of adding clarity to how treatment decisions should be made. We also highlight recent advances made in the field and future efforts that can minimize rates of missing cancer while also reducing the number of unnecessary operations.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Yasmin G Hernandez-Barco
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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32
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Kin T, Shimizu Y, Hijioka S, Hara K, Katanuma A, Nakamura M, Yamada R, Itoi T, Ueki T, Masamune A, Hirono S, Koshita S, Hanada K, Kamata K, Yanagisawa A, Takeyama Y. A comparative study between computed tomography and endoscopic ultrasound in the detection of a mural nodule in intraductal papillary mucinous neoplasm -Multicenter observational study in Japan. Pancreatology 2023; 23:550-555. [PMID: 37286439 DOI: 10.1016/j.pan.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 04/20/2023] [Accepted: 05/22/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND/OBJECTIVES The detection of malignancy is a major concern in the management of intraductal papillary mucinous neoplasm (IPMN). The height of the mural nodule (MN), estimated using endoscopic ultrasound (EUS) and computed tomography (CT), has been considered crucial for predicting malignant IPMN. Currently, whether surveillance using CT or EUS alone is sufficient for detecting MNs remains unclear. This study aimed to compare the ability of CT and EUS to detect MNs in IPMN. METHODS This multicenter, retrospective observational study was conducted in 11 Japanese tertiary institutions. Patients who underwent surgical resection of IPMN with MN after CT and EUS examinations were eligible to participate. The MN detection rates between CT and EUS were examined. RESULTS Two-hundred-and-forty patients who underwent preoperative EUS and CT had pathologically confirmed MNs. The MN detection rates of EUS and CT were 83% and 53%, respectively (p < 0.001). Additionally, the MN detection rate of EUS was significantly higher than that of CT regardless of morphological type (76% vs. 47% in branch-duct-type IPMN; 90% vs. 54% in mixed IPMN; 98% vs. 56% in main-duct-type IPMN; p < 0.001). Further, pathologically confirmed MNs ≥5 mm were more frequently observed on EUS than on CT (95% vs. 76%, p < 0.001). CONCLUSIONS EUS was superior to CT for the detection of MN in IPMN. EUS surveillance is essential for the detection of MNs.
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Affiliation(s)
- Toshifumi Kin
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan.
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Akio Katanuma
- Center for Gastroenterology, Teine-Keijinkai Hospital, Sapporo, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Reiko Yamada
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Toshiharu Ueki
- Department of Gastroenterology, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Seiko Hirono
- Department of Hepato-Biliary-Pancreatic Surgery, Hyogo College of Medicine, Nishinomiya, Japan; Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Shinsuke Koshita
- Department of Gastroenterology, Sendai City Medical Center Sendai Open Hospital, Sendai, Japan
| | - Keiji Hanada
- Department of Gastroenterology, JA Onomichi General Hospital, Hiroshima, Japan
| | - Ken Kamata
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Akio Yanagisawa
- Department of Pathology and Laboratory Medicine, Kyoto First Red Cross Hospital, Kyoto, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kindai University Faculty of Medicine, Osakasayama, Japan
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33
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Huang X, Guo T, Zhang Z, Cai M, Guo X, Zhang J, Yu Y. Prediction of malignant intraductal papillary mucinous neoplasm: A nomogram based on clinical information and radiological outcomes. Cancer Med 2023; 12:16958-16971. [PMID: 37434479 PMCID: PMC10501290 DOI: 10.1002/cam4.6326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 05/02/2023] [Accepted: 06/28/2023] [Indexed: 07/13/2023] Open
Abstract
OBJECTIVE Clinical practitioners face a significant challenge in maintaining a healthy balance between overtreatment and missed diagnosis in the management of intraductal papillary mucinous neoplasm (IPMN). The current study aimed to identify significant risk factors of malignant IPMN from a series of clinical and radiological parameters that are widely available and noninvasive and develop a method to individually predict the risk of malignant IPMN to improve its management. METHODS We retrospectively investigated 168 patients who were pathologically diagnosed with IPMN after individualized pancreatic resection between June, 2012 and December, 2020. Independent predictors determined using both univariate and multivariate analyses to construct a predictive model. The discriminatory power of the nomogram was assessed using the area under the receiver operating characteristic curve (AUC). Decision curve analysis was performed to demonstrate the clinical usefulness of the nomogram. Internal cross validation was performed to assess the validity of the predictive model. RESULTS In the multivariate analysis, five significant independent risk factors were identified: increased serum CA19-9 level, low prognostic nutritional index (PNI), cyst size, enhancing mural nodule, and main pancreatic duct diameter. The nomogram based on the parameters mentioned above had outstanding performance in distinguishing malignancy, with an AUC of 0.907 (95% confidence interval: 0.859-0.956, p < 0.05), which remained 0.875 after internal cross-validation, and showed good clinical usefulness. CONCLUSION A novel nomogram for predicting malignant IPMN first introducing PNI was developed, which may aid in improving IPMN management. Nevertheless, external validation is required to confirm its efficacy.
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Affiliation(s)
- Xiaorui Huang
- Department of Biliopancreatic SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanChina
| | - Tong Guo
- Department of Biliopancreatic SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanChina
| | - Zhiwei Zhang
- Department of Biliopancreatic SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanChina
| | - Ming Cai
- Department of Biliopancreatic SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanChina
| | - Xinyi Guo
- Department of Biliopancreatic SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanChina
| | - Jingzhao Zhang
- Department of Biliopancreatic SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanChina
| | - Yahong Yu
- Department of Biliopancreatic SurgeryTongji Hospital of Tongji Medical College of Huazhong University of Science and TechnologyWuhanChina
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Kuvendjiska J, Müller F, Bronsert P, Timme-Bronsert S, Fichtner-Feigl S, Kulemann B. Circulating Epithelial Cells in Patients with Intraductal Papillary Mucinous Neoplasm of the Pancreas. Life (Basel) 2023; 13:1570. [PMID: 37511945 PMCID: PMC10381561 DOI: 10.3390/life13071570] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/03/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Intraductal papillary mucinous neoplasm (IPMN) is the most common pancreatic cyst and a precursor of pancreatic cancer (PDAC). Since PDAC has a devastatingly high mortality rate, the early diagnosis and treatment of any precursor lesion are rational. The safety of the existing guidelines on the clinical management of IPMN has been criticized due to unsatisfactory sensitivity and specificity, showing the need for further markers. Blood obtained from patients with IPMN was therefore subjected to size-based isolation of circulating epithelial cells (CECs). We isolated CECs and evaluated their cytological characteristics. Additionally, we compared Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations in CECs and the primary IPMN tissue, since KRAS mutations are very typical for PDAC. Samples from 27 IPMN patients were analyzed. In 10 (37%) patients, CECs were isolated and showed a hybrid pattern of surface markers involving both epithelial and mesenchymal markers, suggesting a possible EMT process of the cells. Especially, patients with high-grade dysplasia in the main specimen were all CEC-positive. KRAS mutations were also present in CECs but less common than in IPMN tissue. The existence of CEC in IPMN patients offers additional blood-based research possibilities for IMPN biology.
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Affiliation(s)
- Jasmina Kuvendjiska
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79110 Freiburg im Breisgau, Germany
- Department of General and Visceral Surgery, University Medical Center Freiburg, 79106 Freiburg im Breisgau, Germany
| | - Felix Müller
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79110 Freiburg im Breisgau, Germany
| | - Peter Bronsert
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79110 Freiburg im Breisgau, Germany
- Tumorbank, Comprehensive Cancer Center Freiburg, University Medical Center Freiburg, 79106 Freiburg im Breisgau, Germany
- Institute for Surgical Pathology, University Medical Center Freiburg, 79106 Freiburg im Breisgau, Germany
| | - Sylvia Timme-Bronsert
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79110 Freiburg im Breisgau, Germany
- Tumorbank, Comprehensive Cancer Center Freiburg, University Medical Center Freiburg, 79106 Freiburg im Breisgau, Germany
- Institute for Surgical Pathology, University Medical Center Freiburg, 79106 Freiburg im Breisgau, Germany
| | - Stefan Fichtner-Feigl
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79110 Freiburg im Breisgau, Germany
- Department of General and Visceral Surgery, University Medical Center Freiburg, 79106 Freiburg im Breisgau, Germany
| | - Birte Kulemann
- Faculty of Medicine, Albert-Ludwigs-University of Freiburg, 79110 Freiburg im Breisgau, Germany
- Department of Surgery, University Medical Center Schleswig-Holstein, 23538 Lübeck, Germany
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35
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Megibow AJ. Pancreatic Cysts: Radiology. Gastrointest Endosc Clin N Am 2023; 33:519-531. [PMID: 37245933 DOI: 10.1016/j.giec.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This article reviews the types of pancreatic cysts encountered in Radiologic practice. It summarizes the malignancy risk of each of the following: serous cystadenoma, mucinous cystic tumor, intraductal papillary mucinous neoplasm main duct and side branch, and some miscellaneous cysts such as neuroendocrine tumor and solid pseudopapillary epithelial neoplasm. Specific reporting recommendations are given. The choice between radiology follow-up versus endoscopic analysis is discussed.
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Affiliation(s)
- Alec J Megibow
- Department of Radiology, NYU-Langone Health, 550 1st Avenue, Room HCC 232, New York, NY 10016, USA.
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36
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Chhoda A, Schmidt J, Farrell JJ. Surveillance of Pancreatic Cystic Neoplasms. Gastrointest Endosc Clin N Am 2023; 33:613-640. [PMID: 37245939 DOI: 10.1016/j.giec.2023.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Pancreatic cystic neoplasms (PCNs) are increasingly detected because of the widespread use of cross-sectional imaging and overall aging population. While the majority of these cysts are benign, some can progress to advanced neoplasia (defined as high-grade dysplasia and invasive cancer). As the only widely accepted treatment for PCNs with advanced neoplasia is surgical resection, accurate preoperative diagnosis, and stratification of malignant potential for deciding about surgery, surveillance or doing nothing remains a clinical challenge. Surveillance strategies for pancreatic cysts (PCNs) combine clinical evaluation and imaging to assess changes in cyst morphology and symptoms that may indicate advanced neoplasia. PCN surveillance heavily relies on various consensus clinical guidelines that focus on high-risk morphology, surgical indications, and surveillance intervals and modalities. This review will focus on current concepts in the surveillance of newly diagnosed PCNs, especially on low-risk presumed intraductal papillary mucinous neoplasms (those without worrisome features and high-risk stigmata), and appraise current clinical surveillance guidelines.
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Affiliation(s)
- Ankit Chhoda
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Julie Schmidt
- Yale Multidisciplinary Pancreatic Cyst Clinic (Yale MPaCC), Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University School of Medicine, New Haven, CT, USA
| | - James J Farrell
- Yale Multidisciplinary Pancreatic Cyst Clinic (Yale MPaCC), Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University School of Medicine, New Haven, CT, USA.
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37
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Schleimer LE, Chabot JA, Kluger MD. Innovation in the Surgical Management of Pancreatic Cystic Neoplasms: Same Operations, Narrower Indications, and an Individualized Approach to Decision-Making. Gastrointest Endosc Clin N Am 2023; 33:655-677. [PMID: 37245941 DOI: 10.1016/j.giec.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Historically, the management of pancreatic cystic neoplasms (PCN) has been operative. Early intervention for premalignant lesions, including intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN), offers an opportunity to prevent pancreatic cancer-with potential decrement to patients' short-term and long-term health. The operations performed have remained fundamentally the same, with most patients undergoing pancreatoduodenectomy or distal pancreatectomy using oncologic principles. The role of parenchymal-sparing resection and total pancreatectomy remains controversial. We review innovations in the surgical management of PCN, focusing on the evolution of evidence-based guidelines, short-term and long-term outcomes, and individualized risk-benefit assessment.
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Affiliation(s)
- Lauren E Schleimer
- Department of Surgery, Columbia University Irving Medical Center, 177 Fort Washington Avenue, 8 Garden South, New York, NY 10032, USA. https://twitter.com/lschleim
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Herbert Irving Pavilion, Columbia University Irving Medical Center, Columbia University, Vagelos College of Physicians & Surgeons, 161 Fort Washington Avenue, Suite 819, New York, NY 10032, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Herbert Irving Pavilion, Columbia University Irving Medical Center, Columbia University, Vagelos College of Physicians & Surgeons, 161 Fort Washington Avenue, Suite 823, New York, NY 10032, USA.
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Yang AZ, Kongboonvijit S, Fernandez-Del Castillo CF, Fong ZV, Zelga PJ, Ferrone CR, Lillemoe KD, Kambadakone A, Qadan M. Uncinate Duct Dilatation Predicts Additional Risk for High-Grade Dysplasia or Invasive Carcinoma Among Fukuoka-Positive Intraductal Papillary Mucinous Neoplasms. Ann Surg 2023; 277:988-994. [PMID: 36804283 DOI: 10.1097/sla.0000000000005834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
OBJECTIVE To determine whether uncinate duct dilatation (UDD) increases the risk of high-grade dysplasia or invasive carcinoma (HGD/IC) in Fukuoka-positive intraductal papillary mucinous neoplasms (IPMNs). BACKGROUND Though classified as a branch duct, the uncinate duct is the primary duct of the pancreatic ventral anlage. We hypothesized that UDD, like main duct dilatation, confers additional risk for HGD/IC. METHODS A total of 467 patients met inclusion criteria in a retrospective cohort study of surgically resected IPMNs at the Massachusetts General Hospital. We used multivariable logistic regression to analyze the association between UDD (defined as ≥4 mm) and HGD/IC, controlling for Fukuoka risk criteria. In a secondary analysis, the modeling was repeated in the 194 patients with dorsal branch duct IPMNs (BD-IPMNs) in the pancreatic neck, body, or tail. RESULTS Mean age at surgery was 70, and 229 (49%) patients were female. In total, 267 (57%) patients had only worrisome features and 200 (43%) had at least 1 high-risk feature. UDD was present in 164 (35%) patients, of whom 118 (73%) had HGD/IC. On multivariable analysis, UDD increased the odds of HGD/IC by 2.8-fold, even while controlling for Fukuoka risk factors (95% CI: 1.8-4.4, P <0.001). Prevalence of HGD/IC in all patients with UDD was 73%, compared with 74% in patients with high-risk stigmata and 73% in patients with main duct IPMNs. In the secondary analysis, UDD increased the odds of HGD/IC by 3.2-fold in patients with dorsal BD-IPMNs (95% CI: 1.3-7.7, P =0.010). CONCLUSIONS UDD confers additional risk for HGD/IC unaccounted for by current Fukuoka criteria. Further research can extend this study to Fukuoka-negative patients, including unresected patients.
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Affiliation(s)
| | | | | | - Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Piotr J Zelga
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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Xia Q, Li F, Min R, Sun S, Han YX, Feng ZZ, Li N. Malignancy risk factors and prognostic variables of pancreatic mucinous cystic neoplasms in Chinese patients. World J Gastroenterol 2023; 29:3119-3132. [PMID: 37346158 PMCID: PMC10280801 DOI: 10.3748/wjg.v29.i20.3119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/21/2023] [Accepted: 05/04/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Pancreatic mucinous cystic neoplasms (MCNs) represent one of the precursor lesions of pancreatic ductal adenocarcinoma, and their detection has been facilitated by advances in preoperative imaging. Due primarily to the rarity of MCNs, however, there is limited knowledge regarding the prognostic variables and high-risk factors for malignant transformation. A more comprehensive and nuanced approach is necessary to fill this gap and provide a basis for improved treatment decisions and patient outcomes.
AIM To investigate the high-risk factors associated with malignant MCNs and to explore the prognostic factors of MCN with associated invasive carcinoma (MCN-AIC).
METHODS All cases of resected MCNs from a single high-volume institution between January 2012 and January 2022 were retrospectively reviewed. Only cases with ovarian-type stroma verified by progesterone receptor staining were included. Preoperative features, histological findings and postoperative course were documented. Multivariate logistic regression was employed to investigate variables related to malignancy. Survival analysis was performed using the Kaplan-Meier curve, and the prognostic factors were assessed to evaluate the postoperative course of patients with MCN-AIC.
RESULTS Among the 48 patients, 36 had benign MCNs, and 12 had malignant MCNs (1 high-grade atypical hyperplasia and 11 MCN-AIC). Age, tumour size, presence of solid components or mural nodules and pancreatic duct dilatation were identified as independent risk factors associated with malignancy. The follow-up period ranged from 12 mo to 120 mo, with a median overall survival of 58.2 mo. Only three patients with MCN-AIC died, and the 5-year survival rate was 70.1%. All 11 cases of MCN-AIC were stage I, and extracapsular invasion was identified as a prognostic factor for poorer outcomes.
CONCLUSION The risk factors independently associated with malignant transformation of MCNs included age, tumour size, presence of solid components or mural nodules, and pancreatic duct dilatation. Our study also revealed that encapsulated invasion was a favourable prognostic factor in MCN-AIC patients.
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MESH Headings
- Humans
- Carcinoma, Pancreatic Ductal/epidemiology
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Pancreatic Ductal/surgery
- East Asian People
- Neoplasms, Cystic, Mucinous, and Serous/epidemiology
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/surgery
- Pancreatic Neoplasms/epidemiology
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/surgery
- Prognosis
- Receptors, Progesterone
- Retrospective Studies
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Affiliation(s)
- Qing Xia
- Department of Pathology, The First Affiliated Hospital of Bengbu Medical College, Bengbu Medical College, Bengbu 233004, Anhui Province, China
| | - Fan Li
- Department of Pathology, Bengbu Medical College, Bengbu 233030, Anhui Province, China
| | - Rui Min
- Department of Pathology, The First Affiliated Hospital of Bengbu Medical College, Bengbu Medical College, Bengbu 233004, Anhui Province, China
| | - Shuai Sun
- Department of Pathology, Bengbu Medical College, Bengbu 233030, Anhui Province, China
| | - Yue-Xin Han
- School of Clinical Medicine, Bengbu Medical College, Bengbu 233030, Anhui Province, China
| | - Zhen-Zhong Feng
- Department of Pathology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, Anhui Province, China
| | - Nan Li
- Department of Pathology, The First Affiliated Hospital of Bengbu Medical College, Bengbu Medical College, Bengbu 233004, Anhui Province, China
- Department of Pathology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, Anhui Province, China
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Balaban DV, Coman L, Balaban M, Zoican A, Pușcașu DA, Ayatollahi S, Mihălțeanu E, Costache RS, Ioniță-Radu F, Jinga M. Glycemic Abnormalities in Pancreatic Cystic Lesions—A Single-Center Retrospective Analysis. GASTROENTEROLOGY INSIGHTS 2023; 14:191-203. [DOI: doi.org/10.3390/gastroent14020015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
Abstract
Background and Objectives: Glucose metabolism alterations are very common in solid pancreatic lesions, particularly in pancreatic cancer. Similarly, diabetes and especially new-onset diabetes (NOD) have been associated with the malignant transformation of pancreatic cysts. We aimed to assess the prevalence and relevant associations of glycemic abnormalities in pancreatic cystic lesions (PCLs) in a retrospective analysis. Materials and Methods: We retrospectively recruited all patients who underwent endoscopic ultrasound for a PCL over a period of 36 months (January 2018 to December 2021). Final diagnosis was set by means of tissue acquisition, surgery, follow-up, or board decision. Demographic and clinical data, laboratory workup, and imaging features were extracted from the patients’ charts according to a predefined protocol. We considered fasting blood glucose (FBG) and HbA1c values and stratified the patients as nondiabetic (FBG ≤ 99 mg/dL, HbA1c ≤ 5.6%, no history of glycemic abnormalities), prediabetic (FBG 100–125 mg/dL, HbA1c 5.7–6.4%), or diabetic (long-lasting diabetes or NOD). Results: Altogether, 81 patients were included, with a median age of 66 years, and 54.3% of them were male. The overall prevalence of fasting hyperglycemia was 54.3%, comprising 34.6% prediabetes and 22.2% diabetes, of which 16.7% had NOD. The mean FBG and HbA1c levels were higher in malignant and premalignant PCLs (intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), cystadenocarcinoma, and cystic neuroendocrine tumor) compared to the benign lesions (pseudocysts, walled-off necrosis, and serous cystadenoma): 117.0 mg/dL vs. 108.3 mg/dL and 6.1% vs. 5.5%, respectively. Conclusions: Hyperglycemia and diabetes are common in PCLs, with a high prevalence in premalignant and malignant cysts. Screening and follow-up for glycemic abnormalities should be routinely conducted for PCLs, as they can contribute to a tailored risk assessment of cysts.
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Affiliation(s)
- Daniel Vasile Balaban
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Laura Coman
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Marina Balaban
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Andreea Zoican
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Danusia Adriana Pușcașu
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Simin Ayatollahi
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Emanuela Mihălțeanu
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Raluca Simona Costache
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Florentina Ioniță-Radu
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Mariana Jinga
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
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Hozaka Y, Ohtsuka T, Nakamura M, Hijioka S, Unno M, Shimizu Y, Tanabe M, Nagakawa Y, Hatano E, Kawai M, Sano T, Koshita S, Katanuma A, Kita E, Hanada K, Nakai Y, Aoki T, Serikawa M, Okamoto K, Takeyama Y. Feasibility of Surveillance for Mucinous Cystic Neoplasm of the Pancreas: A Multi-Institutional Retrospective Study of 328 Patients by the Japanese Pancreatic Society. Pancreas 2023; 52:e288-e292. [PMID: 37922344 DOI: 10.1097/mpa.0000000000002254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2023]
Abstract
OBJECTIVE We aimed to elucidate the feasibility of surveillance of patients with mucinous cystic neoplasm (MCN). METHODS We performed a retrospective, multi-institutional study of 328 patients who underwent surgery for MCN at 18 Japanese institutions. Patients with MCN were divided into an immediate surgery group and a surveillance group, which underwent surgery after surveillance. RESULTS The median surveillance period until surgery in the surveillance group was 27 months (range, 7-165 months). Compared with the immediate surgery group, the surveillance group showed smaller tumor diameter (46 vs 50 mm, P = 0.01), more frequent laparoscopic approach (58% vs 37%, P < 0.01), and less frequent malignancy (7% vs 15%, P = 0.03). The new appearance of mural nodules and elevation of serum tumor markers were associated with malignancy in the surveillance group. Two patients in the surveillance group experienced postoperative recurrence, although there was no significant difference in recurrence or disease-free survival between the two groups. In the surveillance group, the 1-, 5-, and 10-year cumulative incidence rates of malignant MCN were 0.8%, 5.6%, and 36.5%, respectively. CONCLUSION As the risk of progression to malignant MCNs increases over the long term, MCNs should be resected rather than subjected to unnecessary surveillance.
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Affiliation(s)
- Yuto Hozaka
- From the Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Takao Ohtsuka
- From the Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Etsuro Hatano
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Manabu Kawai
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - Tsuyoshi Sano
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Aichi, Japan
| | - Shinsuke Koshita
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Akio Katanuma
- Center for Gastroenterology, Teine Keijinkai Hospital, Hokkaido, Japan
| | - Emiri Kita
- Department of Gastroenterology, Chiba Cancer Center, Chiba, Japan
| | - Keiji Hanada
- Department of Gastroenterology, Onomichi General Hospital, Onomichi, Japan
| | | | - Takeshi Aoki
- Department of Gastroenterological and General Surgery, School of Medicine, Showa University, Tokyo, Japan
| | - Masahiro Serikawa
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kojun Okamoto
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kinki University Faculty of Medicine, Osaka, Japan
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Kubota K, Oguchi T, Fujimori N, Yamada K, Naitoh I, Okabe Y, Iwasaki E, Masamune A, Ikeura T, Kamisawa T, Inoue D, Kumagi T, Ogura T, Kodama Y, Katanuma A, Hirano K, Inui K, Isayama H, Sakagami J, Nishino T, Kanno A, Kurita Y, Okazaki K, Nakamura S. Steroid therapy has an acceptable role as the initial treatment in autoimmune pancreatitis patients with pancreatic cyst formation: Based on a Japanese nationwide study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:664-677. [PMID: 35950952 DOI: 10.1002/jhbp.1227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/14/2022] [Accepted: 08/07/2022] [Indexed: 05/26/2023]
Abstract
BACKGROUND We attempted to determine the indications and limitations of steroid therapy as the first-line therapy in patients with autoimmune pancreatitis (AIP) with cyst formation (ACF). METHODS This Japanese multicenter survey was conducted to examine the merits/demerits of steroid treatment as the initial therapy for ACF. RESULTS Data of a total of 115 patients with ACF were analyzed. Complete remission was achieved in 86% (86/100) of patients who had received steroid treatment, but only 33.3% (5/15) of patients who had not received steroids. Relapse after the remission (n = 86) occurred in 7.6% (6/86) of patients who had received steroid therapy, but 40% (2/5) of patients who had not received steroid therapy. Multivariate analysis identified adoption of the wait and watch approach without steroid treatment (odds ratio = 0.126, P < .001) as a significant and independent negative predictor of remission of ACF. As for predictors of relapse, the presence of varix (odds ratio = 5.83, P = .036) was identified as an independent risk factor. CONCLUSION Steroid therapy plays an important role as first-line therapy in AIP patients with pancreatic cyst formation, however, varix formation, besides the diameter of the cyst(s), is a risk factor for refractoriness to steroid therapy.
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Affiliation(s)
- Kensuke Kubota
- Endoscopic Unit, Yokohama City University Hospital, Yokohama, Japan
| | - Takaya Oguchi
- Department of Gastroenterology, Graduate School of Medicine, Shinshu University, Matsumoto, Japan
| | - Nao Fujimori
- Department of Gastroenterology, Graduate School of Medicine, Kyushu University, Fukuoka, Japan
| | - Kenta Yamada
- Department of Gastroenterology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Itaru Naitoh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yoshinobu Okabe
- Department of Gastroenterology, Kurume University, Kurume, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University, Shinagawa, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tsukasa Ikeura
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Japan
| | - Terumi Kamisawa
- Department of Internal Medicine, Tokyo Komagome Metropolitan Hospital, Tokyo, Japan
| | - Dai Inoue
- Department of Radiology, Graduate School of Medicine, Kanazawa University, Kanazawa, Japan
| | - Teru Kumagi
- Department of Gastroenterology, Graduate School of Medicine, Ehime University, Matsuyama, Japan
| | - Takeshi Ogura
- Department of Gastroenterology, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Yuzo Kodama
- Department of Gastroenterology, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Akio Katanuma
- Department of Gastroenterology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Kenji Hirano
- Department of Gastroenterology, Takanawa Hospital, Tokyo, Japan
| | - Kazuo Inui
- Department of Gastroenterology, Bantane Hospital, Fujita Health University, Nagoya, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Junichi Sakagami
- Department of Gastroenterology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takayoshi Nishino
- Department of Gastroenterology, Tokyo Women's Medical University, Yachiyo Medical Center, Yachiyo, Japan
| | - Atsushi Kanno
- Department of Gastroenterology, Jichi Medical University, Shimono, Japan
| | - Yusuke Kurita
- Endoscopic Unit, Yokohama City University Hospital, Yokohama, Japan
| | - Kazuichi Okazaki
- Department of Gastroenterology and Hepatology, Kansai Medical University, Hirakata, Japan
| | - Seiji Nakamura
- Section of Oral and Maxillofacial Oncology, Division of Maxillofacial Diagnostic and Surgical Sciences, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
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Park JK, Hwang JW. Research progress and future directions on intraductal papillary mucinous neoplasm: A bibliometric and visualized analysis of over 30 years of research. Medicine (Baltimore) 2023; 102:e33568. [PMID: 37058017 PMCID: PMC10101262 DOI: 10.1097/md.0000000000033568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/29/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Malignant change from low-grade dysplasia to high-grade dysplasia and invasive carcinoma following an adenoma-carcinoma sequence is becoming more common in intraductal papillary mucinous neoplasm (IPMN) of the pancreas. The aim of this study is to analyze their main characteristics and recent research trends in IPMNs and consequently create better understandings of the current situation and trends. METHODS A comprehensive search was performed in The Science Citation Index Expanded of the Web of Science. All articles between 1990 and 2021 were searched. VOS viewer (Leiden University, Leiden, Netherlands) was used for a qualitative and quantitative analysis of keywords, constituting maps based on co-occurrence matrix. RESULTS A total of 1658 eligible articles were screened among the 3950 identified articles for this subject. Finally, 879 articles were included in this study. Many articles on IPMN have been published in Japan and South Korea. Tanaka published the highest number of articles (n = 26, citations = 11,143). The Pancreas published the highest number of articles. (n = 100, citations = 2533). These articles were grouped into 4 clusters including basic research, disease overview, management/prognosis and malignant IPMN by using bibliometric keywords network analysis. Overlay visualization demonstrates, a trend of the studies has been changed from basic research or disease to management or prognosis. CONCLUSIONS In this study, we found and highlight the most cited and influential articles related to IPMN. Plus, this study analyzed global research trends in IPMN over the past 30 years and provides insight into the features and research hotspots of the articles in IPMN research.
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Affiliation(s)
- Jae Keun Park
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Ji Woong Hwang
- Department of Surgery, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, Gwangmyeong, Republic of Korea
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Pollini T, Marchegiani G, Facciorusso A, Balduzzi A, Biancotto M, Bassi C, Maker AV, Salvia R. It is not necessary to resect all mucinous cystic neoplasms of the pancreas: current guidelines do not reflect the actual risk of malignancy. HPB (Oxford) 2023:S1365-182X(23)00074-6. [PMID: 37003852 DOI: 10.1016/j.hpb.2023.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 02/06/2023] [Accepted: 03/03/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Mucinous Cystic Neoplasms (MCN) of the pancreas are premalignant cysts for which current guidelines support pancreatic resection. The primary aim of this systematic review and meta-analysis is to define the pooled rate of malignancy for MCN. METHODS A systematic review of eligible studies published between 2000 and 2021 was performed on PubMed and Embase. Primary outcome was rate of malignancy. Data regarding high-risk features, including cyst size and mural nodules, were collected and analyzed. RESULTS A total of 40 studies and 3292 patients with resected MCN were included in the final analysis. The pooled rate of malignancy was 16.1% (95%CI 13.1-19.0). The rate of malignant MCN in studies published before 2012 was significantly higher than that of studies published after recent guidelines were published (21.0% vs 14.9%, p < 0.001). Malignant MCN were larger than benign (mean difference 25.9 mm 95%CI 14.50-37.43, p < 0.001) with a direct correlation between size and presence of malignant MCN (R2 = 0.28, p = 0.020). A SROC identified a threshold of 65 mm to be associated with the diagnosis of malignant MCN. Presence of mural nodules was associated with the diagnosis of a malignant MCN (OR = 4.34, 95%CI 3.00-6.29, p < 0.001). CONCLUSION Whereas guidelines recommend resection of all MCN, the rate of malignancy in resected MCN is 16%, implying that surveillance has a role in most cases, and that surgical selection criteria are warranted. Size and presence of mural nodules are significantly associated with an increased risk of malignant degeneration, small MCN and without mural nodules can be considered for surveillance.
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Affiliation(s)
- Tommaso Pollini
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, USA; The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Giovanni Marchegiani
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Alberto Balduzzi
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Marco Biancotto
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Claudio Bassi
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona, Verona, Italy
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, USA
| | - Roberto Salvia
- The Pancreas Institute, Department of General and Pancreatic Surgery, University of Verona, Verona, Italy.
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Sugawara T, Franco SR, Ishida J, Kalra A, Saben JL, Gálvez KN, Kirsch MJ, Al-Musawi MH, Kaplan B, Pomfret EA, Schulick RD, Del Chiaro M. Prevalence and progression of intraductal papillary mucinous neoplasms of the pancreas in solid organ transplant recipients: A systematic review. Am J Transplant 2023; 23:429-436. [PMID: 36695699 DOI: 10.1016/j.ajt.2022.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/17/2022] [Accepted: 11/27/2022] [Indexed: 01/13/2023]
Abstract
Solid organ transplantation (SOT) recipients are known to carry an increased risk of malignancy because of long-term immunosuppression. However, the progression of intraductal papillary mucinous neoplasm of the pancreas (IPMN) in this population remains unclear. We performed a systematic review by searching PubMed, Embase, Scopus, and Google Scholar. All studies containing IPMNs in solid organ transplantation recipients were screened. We included 11 studies in our final analysis, totaling 274 patients with IPMNs of the 8213 SOT recipients. The prevalence from 8 studies was 4.7% (95% CI 2.4%-7.7%) in a random-effects model with median study periods of 24 to 220 months. The median rate for all progressions from 10 studies was 20% (range, 0%-88%) within 13 to 41 months of the median follow-up time. By utilizing the results of 3 case-control studies, the relative risk from a random-effects model for progression (worrisome features and high-risk stigmata) of IPMNs was 0.39 (95% CI 0.12-1.31). No adenocarcinoma derived from IPMN was reported in the included studies. Overall, this study indicates that the progression of pretransplant IPMN does not increase drastically compared with the general nontransplant population. However, considering the limited literature, further studies are required for confirmation.
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Affiliation(s)
- Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Salvador Rodriguez Franco
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jun Ishida
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Avash Kalra
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jessica L Saben
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Karla Navarrete Gálvez
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael J Kirsch
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Mohammed H Al-Musawi
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Bruce Kaplan
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Elizabeth A Pomfret
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Richard D Schulick
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA; University of Colorado Cancer Center, Aurora, Colorado, USA
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA; University of Colorado Cancer Center, Aurora, Colorado, USA.
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46
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Ormsby EL, Kojouri K, Chang PC, Lin TY, Vuong B, Ramirez RM, Schueler KM, Sweet CF, Herrinton LJ. Association of Standardized Radiology Reporting and Management of Abdominal CT and MRI With Diagnosis of Pancreatic Cancer. Clin Gastroenterol Hepatol 2023; 21:644-652.e2. [PMID: 35436626 DOI: 10.1016/j.cgh.2022.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 03/24/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Follow-up of abdominal computed tomography (CT) and magnetic resonance imaging (MRI) findings suspicious for pancreatic cancer may be delayed if documentation is unclear. We evaluated whether standardized reporting and follow-up of imaging results reduced time to diagnosis of pancreatic cancer. METHODS We used a quasi-experimental stepped-wedge cluster design to evaluate the effectiveness of newly implemented radiology reporting system. The system standardizes the reporting of CT and MRI reports using hashtags that classify pancreatic findings. The system also automates referral of patients with findings suspicious for pancreatic cancer to a multidisciplinary care team for rapid review and follow-up. The study examined 318,331 patients who underwent CT or MRI that included the abdomen from 2016 through 2019 who had not had an eligible CT or MRI in the preceding 24 months. We evaluated the association of the intervention with incidence of pancreatic cancer within 60 days and 120 days after imaging. RESULTS Thirty-eight percent of patients received the intervention, and 1523 patients (0.48%) were diagnosed with pancreatic cancer. In multivariable analysis accounting for age, race/ethnicity, sex, Charlson comorbidity, history of cancer, diabetes, and 4-month calendar period, the intervention was associated with nearly 50% greater odds of diagnosing pancreatic cancer within 60 days (adjusted odds ratio, 1.47; 95% confidence interval, 1.05-2.06) and 120 days (adjusted odds ratio, 1.46; 95% confidence interval, 1.04-2.06). CONCLUSIONS In this large quasi-experimental, community-based observational study, implementing standardized reporting of abdominal CT and MRI reports with clinical navigation was effective for increasing the detection and diagnosis of pancreatic cancer.
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Affiliation(s)
| | | | | | - Teresa Y Lin
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Brooke Vuong
- Department of Surgical Oncology, Oakland, California
| | | | | | | | - Lisa J Herrinton
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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47
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Pollini T, Wong P, Maker AV. The Landmark Series: Intraductal Papillary Mucinous Neoplasms of the Pancreas-From Prevalence to Early Cancer Detection. Ann Surg Oncol 2023; 30:1453-1462. [PMID: 36600097 PMCID: PMC9908620 DOI: 10.1245/s10434-022-12870-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/14/2022] [Indexed: 01/06/2023]
Abstract
Modern series report a prevalence of pancreatic cysts in the general population of up to 50% in prospective studies. Of these, about half will be pancreatic cystic neoplasms (PCNs) that have varying degrees of malignant potential. Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are the most common PCNs and are known predecessors of pancreatic adenocarcinoma. Critically, they are one of the only radiographically identifiable precursors of pancreatic cancer and thus provide an opportunity for early cancer detection and surgical resection with curative intent. The combination of high prevalence and potential for malignant degeneration underscore the relevance of discussing the best management of IPMNs and improving the existing standard of care. Landmark data on IPMN prevalence, guidelines, surveillance, biomarkers, and immune landscape are highlighted.
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Affiliation(s)
- Tommaso Pollini
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Paul Wong
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
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48
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Servin-Rojas M, Fong ZV, Fernandez-Del Castillo C, Ferrone CR, Rocha-Castellanos DM, Roldan J, Zelga PJ, Warshaw AL, Lillemoe KD, Qadan M. Identification of high-risk features in mucinous cystic neoplasms of the pancreas. Surgery 2023; 173:1270-1274. [PMID: 36822873 DOI: 10.1016/j.surg.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/25/2022] [Accepted: 01/17/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Mucinous cystic neoplasms of the pancreas are uncommon tumors that have the potential of becoming cancer. There is no consensus regarding the high-risk features of these tumors. Our study aimed to identify the preoperative demographic, clinical, or radiologic factors that can predict the presence of high-grade dysplasia or invasive carcinoma in mucinous cystic neoplasms of the pancreas. METHODS We identified 157 patients who underwent resection and fulfilled the pathologic criteria for mucinous cystic neoplasms of the pancreas in a prospectively maintained database spanning 3 decades (1990-2020). Multivariable logistic regression was used to identify predictors of high-grade dysplasia or invasive carcinoma in mucinous cystic neoplasms of the pancreas. RESULTS The rate of high-grade dysplasia or invasive carcinoma was 11%. Tumor size ≥4 cm (P < .001), mural nodularity (P = .04), and a serum CA 19-9 level >37 U/mL (P < .001) were associated with high-grade dysplasia or invasive carcinoma. In the multivariable analysis, tumor size ≥4 cm (odds ratio 16.9, 95% confidence interval 2.04-140, P = .009) and a CA 19-9 level >37 U/mL (odds ratio 5.68, 95% confidence interval 1.52-21.3, P = .010) were predictors of high-grade dysplasia or invasive carcinoma. There were no tumors with high-grade dysplasia or invasive carcinoma in patients with tumor size <4 cm in the absence of an elevated CA 19-9 or mural nodularity. CONCLUSION Tumors with a size ≥4 cm and/or a high CA 19-9 level should be considered for prompt surgical resection. Conversely, tumors <4 cm with no other high-risk features have a negligible risk for high-grade dysplasia or invasive carcinoma and may benefit from nonoperative surveillance. Mural nodularity is an additional suspicious feature. These findings may contribute to future guidelines.
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Affiliation(s)
- Maximiliano Servin-Rojas
- Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/servinrojasmd
| | - Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/ZhiVenFongMD
| | | | | | | | - Jorge Roldan
- Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/md_roldan
| | - Piotr J Zelga
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Boston, MA.
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49
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Chhoda A, Sharma A, Sailo B, Tang H, Ruzgar N, Tan WY, Ying L, Khatri R, Narayanan A, Mane S, De Kumar B, Wood LD, Iacobuzio-Donahue C, Wolfgang CL, Kunstman JW, Salem RR, Farrell JJ, Ahuja N. Utility of promoter hypermethylation in malignant risk stratification of intraductal papillary mucinous neoplasms. Clin Epigenetics 2023; 15:28. [PMID: 36803844 PMCID: PMC9942382 DOI: 10.1186/s13148-023-01429-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 01/14/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMNs), a type of cystic pancreatic cancer (PC) precursors, are increasingly identified on cross-sectional imaging and present a significant diagnostic challenge. While surgical resection of IPMN-related advanced neoplasia, i.e., IPMN-related high-grade dysplasia or PC, is an essential early PC detection strategy, resection is not recommended for IPMN-low-grade dysplasia (LGD) due to minimal risk of carcinogenesis, and significant procedural risks. Based on their promising results in prior validation studies targeting early detection of classical PC, DNA hypermethylation-based markers may serve as a biomarker for malignant risk stratification of IPMNs. This study investigates our DNA methylation-based PC biomarker panel (ADAMTS1, BNC1, and CACNA1G genes) in differentiating IPMN-advanced neoplasia from IPMN-LGDs. METHODS Our previously described genome-wide pharmaco-epigenetic method identified multiple genes as potential targets for PC detection. The combination was further optimized and validated for early detection of classical PC in previous case-control studies. These promising genes were evaluated among micro-dissected IPMN tissue (IPMN-LGD: 35, IPMN-advanced neoplasia: 35) through Methylation-Specific PCR. The discriminant capacity of individual and combination of genes were delineated through Receiver Operating Characteristics curve analysis. RESULTS As compared to IPMN-LGDs, IPMN-advanced neoplasia had higher hypermethylation frequency of candidate genes: ADAMTS1 (60% vs. 14%), BNC1 (66% vs. 3%), and CACGNA1G (25% vs. 0%). We observed Area Under Curve (AUC) values of 0.73 for ADAMTS1, 0.81 for BNC1, and 0.63 for CACNA1G genes. The combination of the BNC1/ CACNA1G genes resulted in an AUC of 0.84, sensitivity of 71%, and specificity of 97%. Combining the methylation status of the BNC1/CACNA1G genes, blood-based CA19-9, and IPMN lesion size enhanced the AUC to 0.92. CONCLUSION DNA-methylation based biomarkers have shown a high diagnostic specificity and moderate sensitivity for differentiating IPMN-advanced neoplasia from LGDs. Addition of specific methylation targets can improve the accuracy of the methylation biomarker panel and enable the development of noninvasive IPMN stratification biomarkers.
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Affiliation(s)
- Ankit Chhoda
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Anup Sharma
- Department of Surgery, Yale School of Medicine, New Haven, USA
| | - Bethsebie Sailo
- Department of Surgery, Yale School of Medicine, New Haven, USA
| | - Haoyu Tang
- Yale Systems Biology Institute, Yale University, New Haven, USA
| | - Nensi Ruzgar
- Department of Surgery, Yale School of Medicine, New Haven, USA
| | - Wan Ying Tan
- Department of Surgery, Yale School of Medicine, New Haven, USA
| | - Lee Ying
- Department of Surgery, Yale School of Medicine, New Haven, USA
| | - Rishabh Khatri
- Department of Internal Medicine, Temple University Hospital, Philadelphia, USA
| | | | | | | | - Laura D Wood
- Department of Pathology, Johns Hopkins University, Baltimore, USA
| | | | | | - John W Kunstman
- Department of Surgery, Yale School of Medicine, New Haven, USA
| | - Ronald R Salem
- Department of Surgery, Yale School of Medicine, New Haven, USA
| | - James J Farrell
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, USA.
| | - Nita Ahuja
- Department of Surgery, Yale School of Medicine, New Haven, USA.
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, USA.
- Department of Pathology, Yale School of Medicine, New Haven, USA.
- Department of Biological and Biomedical Sciences, Yale School of Medicine, New Haven, USA.
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50
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Mohapatra S, Krishna SG, Pannala R. Pancreatic Cystic Neoplasms: Translating Guidelines into Clinical Practice. Diagnostics (Basel) 2023; 13:diagnostics13040749. [PMID: 36832238 PMCID: PMC9955807 DOI: 10.3390/diagnostics13040749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
A combination of several factors, including the increasing use of cross-sectional imaging and an aging population, has led to pancreatic cystic lesions (PCLs) becoming the most detected incidental pancreatic lesions. Accurate diagnosis and risk stratification of PCLs is challenging. In the last decade, several evidence-based guidelines have been published addressing the diagnosis and management of PCLs. However, these guidelines cover different subsets of patients with PCLs and offer varying recommendations regarding diagnostic assessment, surveillance, and surgical resection. Further, recent studies comparing the accuracy of various guidelines have reported significant variations in the rate of missed cancer versus unnecessary surgical resections. In clinical practice, it is challenging to decide which guideline to follow specifically. This article reviews the varying recommendations of the major guidelines and results of comparative studies, provides an overview of newer modalities not included in the guidelines, and offers perspectives on translating the guidelines into clinical practice.
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Affiliation(s)
- Sonmoon Mohapatra
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ 85259, USA
| | - Somashekar G. Krishna
- Department of Gastroenterology and Hepatology and Nutrition, The Ohio State Wexner Medical Center, Columbus, OH 43210, USA
| | - Rahul Pannala
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ 85259, USA
- Correspondence: ; Tel.: +1-480-301-4755
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