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Dane B, Kim J, Qian K, Megibow A. Pancreatic cyst prevalence and detection with photon counting CT compared with conventional energy integrating detector CT. Eur J Radiol 2024; 175:111437. [PMID: 38520805 DOI: 10.1016/j.ejrad.2024.111437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 03/19/2024] [Indexed: 03/25/2024]
Abstract
PURPOSE To calculate the prevalence of pancreatic cysts on photon counting CT (PCCT) and compare with that of 128-slice conventional energy-integrating detector CT (EIDCT). METHOD A retrospective single institution database search identified all contrast-enhanced abdominal CT examinations performed at an outpatient facility that has both a PCCT and EIDCT between 4/11/2022 and 7/26/2022. The presence and size of pancreatic cysts were recorded. In patients with PCCT reported pancreatic cysts, prior CT imaging (EIDCT) was reviewed for reported pancreatic cysts. Fisher's exact test was used to compare the pancreatic cyst detection rate for PCCT and EIDCT. Wilcoxon rank sum test was used to compare cyst size and patient age. A p <.05 indicated statistical significance. RESULTS 2494 patients were included. Our pancreatic cyst detection rate was 4.9 % (49/1009) with PCCT and 3.0 % (44/1485) for EIDCT (p =.017). For CT angiograms, pancreatic cysts were detected in 6.6 % (21/319) with PCCT and 0.0 % (0/141) with EIDCT (p <.001). Pancreatic cyst detection rate was not statistically different for portal venous, enterography, renal mass, pancreas, 3-phase liver, or venogram protocols (all p >.05). Mean[SD] pancreatic cyst size was 13.7[9.7]mm for PCCT and 15.3[14.7] for EIDCT (p =.95). 55.1 % (27/49) of PCCT and 61.4 % (27/44) of EIDCT that described pancreatic cysts had prior contrast-enhanced EIDCTs. Of these, 40.7 % (11/27) of PCCT and 14.8 % (4/27) of EIDCT described pancreatic cysts were not previously reported (p =.027). CONCLUSIONS Photon-counting CT afforded greater pancreatic cyst detection than conventional energy-integrating detector CT, particularly with CT angiograms.
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Affiliation(s)
- Bari Dane
- Department of Radiology, NYU Langone Health, 660 1(st) Avenue, New York, NY 10016.
| | - Jesi Kim
- Department of Radiology, NYU Langone Health, 660 1(st) Avenue, New York, NY 10016
| | - Kun Qian
- NYU Langone Health Department of Biostatistics, 180 Madison Avenue, New York, NY 10016
| | - Alec Megibow
- Department of Radiology, NYU Langone Health, 660 1(st) Avenue, New York, NY 10016
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2
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Ogura T, Iwatsubo T, Bessho K, Hattori N, Nishikawa H. Novel pancreatoscope improves diagnostic yield of visual findings for intraductal papillary mucinous neoplasms. Endoscopy 2023; 55:E1178-E1179. [PMID: 37963592 PMCID: PMC10645537 DOI: 10.1055/a-2197-8949] [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] [Indexed: 11/16/2023]
Affiliation(s)
- Takeshi Ogura
- Endoscopy Center, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
- 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Taro Iwatsubo
- Endoscopy Center, Osaka Medical and Pharmaceutical University Hospital, Osaka, Japan
- 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Kimi Bessho
- 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Nobuhiro Hattori
- 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Hiroki Nishikawa
- 2nd Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
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3
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Koh S, Lee NK, Kim S, Hong SB, Kim DU, Han SY. The efficacy of low-dose CT with deep learning image reconstruction in the surveillance of incidentally detected pancreatic cystic lesions. Abdom Radiol (NY) 2023; 48:2585-2595. [PMID: 37204510 DOI: 10.1007/s00261-023-03958-2] [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: 03/03/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE To evaluate the efficacy of low-dose CT (LDCT) with deep learning image reconstruction (DLIR) for the surveillance of pancreatic cystic lesions (PCLs) compared with standard-dose CT (SDCT) with adaptive statistical iterative reconstruction (ASIR-V). METHODS The study enrolled 103 patients who underwent pancreatic CT for follow-up of incidentally detected PCLs. The CT protocol included LDCT in the pancreatic phase with 40% ASIR-V, DLIR at medium (DLIR-M) and high levels (DLIR-H), and SDCT in the portal-venous phase with 40% ASIR-V. The overall image quality and conspicuity of PCLs were qualitatively assessed using five-point scales by two radiologists. The size of PCLs, presence of thickened/enhancing walls, enhancing mural nodules, and main pancreatic duct dilatation were reviewed. CT noise and cyst-to-pancreas contrast-to-noise ratio (CNR) were measured. Qualitative and quantitative parameters were analyzed using the chi-squared test, one-way ANOVA, and t-test. Additionally, interobserver agreement was analyzed using the kappa and weighted-kappa statistics. RESULTS The volume CT dose-indexes in LDCT and SDCT were 3.0 ± 0.6 mGy and 8.4 ± 2.9 mGy, respectively. LDCT with DLIR-H showed the highest overall image quality, the lowest noise, and the highest CNR. The PCL conspicuity in LDCT with either DLIR-M or DLIR-H was not significantly different from that in SDCT with ASIR-V. Other findings depicting PCLs also revealed no significant differences between LDCT with DLIR and SDCT with ASIR-V. Moreover, the results revealed good or excellent interobserver agreement. CONCLUSION LDCT with DLIR has a comparable performance with SDCT for the follow-up of incidentally detected PCLs.
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Affiliation(s)
- Sungho Koh
- Department of Radiology, Biomedical Research Institute, Pusan National University Hospital, and Pusan National University School of Medicine, Pusan National University, #179, Gudeok-Ro, Seo-Gu, Busan, 49241, Republic of Korea
| | - Nam Kyung Lee
- Department of Radiology, Biomedical Research Institute, Pusan National University Hospital, and Pusan National University School of Medicine, Pusan National University, #179, Gudeok-Ro, Seo-Gu, Busan, 49241, Republic of Korea.
| | - Suk Kim
- Department of Radiology, Biomedical Research Institute, Pusan National University Hospital, and Pusan National University School of Medicine, Pusan National University, #179, Gudeok-Ro, Seo-Gu, Busan, 49241, Republic of Korea
| | - Seung Baek Hong
- Department of Radiology, Biomedical Research Institute, Pusan National University Hospital, and Pusan National University School of Medicine, Pusan National University, #179, Gudeok-Ro, Seo-Gu, Busan, 49241, Republic of Korea
| | - Dong Uk Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, and Pusan National University School of Medicine, Pusan National University, Busan, Republic of Korea
| | - Sung Yong Han
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, and Pusan National University School of Medicine, Pusan National University, Busan, Republic of Korea
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4
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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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5
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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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6
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Pu N, Chen Q, Zhang J, Yin H, Wang D, Ji Y, Rao S, Kuang T, Xu X, Wu W, Lou W. Circulating cytokines allow for identification of malignant intraductal papillary mucinous neoplasms of the pancreas. Cancer Med 2023; 12:3919-3930. [PMID: 35871313 PMCID: PMC9972143 DOI: 10.1002/cam4.5051] [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: 04/04/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMNs) are the precursor lesions of pancreatic cancers, requiring active surgical intervention during cancer development. However, the current criteria for predicting malignant IPMNs remain challenging and limited. Hence, this study aimed to assess the discriminatory performance of circulating cytokines, including TNF-α, IL-2R, IL-6, and IL-8, then build a novel predictive model to improve the diagnostic accuracy. METHOD A total of 131 retrospective (from March 2016 to December 2019) and 53 prospective (from March 2020 to January 2021) patients who were histologically confirmed as IPMNs were consecutively collected and analyzed. RESULT The circulating levels of TNF-α, IL-2R, IL-6, and IL-8 were significantly elevated in malignant IPMNs, and were verified as independent factors for malignant IPMNs (p < 0.05). Then, a novel score, the circulating cytokine score (CCS), was calculated and demonstrated as an independent predictive indicator with a higher area under the curve (AUC) than each cytokine alone (p < 0.001). Besides the CCS, two high-risk stigmata features, the presence of solid component (PSC), and main pancreatic duct (MPD) dilation ≥10 mm were also demonstrated as independent indicators for predicting malignant IPMNs. Finally, a novel nomogram incorporating the CCS and these two high-risk stigmata features presented a remarkable diagnostic performance, both in the training and validation cohorts with AUCs of 0.928 and 0.873, respectively. CONCLUSION The CCS can be considered a novel independent predictive indicator for malignant IPMNs. Additionally, the formulated nomogram model integrating the CCS, PSC, and MPD ≥10 mm can be a valuable and promising tool for predicting the malignant transformation of IPMNs during long-term follow-ups to assist in timely and accurate surgical decisions.
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Affiliation(s)
- Ning Pu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qiangda Chen
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jicheng Zhang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hanlin Yin
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dansong Wang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuan Ji
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China.,Department of Pathology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shengxiang Rao
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tiantao Kuang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xuefeng Xu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenchuan Wu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenhui Lou
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.,Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
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7
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de Jong DM, Stassen PMC, Groot Koerkamp B, Ellrichmann M, Karagyozov PI, Anderloni A, Kylänpää L, Webster GJM, van Driel LMJW, Bruno MJ, de Jonge PJF. The role of pancreatoscopy in the diagnostic work-up of intraductal papillary mucinous neoplasms: a systematic review and meta-analysis. Endoscopy 2022; 55:25-35. [PMID: 35668651 PMCID: PMC9767751 DOI: 10.1055/a-1869-0180] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Confirming the diagnosis, invasiveness, and disease extent of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas is challenging. The aim of this study was to summarize the literature on the efficacy and safety of peroral pancreatoscopy (POP) in the diagnosis of IPMN, including the impact of pre- and intraoperative POP on the management of IPMN. METHODS The EMBASE, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar databases were systematically searched for articles. Eligible articles investigated cohorts of patients who underwent POP for (suspected) IPMN. RESULTS 25 articles were identified and included in this review; with 22 of these reporting on the diagnostic yield of POP in IPMN and 11 reporting on the effect of pre- or intraoperative POP on clinical decision-making. Cannulation and observation rates, and overall diagnostic accuracy were high across all studies. Frequently reported visual characteristics of IPMN were intraductal fish-egg-like lesions, hypervascularity, and granular mucosa. Overall, the adverse event rate was 12 %, primarily consisting of post-endoscopic retrograde cholangiopancreatography pancreatitis, with a pooled rate of 10 %, mostly of mild severity. Regarding the impact of POP on clinical decision-making, POP findings altered the surgical approach in 13 %-62 % of patients. CONCLUSION POP is technically successful in the vast majority of patients with (suspected) IPMN, has a consistently high diagnostic accuracy, but an adverse event rate of 12 %. Data on intraoperative pancreatoscopy are scarce, but small studies suggest its use can alter surgical management. Future studies are needed to better define the role of POP in the diagnostic work-up of IPMN.
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Affiliation(s)
- David M. de Jong
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pauline M. C. Stassen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mark Ellrichmann
- Department of Interdisciplinary Endoscopy, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Petko I. Karagyozov
- Department of Interventional Gastroenterology, Acibadem City Clinic Tokuda University Hospital, Sofia, Bulgaria
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Department of Gastroenterology, Humanitas Clinical and Research Center, IRCCS, Milan, Italy
| | - Leena Kylänpää
- Abdominal Center, Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - George J. M. Webster
- Department of Gastroenterology, University College London Hospitals, London, UK,Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
| | - Lydi M. J. W. van Driel
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter J. F. de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Fujita Y, Hirono S, Kawai M, Okada KI, Miyazawa M, Kitahata Y, Ueno M, Hayami S, Kobayashi R, Yanagisawa A, Yamaue H. Malignant potential and specific characteristics of pure main duct type intraductal papillary mucinous neoplasm. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1054-1061. [PMID: 34933794 DOI: 10.1016/j.ejso.2021.11.137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/03/2021] [Accepted: 11/29/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND As the malignant potential of main duct (MD-) type intraductal papillary mucinous neoplasm (IPMN) has been discussed together with Mixed-type in most previous studies, the malignant potential of pure MD-type IPMN remains unclear. This study evaluated the specific characteristics and predictors of high-grade dysplasia (HGD) and invasive intraductal papillary mucinous carcinoma (IPMC) for pure MD-type IPMN. METHODS From 1,100 patients with IPMN, this study includes 387 patients that underwent surgery. We evaluated the specific characteristics of pure MD-type IPMN by comparing clinicopathological factors between MD-type (n = 79) and branch duct (BD-) type (n = 146) or Mixed-type IPMN (n = 162), and predictors of HGD/invasive IPMC in pure MD-type IPMN. RESULTS The rate of HGD/invasive IPMC was significantly higher in MD-type than in BD-type (70.9 vs. 48.6%, P = 0.001), although there was no difference between MD-type and Mixed-type IPMNs (P = 0.343). Recurrence-free survival (RFS) and disease-specific survival (DSS) of patients with MD-type were better than those of patients with Mixed-type (P = 0.008 and P = 0.009, respectively). There were no significant differences in RFS, overall survival, and DSS between patients with MD-type and patients with BD-type IPMNs. Multivariate analysis showed two independent predictors of HGD/invasive IPMC in MD-type IPMN; mural nodule height ≥5 mm (P = 0.025, odds ratio [OR]; 16.949) and carcinoembryonic antigen (CEA) level in the pancreatic juice obtained by preoperative endoscopic retrograde pancreatography ≥50 ng/ml (P = 0.039, OR; 9.091). CONCLUSIONS Measurement of mural nodule height and CEA in the pancreatic juice might be useful in determining surgical indication for pure MD-type IPMN, although further studies for confirmation are essential.
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Affiliation(s)
- Yoichi Fujita
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Seiko Hirono
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan.
| | - Manabu Kawai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Ken-Ichi Okada
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Motoki Miyazawa
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Yuji Kitahata
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Masaki Ueno
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Shinya Hayami
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Ryohei Kobayashi
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
| | - Akio Yanagisawa
- Department of Pathology, Japanese Red Cross Kyoto Daiichi Hospital, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Japan
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9
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Yamada D, Kobayashi S, Takahashi H, Yoshioka T, Iwagami Y, Tomimaru Y, Shigekawa M, Akita H, Noda T, Asaoka T, Gotoh K, Tanemura M, Doki Y, Eguchi H. Pancreatic CT density is an optimal imaging biomarker for earlier detection of malignancy in the pancreas with intraductal papillary mucinous neoplasm. Pancreatology 2022; 22:488-496. [PMID: 35396159 DOI: 10.1016/j.pan.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/04/2022] [Accepted: 03/22/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMNs) are typically detected as incidental findings by computed tomography (CT); however, the conventional surveillance is not valid for the early detection of concomitant pancreatic cancer. The pancreas of IPMN is often accompanied by fatty infiltration in the parenchyma, and pancreatic fatty infiltration could be evaluated by pancreatic CT density (pancreatic index, PI). We aimed to investigate whether PI could be an imaging biomarker for the early prediction of malignancies in the pancreas with IPMN. METHODS Two different cohorts were investigated. (Investigation cohort): A total of 1137 patients with initially low-risk IPMN were compensated by initial IPMN findings, and 2 groups (malignancy/possible benign, 50 cases each) were investigated for yearly changes in PI and for the cutoff value of PI indicating the development of malignancies. (Validation cohort): To validate the cutoff value, 256 patients radiologically suspected of having IPMNs were investigated. RESULTS (Investigation-cohort): The malignancy group showed a gradual decrease in PI every year, and PI significantly differed among the 2 groups 1 year prior to the last investigation. The cutoff value of PI was set at 0.65. (Validation-cohort): A total of 55% of the patients with a PI below the cutoff value had malignancy in the pancreas, including concomitant pancreatic cancer, and the cutoff value was the most significant risk factors for the development of malignancies in the pancreas compared to the conventional risk factors for IPMN. CONCLUSIONS Decreasing PI would be an optimal imaging biomarker for earlier detection of malignancies in the pancreas with IPMN.
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Affiliation(s)
- Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan.
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Teppei Yoshioka
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Yoshito Tomimaru
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Minoru Shigekawa
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Hirofumi Akita
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Tadafumi Asaoka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan; Department of Surgery, Osaka Police Hospital, Tennoji-ku Kitayamacho 10-31, Osaka, 543-0035, Japan
| | - Kunihito Gotoh
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Masahiro Tanemura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan; Department of Gastroenterological Surgery, Rinku General Medical Center, Rinku-Ourai-Kita 2-23, Izumisano, Osaka, 598-8577, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
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10
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Nakanuma Y, Nomura Y, Watanabe H, Terada T. Polypoid invasive carcinoma of bile duct: report of four cases. Clin J Gastroenterol 2022; 15:630-634. [PMID: 35334086 DOI: 10.1007/s12328-022-01626-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/14/2022] [Indexed: 11/26/2022]
Abstract
Recently, "polypoid invasive carcinoma (PICA)" showing grossly visible polypoid, invasive carcinoma with no adenoma component was proposed as a neoplastic polyp of the gallbladder. Herein, we report four cases of PICA of the bile duct. PICA cases of bile duct showed single, sessile polypoid growth grossly, and polypoid components were composed of invasive carcinoma of papillary/tubular patterns with active desmoplasia, and invaded directly and continuously into the bile duct wall and periductal tissue. While PICA and other intraductal papillary neoplasm of bile duct (IPNB) shared several features, PICA showed an invasive carcinoma growing in the duct lumen and also invading into the bile duct wall, thus different from IPNB which is the intraluminal polypoid, preinvasive epithelial neoplasia with back-to-back epithelial units. Taken together, PICA and IPNB could be differentiated from each other.
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Affiliation(s)
- Yasuni Nakanuma
- Department of Diagnostic Pathology, Fukui Prefecture Saiseikai Hospital, Wadanakacho Funahashi 7-1, Fukui, 918-8503, Japan.
| | - Yoshikatsu Nomura
- Department of Digestive Medicine, Fukui Prefecture Saiseikai Hospital, Fukui, Japan
| | - Hiroyuki Watanabe
- Department of Digestive Medicine, Fukui Prefecture Saiseikai Hospital, Fukui, Japan
| | - Takuro Terada
- Department of Digestive Surgery, Fukui Prefecture Saiseikai Hospital, Fukui, Japan
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11
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Kishimoto Y, Okano N, Ito K, Takuma K, Hara S, Iwasaki S, Yoshimoto K, Ymada Y, Watanabe K, Kimura Y, Nakagawa H, Igarashi Y. Peroral Pancreatoscopy with Videoscopy and Narrow-Band Imaging in Intraductal Papillary Mucinous Neoplasms with Dilatation of the Main Pancreatic Duct. Clin Endosc 2021; 55:270-278. [PMID: 34865339 PMCID: PMC8995986 DOI: 10.5946/ce.2021.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 07/27/2021] [Indexed: 12/02/2022] Open
Abstract
Background/Aims Endoscopic evaluation of intraductal papillary mucinous neoplasms (IPMNs) is useful in determining whether the lesions are benign or malignant. This study aimed to examine the usefulness of peroral pancreatoscopy (POPS) in determining the prognosis of IPMNs.
Methods POPS with videoscopy was performed using the mother–baby scope technique. After surgery, computed tomography/magnetic resonance cholangiopancreatography or ultrasonography and blood tests were performed every 6 months during the follow-up.
Results A total of 39 patients with main pancreatic duct (MPD)–type IPMNs underwent POPS using a videoscope, and the protrusions in the MPD were observed in 36 patients. The sensitivity and specificity of cytology/biopsy performed at the time of POPS were 85% and 87.5%, respectively. Of 19 patients who underwent surgery, 18 (95%) patients had negative surgical margins and 1 (5%) patient had a positive margin.
Conclusions In IPMNs with dilatation of the MPD, POPS is considered effective if the lesions can be directly observed. The diagnosis of benign and malignant lesions is possible depending on the degree of lesion elevation. However, in some cases, slightly elevated lesions may increase in size during the follow-up or multiple lesions may be simultaneously present; therefore, careful follow-up is necessary.
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Affiliation(s)
- Yui Kishimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Naoki Okano
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Ken Ito
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Kensuke Takuma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Seiichi Hara
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Susumu Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Kensuke Yoshimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Yuuto Ymada
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Koji Watanabe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Yuusuke Kimura
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Hiroki Nakagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
| | - Yoshinori Igarashi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Omori Medical Center, Tokyo, Japan
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12
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Kaida H, Miyasaka Y, Morishita M, Koreeda N, Hirano Y, Ohmiya T, Uwatoko S, Kawamoto M, Komono A, Sakamoto R, Shibata R, Higashi D, Nimura S, Watanabe M. Laparoscopic distal pancreatectomy for intraductal papillary mucinous neoplasm-associated pancreatic cancer: A case report. Int J Surg Case Rep 2021; 87:106376. [PMID: 34537524 PMCID: PMC8455712 DOI: 10.1016/j.ijscr.2021.106376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/25/2021] [Accepted: 09/02/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction and importance Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is often found incidentally during examination for other diseases. In addition to the risk of malignant transformation, patients with IPMN are at risk of developing pancreatic cancer. We report a case of pancreatic tail cancer that developed separately from a preexisting IPMN after minimally invasive esophagectomy for cancer of the esophagogastric junction and was resected successfully by laparoscopic distal pancreatectomy. Case presentation A 72-year-old man underwent thoracoscopic and laparoscopic esophagectomy for esophagogastric junction cancer. He had undergone surgery for ascending colon cancer 20 years ago. At that time, IPMN was confirmed in the pancreatic body by a preoperative examination. Computed tomography was regularly performed for postoperative work-up and follow-up of the IPMN, and a solid lesion with cystic components was detected in the pancreatic tail 9 months after the operation. On detailed examination, pancreatic ductal adenocarcinoma concomitant with IPMN, accompanied by a retention cyst, was considered. Laparoscopic distal pancreatectomy was successfully performed after neoadjuvant chemotherapy. Pathological diagnosis of the lesion in the pancreatic tail was of an invasive intraductal papillary mucinous carcinoma (ypT3ypN0yM0 ypStageIIA). Clinical discussion If an IPMN is detected during preoperative examination for malignancies of other organs, careful follow-up is necessary due to the high risk of pancreatic cancer development. Furthermore, initial operation with minimally invasive surgery may reduce adhesion and facilitate subsequent surgeries. Conclusion We have provided evidence that supports the importance of a careful follow-up of IPMNs, even if they are low risk. Intraductal papillary mucinous neoplasm of the pancreas is found incidentally. A pre-existing neoplasm led to pancreatic tail cancer in one patient. Due to careful follow-up of the neoplasm, the secondary cancer was detected rapidly. It was resected successfully by laparoscopic distal pancreatectomy. Careful follow is necessary if this neoplasm is detected.
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Affiliation(s)
- Hiroki Kaida
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Yoshihiro Miyasaka
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Marina Morishita
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Nobuhiko Koreeda
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Yousuke Hirano
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Toshihiro Ohmiya
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Shugo Uwatoko
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Makoto Kawamoto
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Akira Komono
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Ryohei Sakamoto
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Ryosuke Shibata
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Daijiro Higashi
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Satoshi Nimura
- Department of Pathology, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan
| | - Masato Watanabe
- Department of Surgery, Fukuoka University Chikushi Hospital, 1-1-1 Zokumyoin, Chikushinoshi, Fukuoka 818-8502, Japan.
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13
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Beato F, Reverón D, Dezsi KB, Ortiz A, Johnson JO, Chen DT, Ali K, Yoder SJ, Jeong D, Malafa M, Hodul P, Jiang K, Centeno BA, Abdalah MA, Balasi JA, Tassielli AF, Sarcar B, Teer JK, DeNicola GM, Permuth JB, Fleming JB. Establishing a living biobank of patient-derived organoids of intraductal papillary mucinous neoplasms of the pancreas. J Transl Med 2021; 101:204-217. [PMID: 33037322 PMCID: PMC7855435 DOI: 10.1038/s41374-020-00494-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 09/17/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer (PaCa) is the third leading cause of cancer-related deaths in the United States. There is an unmet need to develop strategies to detect PaCa at an early, operable stage and prevent its progression. Intraductal papillary mucinous neoplasms (IPMNs) are cystic PaCa precursors that comprise nearly 50% of pancreatic cysts detected incidentally via cross-sectional imaging. Since IPMNs can progress from low- and moderate-grade dysplasia to high-grade dysplasia and invasion, the study of these lesions offers a prime opportunity to develop early detection and prevention strategies. Organoids are an ideal preclinical platform to study IPMNs, and the objective of the current investigation was to establish a living biobank of patient-derived organoids (PDO) from IPMNs. IPMN tumors and adjacent normal pancreatic tissues were successfully harvested from 15 patients with IPMNs undergoing pancreatic surgical resection at Moffitt Cancer Center & Research Institute (Tampa, FL) between May of 2017 and March of 2019. Organoid cultures were also generated from cryopreserved tissues. Organoid count and size were determined over time by both Image-Pro Premier 3D Version 9.1 digital platform and Matlab application of a Circular Hough Transform algorithm, and histologic and genomic characterization of a subset of the organoids was performed using immunohistochemistry and targeted sequencing, respectively. The success rates for organoid generation from IPMN tumor and adjacent normal pancreatic tissues were 81% and 87%, respectively. IPMN organoids derived from different epithelial subtypes showed different morphologies in vitro, and organoids recapitulated histologic and genomic characteristics of the parental IPMN tumor. In summary, this preclinical model has the potential to provide new opportunities to unveil mechanisms of IPMN progression to invasion and to shed insight into novel biomarkers for early detection and targets for chemoprevention.
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Affiliation(s)
- Francisca Beato
- Department of Gastrointestinal Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | - Kaleena B Dezsi
- Department of Cancer Epidemiology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Antonio Ortiz
- Analytical Microscopy Core Facility, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Joseph O Johnson
- Analytical Microscopy Core Facility, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Dung-Tsa Chen
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Karla Ali
- Department of Cancer Epidemiology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Sean J Yoder
- Molecular Genomics Core Facility, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Daniel Jeong
- Department of Diagnostic Imaging, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Mokenge Malafa
- Department of Gastrointestinal Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Pamela Hodul
- Department of Gastrointestinal Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kun Jiang
- Department of Anatomic Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Barbara A Centeno
- Department of Anatomic Pathology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Mahmoud A Abdalah
- Imaging Response Assessment Team Core Facility, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jodi A Balasi
- Tissue Core Histology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Alexandra F Tassielli
- Department of Gastrointestinal Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Bhaswati Sarcar
- Department of Gastrointestinal Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jamie K Teer
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Gina M DeNicola
- Department of Cancer Physiology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jennifer B Permuth
- Department of Gastrointestinal Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
- Department of Cancer Epidemiology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jason B Fleming
- Department of Gastrointestinal Oncology, Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
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14
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Giuffrida P, Biagiola D, Ardiles V, Uad P, Palavecino M, de Santibañes M, Clariá RS, Pekolj J, de Santibañes E, Mazza O. Long-term follow-up of Branch-Duct Intraductal Papillary Mucinous Neoplasms with negative Sendai Criteria: the therapeutic challenge of patients who convert to positive Sendai Criteria. HPB (Oxford) 2021; 23:290-300. [PMID: 32709558 DOI: 10.1016/j.hpb.2020.06.011] [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] [Received: 10/05/2019] [Revised: 04/15/2020] [Accepted: 06/19/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The management of Branch-Duct Intraductal Papillary Mucinous Neoplasm (BD-IPMN) is still controversial. Our objective was to assess the long-term follow-up (FU) of patients with "low-risk" BD-IPMN according to the Sendai-International Consensus Guidelines (ICG-I). METHODS We retrospectively analyzed a cohort of patients with BD-IPMN and Negative Sendai-Criteria (NSC) from January 2004 to October 2019. A univariate analysis was performed to determine factors associated with conversion to Positive Sendai-Criteria (PSC) and malignancy. Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of the IGC-I were assessed for the development of malignancy. RESULTS A total of 219 patients were selected and underwent a median 58-month FU. Thirty-seven (17%) patients developed PSC during FU including 12 (5.5%) with malignant lesions. Conversely, 182 patients (83%) did not develop malignancy. The NPV and PPV of ICG-I for malignancy were 100% and 32.4%, respectively. Among patients who developed PSC, those with cancer were >65years (OR = 3.57;p = 0.015) and had significantly higher serum CA-19-9 levels (OR = 5.27;p = 0.007). CONCLUSION The ICG-I is a safe strategy for FU of patients with BD-IPMN. The absence of PSC exclude malignancy. Among patients who develops PSC, the risk of cancer remains low and surgery should be decided according to their surgical risk and life expectancy.
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Affiliation(s)
- Pablo Giuffrida
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - David Biagiola
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Victoria Ardiles
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Pedro Uad
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Martin Palavecino
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Martín de Santibañes
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Rodrigo S Clariá
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Juan Pekolj
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Oscar Mazza
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina.
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15
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Liu H, Cui Y, Shao J, Shao Z, Su F, Li Y. The diagnostic role of CT, MRI/MRCP, PET/CT, EUS and DWI in the differentiation of benign and malignant IPMN: A meta-analysis. Clin Imaging 2020; 72:183-193. [PMID: 33321460 DOI: 10.1016/j.clinimag.2020.11.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 10/09/2020] [Accepted: 11/08/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE The objective of this study was to assess the diagnostic properties of computed tomography (CT), magnetic resonance imaging (MRI/MRCP) /Magnetic Resonance Cholangiopancreatography (MRCP), positron emission tomography/computed tomography (PET/CT), endoscopic ultrasound (EUS) and diffusion-weighted magnetic resonance imaging (DWI) in distinguishing benign and malignant intraductal papillary mucinous neoplasm (IPMN). MATERIALS AND METHODS Eligible databases were searched for eligible studies, published through July 2020 on the diagnostic accuracy of these modalities. Diagnostic accuracy parameters, including sensitivity, specificity, diagnostic odds ratio (DOR), and summary receiver operating characteristic curves (SROC) were calculated. Meta-regression was performed to identify the source of heterogeneity. RESULTS In total, 28 studies were included. Pooled sensitivities for CT, MRI/MRCP, PET/CT, EUS and DWI were 0.7, 0.76, 0.8, 0.6 and 0.72, respectively. Pooled specificities were 0.78, 0.83, 0.9, 0.8 and 0.97. The DORs were 8, 16, 35, 6 and 88. The areas under the curve (AUC) of SROC for CT, MRI/MRCP/MRCP, PET/CT, EUS and DW were 0.8, 0.87, 0.92, 0.79 and 0.82, respectively. CONCLUSION PET/CT showed the highest AUC and the overall diagnostic accuracy results support the use of MRI/MRCP, PET/CT interchangeably as a first-line examination in the diagnosis of malignant IPMN. With regard to DWI, EUS and CT, each techniques have their advantages and supportive to MRI/MRCP.
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Affiliation(s)
- Hongjie Liu
- Department of Radiology, The Fifth Central Hospital, Tianjin, China
| | - Yu Cui
- Department of General Surgery, The Fifth Central Hospital, Tianjin, China
| | - Jianping Shao
- Department of General Surgery, The Fifth Central Hospital, Tianjin, China
| | - Zhijiang Shao
- Department of General Surgery, The Fifth Central Hospital, Tianjin, China
| | - Feng Su
- Department of General Surgery, The Fifth Central Hospital, Tianjin, China
| | - Yongyuan Li
- Department of General Surgery, The Fifth Central Hospital, Tianjin, China.
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16
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Jan IS, Chang MC, Yang CY, Tien YW, Jeng YM, Wu CH, Chen BB, Chang YT. Validation of Indications for Surgery of European Evidence-Based Guidelines for Patients with Pancreatic Intraductal Papillary Mucinous Neoplasms. J Gastrointest Surg 2020; 24:2536-2543. [PMID: 31745906 DOI: 10.1007/s11605-019-04420-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Which patients with pancreatic intraductal papillary mucinous neoplasms (IPMNs) should undergo surgical intervention remains a controversial issue. The aim of this retrospective study was to validate the new European evidence-based guidelines on pancreatic cystic neoplasms (EEBGPCN) for the management of IPMNs. METHODS One hundred fifty-eight patients with resected IPMNs at National Taiwan University Hospital between January 1994 and December 2016 were enrolled. Clinical information, including new-onset diabetes mellitus (DM) and preoperative CA 19-9 levels, were collected. All patients were stratified into three groups-absolute, relative indications, and conservative approach-according to EEBGPCN. The performance characteristics of EEBGPCN for high-grade dysplasia (HGD)/invasive carcinoma (IC) of IPMNs were calculated. RESULTS One hundred seven (67.7%) patients with low-grade dysplasia and 51 patients with HGD/IC, including 10 HGD and 41 IC, were analyzed. The missed rate for HGD/IC by EEBGPCN was 1.9% (3/158). The sensitivity, specificity, positive and negative predictive values, and accuracy of the absolute or relative indications for resecting IPMN according to EEBGPCN were 94.1%, 28.0%, 38.4%, 90.9%, and 49.4%. Jaundice, enhancing mural nodule < 5 mm, cyst diameter > 40 mm, increased levels of serum CA 19-9, new-onset DM, and main pancreatic duct dilation were associated with HGD/IC. CONCLUSIONS The missed rate for HGD/IC is low by EEBGPCN. Increased serum CA 19-9 and new-onset DM in EEBGPCN were verified as the indications for the surgical resection of IPMNs.
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Affiliation(s)
- I-Shiow Jan
- Department of Laboratory Medicine, National Taiwan University College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ming-Chu Chang
- Department of Internal Medicine, National Taiwan University College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7 Chung Shan South Road, Taipei, 100, Taiwan
| | - Ching-Yao Yang
- Department of Surgery, National Taiwan University College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Wen Tien
- Department of Surgery, National Taiwan University College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Surgery, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yung-Ming Jeng
- Department of Pathology, National Taiwan University College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Pathology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Horng Wu
- Department of Medical Image, National Taiwan University College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Medical Image, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Bang-Bin Chen
- Department of Medical Image, National Taiwan University College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Medical Image, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Ting Chang
- Department of Internal Medicine, National Taiwan University College of Medicine, National Taiwan University, Taipei, Taiwan.
- Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7 Chung Shan South Road, Taipei, 100, Taiwan.
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17
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Sharib J, Esserman L, Koay EJ, Maitra A, Shen Y, Kirkwood KS, Ozanne EM. Cost-effectiveness of consensus guideline based management of pancreatic cysts: The sensitivity and specificity required for guidelines to be cost-effective. Surgery 2020; 168:601-609. [PMID: 32739138 PMCID: PMC8754171 DOI: 10.1016/j.surg.2020.04.052] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/25/2020] [Accepted: 04/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Detection of cystic lesions of the pancreas has outpaced our ability to stratify low-grade cystic lesions from those at greater risk for pancreatic cancer, raising a concern for overtreatment. METHODS We developed a Markov decision model to determine the cost-effectiveness of guideline-based management for asymptomatic pancreatic cysts. Incremental costs per quality-adjusted life year gained and survival were calculated for current management guidelines. A sensitivity analysis estimated the effect on cost-effectiveness and mortality if overtreatment of low-grade cysts is avoided, and the sensitivity and specificity thresholds required of methods of cyst stratification to improve costs expended. RESULTS "Surveillance" using current management guidelines had an incremental cost-effectiveness ratio of $171,143/quality adjusted life year compared with no surveillance or operative treatment ("do nothing"). An incremental cost-effectiveness ratio for surveillance decreases to $80,707/quality adjusted life year if the operative overtreatment of low-grade cysts was avoided. Assuming a societal willingness-to-pay of $100,000/quality adjusted life year, the diagnostic specificity for high-risk cysts must be >67% for surveillance to be preferred over surgery and "do nothing." Changes in sensitivity alone cannot make surveillance cost-effective. Most importantly, survival in surveillance is worse than "do nothing" for 3 years after cyst diagnosis, although long-term survival is improved. The disadvantage is eliminated when overtreatment of low-grade cysts is avoided. CONCLUSION Current management of pancreatic cystic lesions is not cost-effective and may increase mortality owing to overtreatment of low-grade cysts. The specificity for risk stratification for high-risk cysts must be greater than 67% to make surveillance cost-effective.
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Affiliation(s)
- Jeremy Sharib
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA
| | - Laura Esserman
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA
| | - Eugene J Koay
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Anirban Maitra
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yu Shen
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kimberly S Kirkwood
- Department of Surgery, University of California San Francisco, Helen Diller Cancer Center, San Francisco, CA.
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT
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Morais R, Vilas-Boas F, Santos-Antunes J, Pereira P, Macedo G. Single-Operator Pancreatoscopy for Diagnosis, Evaluation, and Staging of Mixed-Type Intraductal Papillary Mucinous Neoplasm. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:368-371. [PMID: 32999911 PMCID: PMC7506227 DOI: 10.1159/000505273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/06/2019] [Indexed: 06/11/2023]
Affiliation(s)
- Rui Morais
- *Rui Morais, MD, Gastroenterology Department, Centro Hospitalar São João, Al. Prof. Hernâni Monteiro, PT–4200-319 Porto (Portugal),
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Brunner M, Belyaev O, Bösch F, Müller-Debus CF, Radulova-Mauersberger O, Wellner UF, Keck T, Uhl W, Werner J, Witzigmann H, Grützmann R. [Indications for the Surgical Management of Pancreatic Cystic Lesions]. Zentralbl Chir 2020; 145:344-353. [PMID: 32498095 DOI: 10.1055/a-1158-9536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
A steady improvement in modern imaging as well as increasing age in society have led to an increasing number of cystic pancreatic tumours being detected. Pancreatic cysts are a clinically challenging entity because they span a broad biological spectrum and their differentiation is often difficult, especially in small tumours. Therefore, they require a differentiated indication for indication of surgery. To determine recommendations for the surgical indication in cystic tumours of the pancreas, a quality committee for pancreatic diseases of the German Society for General and Visceral Surgery performed a systematic literature search and created this review. Based on the current evidence, signs of malignancy and high-risk criteria (icterus due to cystic pancreatic duct obstruction in the bile duct, enhancing mural nodules ≥ 5 mm or solid components in the cyst or pancreatic duct ≥ 10 mm), as well as symptoms, are a surgical indication, independently of the cyst entity (except pseudocysts). If the entity of the pancreatic cyst is detectable by diagnostic imaging, all main duct IPMN and IPMN of the mixed type, all MCN > 4 cm and all SPN should be resected. SCN and branch-duct IPMN without worrisome features do not constitute an indication for surgery. The indication of operation in branch-duct IPMN with relative risk criteria and MCN < 4 cm is the subject of current discussions and should be individualised. By defining indication recommendations, the present work aims to improve the indication quality in cystic pancreatic tumours. However, the surgical indication should always be individualised, taking into account age, comorbidities and the patient's wishes.
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Affiliation(s)
- Maximilian Brunner
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Deutschland
| | - Orlin Belyaev
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum St. Josef-Hospital Bochum, Deutschland
| | - Florian Bösch
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, LMU, Klinikum der Universität München, Deutschland
| | | | | | | | - Tobias Keck
- Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Deutschland
| | - Waldemar Uhl
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum St. Josef-Hospital Bochum, Deutschland
| | - Jens Werner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, LMU, Klinikum der Universität München, Deutschland
| | - Helmut Witzigmann
- Klinik für Allgemein- und Viszeralchirurgie, Städtisches Klinikum Dresden-Friedrichstadt, Deutschland
| | - Robert Grützmann
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Deutschland
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Marinelli V, Secchettin E, Andrianello S, Moretti C, Donvito S, Marchegiani G, Esposito A, Casetti L, Salvia R. Psychological distress in patients under surveillance for intraductal papillary mucinous neoplasms of the pancreas: The "Sword of Damocles" effect calls for an integrated medical and psychological approach a prospective analysis. Pancreatology 2020; 20:505-510. [PMID: 31948794 DOI: 10.1016/j.pan.2020.01.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/19/2019] [Accepted: 01/08/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Most intraductal papillary mucinous neoplasms (IPMNs) of the pancreas can be safely surveilled. Their psychological impact is not known. The aim of this study is to obtain a psychological profile of patients under surveillance and compare the results to patients undergoing surgery. METHODS Patients under surveillance for IPMNs evaluated between 2017 and 2019 at the pancreatic cysts clinic of The Pancreas Institute of Verona were compared to patients undergoing surgery for the same disease. Patients with high-risk stigmata were excluded in both groups. Patients were profiled with the Barratt Simplified Measure of Socio-Economic Status (BSMSS), the Brief Coping Orientation to Problems Experienced (Brief-COPE), the Perceived Stress Scale (PSS), the Symptom Checklist-90 and the Short Form Health Survey (SF-36). Age, sex, BSMSS and Brief-COPE were used to match patients with the propensity score as potential sources of bias. RESULTS Two hundred patients were profiled. After the matching, 74 patients under surveillance were compared to 74 patients who underwent surgery. Patients under surveillance reported significantly increased scores for symptoms such as somatization (0.71 vs. 0.54, p = 0.032), depression (0.45 vs 0.31, p = 0.047) and anxiety (0.45 vs. 0.27, p = 0.002). They also reported a reduced health perception in the domain of physical role functioning (54 vs. 68, p = 0.046). CONCLUSION Patients under surveillance for a presumed IPMN experience anxiety and stress and feel less healthy than do patients undergoing surgery. This reduction in quality of life should always be taken into account and warrants an integrated medical-psychological approach in selected cases.
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Affiliation(s)
- Veronica Marinelli
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Erica Secchettin
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefano Andrianello
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Moretti
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Sara Donvito
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| | - Alessandro Esposito
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luca Casetti
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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21
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EUS-guided confocal laser endomicroscopy: prediction of dysplasia in intraductal papillary mucinous neoplasms (with video). Gastrointest Endosc 2020; 91:551-563.e5. [PMID: 31542380 DOI: 10.1016/j.gie.2019.09.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/10/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Previous studies have validated EUS-guided needle-based confocal laser endomicroscopy (nCLE) diagnosis of intraductal papillary mucinous neoplasms (IPMNs). We sought to derive EUS-guided nCLE criteria for differentiating IPMNs with high-grade dysplasia/adenocarcinoma (HGD-Ca) from those with low/intermediate-grade dysplasia (LGD). METHODS We performed a post hoc analysis of consecutive IPMNs with a definitive diagnosis from a prospective study evaluating EUS-guided nCLE in the diagnosis of pancreatic cysts. Three internal endosonographers reviewed all nCLE videos for the patients and identified potential discriminatory EUS-guided nCLE variables to differentiate HGD-Ca from LGD IPMNs (phase 1). Next, an interobserver agreement (IOA) analysis of variables from phase 1 was performed among 6 blinded external nCLE experts (phase 2). Last, 7 blinded nCLE-naïve observers underwent training and quantified variables with the highest IOA from phase 2 using dedicated software (phase 3). RESULTS Among 26 IPMNs (HGD-Ca in 16), the reference standard was surgical histopathology in 24 and cytology confirmation of metastatic liver lesions in 2 patients. EUS-guided nCLE characteristics of increased papillary epithelial "width" and "darkness" were the most sensitive variables (90%; 95% confidence interval [CI], 84%-94% and 91%; 95% CI, 85%-95%, respectively) and accurate (85%; 95% CI, 78%-90% and 84%; 95% CI, 77%-89%, respectively) with substantial (κ = 0.61; 95% CI, 0.51-0.71) and moderate (κ = 0.55; 95% CI, 0.45-0.65) IOAs for detecting HGD-Ca, respectively (phase 2). Logistic regression models were fit for the outcome of HGD-Ca as predictor variables (phase 3). For papillary width (cut-off ≥50 μm), the sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) for detection of HGD-Ca were 87.5% (95% CI, 62%-99%), 100% (95% CI, 69%-100%), and 0.95, respectively. For papillary darkness (cut-off ≤90 pixel intensity), the sensitivity, specificity, and AUC for detection of HGD-Ca were 87.5% (95% CI, 62%-99%), 100% (95% CI, 69%-100%), and 0.90, respectively. CONCLUSIONS In this derivation study, quantification of papillary epithelial width and darkness identified HGD-Ca in IPMNs with high accuracy. These quantifiable variables can be used in multicenter studies for risk stratification of IPMNs. (Clinical trial registration number: NCT02516488.).
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22
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Farrell JJ. Does Pancreatic Cyst Stability Justify Stopping Intraductal Papillary Mucinous Neoplasm Surveillance? Gastroenterology 2020; 158:44-46. [PMID: 31738923 DOI: 10.1053/j.gastro.2019.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Indexed: 12/16/2022]
Affiliation(s)
- James J Farrell
- Yale Center for Pancreatic Disease, Center for Advanced Endoscopy, Yale School of Medicine, New Haven, Connecticut.
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23
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Lara LF, Luthra A, Conwell DL, Krishna SG. Pancreatic Cysts in the Elderly. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2019; 17:457-469. [PMID: 31707690 DOI: 10.1007/s11938-019-00260-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE OF REVIEW Incidental pancreatic cysts are common, and management strategies continue to evolve. This review summarizes diagnostic and management recommendations in older patients with these lesions based on guidelines and best clinical evidence. RECENT FINDINGS Diagnosis of cyst type has been enhanced with improved imaging and cyst fluid analysis and visualization. Recent outcome studies indicate that certain cyst types should be followed independent of patient age as long as certain criteria which are reviewed are met. Differentiation of pancreatic cyst type is important as this dictates the need for long-term follow-up. Because most cyst-related neoplasia occurs in older patients, surveillance should continue within certain guidelines.
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Affiliation(s)
- Luis F Lara
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA.
| | - Anjuli Luthra
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W 12th Avenue, Room 226, Columbus, OH, 43210, USA
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"Trivial" Cysts Redefine the Risk of Cancer in Presumed Branch-Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Potential Target for Follow-Up Discontinuation? Am J Gastroenterol 2019; 114:1678-1684. [PMID: 31449158 DOI: 10.14309/ajg.0000000000000378] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The management of small and incidental branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) still is of concern. The aim is assessing the safety of a surveillance protocol through the evaluation of their progression to malignancy. METHODS All presumed BD-IPMNs observed from 2000 to 2016 were included. Only patients presenting without worrisome features (WFs) and high-risk stigmata (HRS) at diagnosis were included. Development of WF, HRS, pancreatic cancer (PC), and survival were analyzed. BD-IPMNs were defined as trivial in the continuing absence of WF/HRS after 5 years of surveillance. The age-specific standardized incidence ratio of PC in the general population was used for comparison. RESULTS A total of 1,036 BD-IPMNs without WF/HRS at diagnosis were included, 4.2% developed WF or HRS, and 1.1% developed PC after a median of 62 months. The median cyst growth rate was 0 mm/yr. A growth rate ≥2.5 mm/yr and the development of WF resulted independent predictors of PC. The standardized incidence ratio of PC for trivial BD-IPMN (n = 378) was 22.45 (95% confidence interval 8.19-48.86), but considering only patients aged >65 years (n = 198), it decreased to 3.84 (95% confidence interval 0.77-11.20). DISCUSSION Surveillance of the vast majority of presumed BD-IPMNs is safe, as the risk of PC is comparable to postoperative mortality of pancreatic surgery. A growth rate ≥2.5 mm/yr is the main predictor of PC, reinforcing the role of repeated observations. A trivial BD-IPMN in patients aged >65 years might not increase the risk of developing PC compared with general population, identifying potential targets for follow-up discontinuation.
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Multi-institutional Validation Study of Pancreatic Cyst Fluid Protein Analysis for Prediction of High-risk Intraductal Papillary Mucinous Neoplasms of the Pancreas. Ann Surg 2019; 268:340-347. [PMID: 28700444 DOI: 10.1097/sla.0000000000002421] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Preliminary work by our group suggested that proteins within the pancreatic cyst fluid (CF) may discriminate degree of IPMN dysplasia. We sought to externally validate these markers and determine whether their inclusion in a preoperative clinical nomogram could increase diagnostic accuracy. SUMMARY BACKGROUND DATA IPMN is the most common radiographically identifiable precursor to pancreatic cancer; however, the timing and frequency of its malignant progression are unknown, and there are currently no reliable preoperative tests that can determine the grade of dysplasia in IPMN. METHODS Clinical and radiographic data, as well as CF samples, were obtained from 149 patients who underwent resection for IPMN at 1 of 3 institutions. High-risk disease was defined as the presence of high-grade dysplasia or invasive carcinoma. Multianalyte bead array analysis (Luminex) of CF was performed for 4 protein markers that were previously associated with high-risk disease. Logistic regression models were fit on training data, with and without adjustment for a previously developed clinical nomogram and validated with an external testing set. The models incorporating clinical risk score were presented graphically as nomograms. RESULTS Within the group of 149 resected patients, 89 (60%) had low-risk disease, and 60 (40%) had high-risk disease. All 4 CF markers (MMP9, CA72-4, sFASL, and IL-4) were overexpressed in patients with high-risk IPMN (P < 0.05). Two predictive models based on preselected combinations of CF markers had concordance indices of 0.76 (Model-1) and 0.80 (Model-2). Integration of each CF marker model into a previously described clinical nomogram leads to increased discrimination compared with either the CF models or nomogram alone (c-indices of 0.84 and 0.83, respectively). CONCLUSIONS This multi-institutional study validated 2 CF protein marker models for preoperative identification of high-risk IPMN. When combined with a clinical nomogram, the ability to predict high-grade dysplasia was even stronger.
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26
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Contrast–enhanced endoscopic ultrasound diagnosis of the intraductal papillary mucinous neoplasm. Clin J Gastroenterol 2019; 13:120-126. [DOI: 10.1007/s12328-019-01008-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 06/17/2019] [Indexed: 12/28/2022]
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27
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Kaura T, Willingham FF, Chawla S. Role of pancreatoscopy in management of pancreatic disease: A systematic review. World J Gastrointest Endosc 2019; 11:155-167. [PMID: 30788034 PMCID: PMC6379742 DOI: 10.4253/wjge.v11.i2.155] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/30/2018] [Accepted: 01/23/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Per-oral pancreatoscopy (POP) plays a role in the diagnosis and therapy of pancreatic diseases. With recent technological advances, there has been renewed interest in this modality.
AIM To evaluate the efficacy and safety of POP in management of pancreatic stone disease and pancreatic ductal neoplasia.
METHODS To determine the safety and efficacy of POP in the management of pancreatic diseases, a systematic search was conducted in MEDLINE, EMBASE and Ovid. Articles in languages other than English and case reports were excluded. All published case series were eligible. Data specific to POP were extracted from studies, which combined cholangiopancreatoscopy. Ten studies were included in the analysis of POP therapy for pancreatic stone disease, and 15 case series satisfied the criteria for inclusion for the role of POP in the management of pancreatic ductal neoplasia. The examined data were subcategorized according to adjunctive modalities, such as direct tissue sampling, cytology, the role of intraoperative POP, intraductal ultrasound (IDUS) and POP combined with image-enhancing technology.
RESULTS The success rate for complete ductal stone clearance ranged from 37.5%-100%. Factors associated with failure included the presence of strictures, multiple stones and the inability to visualize the target area. Although direct visualization can identify malignant and premalignant conditions, there is significant overlap with benign diseases. Visually-directed biopsies provide a high degree of accuracy, and represent a unique approach for tissue acquisition in patients with ductal abnormalities. Addition of pancreatic fluid cytology increases diagnostic yield for indeterminate lesions. Protrusions larger than 3 mm noted on IDUS are significantly more likely to be associated with malignancy. The rate of adverse events associated with POP ranged from 0%-35%.
CONCLUSION Current evidence supports wider adoption of pancreatoscopy, as it is safe and effective. Improved patient selection and utilization of novel technologies may further enhance its role in managing pancreatic disease.
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Affiliation(s)
- Tarun Kaura
- Division of Gastroenterology and Hepatology, Aurora St Luke’s Medical center, University of Wisconsin School of Medicine and Public Health, Milwaukee, WI 53215, United States
| | - Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Saurabh Chawla
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, United States
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Abstract
Intraductal papillary mucinous neoplasm (IPMN) is the most common pancreatic cystic neoplasm (PCN). The increased attention to IPMN is due to its unique features of malignant progression, being different between main duct IPMN and branch duct IPMN, and increased de novo development of conventional pancreatic ductal adenocarcinoma elsewhere in the pancreas. The increased interest in IPMN led to publication of many guidelines on its clinical management. This chapter aims to summarize and compare characteristics of nine guidelines on the clinical management of IPMN and other PCNs published in the English literature and further to show a current strategy for surgical decision making in the management of IPMN.
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Affiliation(s)
- Masao Tanaka
- Shimonoseki City Hospital, Kyushu University, Shimonoseki, Yamaguchi, Japan.
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Al Efishat M, Allen PJ. ASO Author Reflections: Progression after Resection of Noninvasive or Microinvasive Intraductal Papillary Mucinous Neoplasms. Ann Surg Oncol 2018; 25:822-823. [PMID: 30324467 DOI: 10.1245/s10434-018-6915-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Mohammad Al Efishat
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Peter J Allen
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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30
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Levink I, Bruno MJ, Cahen DL. Management of Intraductal Papillary Mucinous Neoplasms: Controversies in Guidelines and Future Perspectives. ACTA ACUST UNITED AC 2018; 16:316-332. [PMID: 30196428 PMCID: PMC6153570 DOI: 10.1007/s11938-018-0190-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Purpose of review Management of intraductal papillary mucinous neoplasm (IPMN) is currently based on consensus, in the absence of evidence-based guidelines. In recent years, several consensus guidelines have been published, with distinct management strategies. In this review, we will discuss these discrepancies, in order to guide treating physicians in clinical management. Recent findings The detection rate of pancreatic cysts has increased substantially with the expanded use of high-quality imaging techniques to up to 45%. Of these cysts, 24–82% are IPMNs, which harbour a malignant potential. Timely detection of high-risk lesions is therefore of great importance. Surgical management is based on the presence of clinical and morphological high-risk features, yet the majority of resected specimens appear to be low risk. Summary International collaboration and incentive large-scale prospective registries of individuals undergoing cyst surveillance are needed to accumulate unbiased data and develop evidence-based guidelines. Additionally, development of non-invasive, accurate diagnostic tools (e.g. biomarkers) is needed to differentiate between neoplastic and non-neoplastic pancreatic cysts and detect malignant transformation at an early stage (i.e. high-grade dysplasia).
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Affiliation(s)
- Ijm Levink
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands.
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - D L Cahen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Centre, Floor Na-6, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
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Abstract
PURPOSE OF REVIEW With recent advances in radiographic testing, there have been increases in the incidental identification of pancreatic cysts. Determining management, specifically, which cysts can be watched versus intervened upon has significant impact on at the patient-physician level as well as globally on resource allocation and healthcare expenditures. This review focuses on the three main guidelines (Fukuoka guidelines, European consensus, and American Gastroenterological Association recommendations) for management of pancreatic cystic disease after incidental identification. RECENT FINDINGS There are iterant revisions to each set of recommendations every few years as new data is published on the subject. This review encompasses the most up-to-date recommendations for management while also providing a framework for conceptualizing work-up for varying types of pancreatic cystic disease before and after incidental identification. SUMMARY Pancreatic cystic disease should be approached in thoughtful clinical manner, and each cyst should be evaluated in the context of patient's health and healthcare goals. All cysts, however, should be considered malignant until proven otherwise. Applications of different diagnostic modalities like MRI and EUS with FNA can better characterize cystic lesions and assess malignant potential. Resection should always be considered in cysts with concerning features. If deferred, surveillance should be continued indefinitely. Early termination of surveillance risks future malignant progression.
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Andrianello S, Falconi M, Salvia R, Crippa S, Marchegiani G. Surveillance of Cystic Lesions of the Pancreas: Whom and How to Survey? Visc Med 2018; 34:202-205. [PMID: 30140686 DOI: 10.1159/000489240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The sudden prevalence increase of pancreatic cystic neoplasms (PCN) related to the use of cross-sectional imaging has raised several concerns. Even if there is a tangible risk of progression towards pancreatic cancer (PC), surgical resection cannot be offered to all patients due to the high risk of morbidity and mortality. Available guidelines are useful tools to identify patients at higher risk for harboring cancer thanks to their sensitivity. Because of their low specificity, however, such a risk is often overestimated. Recent evidence deriving from large observational series of surveilled patients suggests that the overall risk of PC is low. A large proportion of patients affected by PCN can be safely observed over time. Several follow-up schedules have been proposed in guidelines but none of them proved to be the most cost-effective. Moreover, it must still be demonstrated that any surveillance protocol can be associated with a reduction in PC-related mortality. By now, with most studies reporting a lifelong risk of malignancy, the only evidence-based recommendation regarding surveillance is that follow-up should never be discontinued as repeated observations are crucial for PC risk stratification.
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Affiliation(s)
- Stefano Andrianello
- Pancreatic Surgery Unit of the Department of Surgery, Verona University Hospital, Verona, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy
| | - Roberto Salvia
- Pancreatic Surgery Unit of the Department of Surgery, Verona University Hospital, Verona, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy
| | - Giovanni Marchegiani
- Pancreatic Surgery Unit of the Department of Surgery, Verona University Hospital, Verona, Italy
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Intraductal Papillary Mucinous Neoplasm of the Pancreas as the Main Focus for Early Detection of Pancreatic Adenocarcinoma. Pancreas 2018; 47:544-550. [PMID: 29702531 DOI: 10.1097/mpa.0000000000001047] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
For early detection of pancreatic cancer, interests are now focused on the detection of high-risk individuals to undergo screening examinations. Intraductal papillary mucinous neoplasm (IPMN) is a unique dual precursor of pancreatic cancer, characterized by progression to invasive cancer and the development of pancreatic adenocarcinoma either concomitantly (synchronous occurrence) or even after resection of IPMN (metachronous occurrence). Careful examination and surveillance of patients with IPMN may therefore lead to early detection of pancreatic cancer. By reviewing only reports describing detailed breakdown of the morphological types of IPMN and numbers of patients with noninvasive and invasive carcinoma in each type, the rough frequencies of noninvasive carcinoma in main duct IPMNs and branch duct IPMNs (BD-IPMNs) are 20% and 10%, respectively, and those of invasive carcinoma are 40% and 13%, respectively. Roughly 5% of all patients with IPMN had concomitant adenocarcinoma. The real frequency of carcinoma in BD-IPMNs would be far lower because most patients with small asymptomatic BD-IPMNs do not undergo resection. Intraductal papillary mucinous neoplasm can be the main focus for early detection of pancreatic cancer to achieve favorable prognosis after surgical resection. The optimal protocol for surveillance and method for early detection of pancreatic cancer are to be determined.
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Abstract
Evidence-based guidelines on the management of pancreatic cystic neoplasms (PCN) are lacking. This guideline is a joint initiative of the European Study Group on Cystic Tumours of the Pancreas, United European Gastroenterology, European Pancreatic Club, European-African Hepato-Pancreato-Biliary Association, European Digestive Surgery, and the European Society of Gastrointestinal Endoscopy. It replaces the 2013 European consensus statement guidelines on PCN. European and non-European experts performed systematic reviews and used GRADE methodology to answer relevant clinical questions on nine topics (biomarkers, radiology, endoscopy, intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystic neoplasm, rare cysts, (neo)adjuvant treatment, and pathology). Recommendations include conservative management, relative and absolute indications for surgery. A conservative approach is recommended for asymptomatic MCN and IPMN measuring <40 mm without an enhancing nodule. Relative indications for surgery in IPMN include a main pancreatic duct (MPD) diameter between 5 and 9.9 mm or a cyst diameter ≥40 mm. Absolute indications for surgery in IPMN, due to the high-risk of malignant transformation, include jaundice, an enhancing mural nodule >5 mm, and MPD diameter >10 mm. Lifelong follow-up of IPMN is recommended in patients who are fit for surgery. The European evidence-based guidelines on PCN aim to improve the diagnosis and management of PCN.
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Al Efishat M, Attiyeh MA, Eaton AA, Gönen M, Basturk O, Klimstra D, D'Angelica MI, DeMatteo RP, Kingham TP, Balachandran V, Jarnagin WR, Allen PJ. Progression Patterns in the Remnant Pancreas after Resection of Non-Invasive or Micro-Invasive Intraductal Papillary Mucinous Neoplasms (IPMN). Ann Surg Oncol 2018; 25:1752-1759. [PMID: 29589164 DOI: 10.1245/s10434-018-6445-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although IPMN are thought to represent a whole-gland disease, segmental resection remains the most frequently performed treatment. We sought to determine the rates, patterns, and predictors of IPMN progression in the pancreatic remnant following segmental resection of noninvasive or microinvasive IPMN. METHODS A prospectively maintained database was queried to identify all patients who underwent resection of noninvasive or microinvasive IPMN (≤ 10 mm of invasive component) between 1989 and 2015. Progression (recurrence) was defined as either the development of cancer, a new IPMN cystic lesion > 1 cm or ≥ 50% increase in the diameter of residual IPMN lesions in the remnant. Univariate and multivariate cox regression models were created to determine predictors of progression. RESULTS A total of 319 patients underwent resection for noninvasive and microinvasive IPMN. The median age was 68, 53% had branch-duct (BD) IPMN, and 6% had microinvasive disease. After a median follow-up of 42 months, 71 patients (22%) experienced IPMN progression. Within this group of 71 patients, 11 (16% of recurrence) developed invasive cancer in the pancreatic remnant after a median of 28 months. Twelve patients (17%) experienced progression > 5 years following initial resection. On multivariate analysis, a distal location of the initial lesion was associated with an increased risk of progression (multivariate hazards ratio = 2.43, confidence interval 1.47-4.0, p < 0.001). CONCLUSIONS In this study, 22% of patients had disease progression following resection of noninvasive or microinvasive IPMN; 16% of these progressions represented invasive disease. These patients represent a high-risk group and should undergo long-term radiographic surveillance.
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Affiliation(s)
- Mohammad Al Efishat
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marc A Attiyeh
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anne A Eaton
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mithat Gönen
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Olca Basturk
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Klimstra
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael I D'Angelica
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ronald P DeMatteo
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - T Peter Kingham
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vinod Balachandran
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William R Jarnagin
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter J Allen
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Marchegiani G, Andrianello S, Borin A, Dal Borgo C, Perri G, Pollini T, Romanò G, D'Onofrio M, Gabbrielli A, Scarpa A, Malleo G, Bassi C, Salvia R. Systematic review, meta-analysis, and a high-volume center experience supporting the new role of mural nodules proposed by the updated 2017 international guidelines on IPMN of the pancreas. Surgery 2018; 163:1272-1279. [PMID: 29454468 DOI: 10.1016/j.surg.2018.01.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 12/19/2017] [Accepted: 01/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Mural nodules (MNs) have a predominant role in the 2016 revision of the international guidelines on intraductal papillary mucinous neoplasms (IPMN) of the pancreas. The aim of this study was to evaluate MNs as predictors of invasive cancer (iCa) or high-grade dysplasia (HGD) in IPMNs and to investigate the role of MN size in risk prediction. METHODS A PRISMA-compliant systematic review of the literature and meta-analysis on selected studies were conducted. The random effect model was adopted, and the pooled SMD (standardized mean difference) obtained. The surgical series of IPMNs at a single high-volume institution was reviewed. RESULTS This review included 70 studies and 2297 resected IPMNs. MNs have a positive predictive value for malignancy of 62.2%. The meta-analysis suggested that MN size has a considerable effect on predicting IPMNs with both iCa or HGD with a mean SMD of 0.79. All studies included in the meta-analysis used contrast-enhanced endosonography (CE-EUS) to assess MNs. Due to the heterogeneity of the proposed thresholds, no reliable MN size cut-off was identified. Of 317 IPMNs resected at our institution, 102 (32.1%) had a preoperative diagnosis of MN. Multivariate analysis showed that MN is the only independent predictor of iCa and HGD for all types of IPMNs. CONCLUSION MNs are reliable predictors of iCa and HGD in IPMNs as proposed by the 2016 IAP guidelines. CE-EUS seems to be the best tool for characterizing size and has the best accuracy for predicting malignancy. Further studies should determine potential MN dimensional cut-offs.
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Affiliation(s)
- Giovanni Marchegiani
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefano Andrianello
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alex Borin
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Chiara Dal Borgo
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giampaolo Perri
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Tommaso Pollini
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giorgia Romanò
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Mirko D'Onofrio
- Radiology, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Armando Gabbrielli
- Gastroenterology and Digestive Endoscopy, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Aldo Scarpa
- Pathology, ARCNet Research Center, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
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Significance of microcystic, elongated, and fragmented glandular-like features in intraductal papillary mucinous neoplasm of the pancreas. Hum Pathol 2018; 78:18-27. [PMID: 29410139 DOI: 10.1016/j.humpath.2018.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/19/2018] [Accepted: 01/24/2018] [Indexed: 11/21/2022]
Abstract
Microcystic, elongated, and fragmented (MELF) glandular features are associated with epithelial-mesenchymal transition, invasion, and progression in endometrioid adenocarcinoma of the uterus. Similar histological features are also observed at the periphery of pancreatic intraductal papillary mucinous neoplasms (IPMNs). However, the clinicopathological significance of MELF-like features-particularly whether they represent regenerative or truly neoplastic conditions-in IPMNs remains unclear. We assessed a total of 152 surgically resected IPMNs. Fifty cases exhibited MELF-like features, including 26 cases of IPMNs with accompanying adenocarcinomas and 24 cases of IPMNs without accompanying adenocarcinomas. MELF-like features were more frequently observed in IPMN cases with accompanying adenocarcinomas, larger tumors, main-duct type, and non-gastric histologic subtype. A positive correlation between the presence of MELF-like features and high-grade dysplasia was observed in IPMNs without accompanying adenocarcinomas. Moreover, DPC4 loss and p53 overexpression in MELF-like glands were more commonly observed in IPMNs with high-grade dysplasia. IPMN patients with MELF-like features had worse overall and disease-specific survival by univariate analyses. Our observations suggest that MELF-like features in some IPMNs with high-grade dysplasia could be related to stromal invasion. Hence, when MELF-like features are observed in IPMNs, pathologists should carefully evaluate the results of microscopic examinations to identify the invasive components; and, immunohistochemical staining for DPC4 and p53 could help clarify its clinicopathological significance.
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Manuel-Vazquez A, Ramia JM, Latorre-Fragua R, Valle-Rubio A, Arteaga-Peralta V, Ramiro-Pérez C, de la Plaza-Llamas R. Pancreatic Neuroendocrine Tumors and Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Systematic Review. Pancreas 2018; 47:551-555. [PMID: 29683974 DOI: 10.1097/mpa.0000000000001048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study aimed to identify factors that explain the association of intraductal papillary mucinous neoplasms-pancreatic neuroendocrine tumors (IPMNs-PNETs), radiological characteristics, and factors that might guide therapy. METHODS We performed a systematic review of the literature to search for articles on concurrent IPMN-PNET, mixed endocrine-exocrine pancreatic tumors, and/or PNET with an intraductal growth pattern. RESULTS A review of the literature suggests that there is some confusion about association of IPMNs-PNETs. Regarding this association, the studies collected data from 32 patients. Eleven patients presented concurrent tumors, 9 mixed endocrine-exocrine tumors, and no data were available in the remaining 7. In addition, the relationship IPMN-PNET focuses not only on the coexistence of the 2 lesions, but also on the possibility of the intraductal growth of the endocrine lesion. In the literature, in 4 cases, the preoperative radiological diagnosis had been IPMN. CONCLUSIONS Intraductal papillary mucinous neoplasms and PNETs may be associated in a number of scenarios. The association may be due to the concurrent existence of independent lesions, may be a mixed endocrine-exocrine tumor, or may be due to intraductal growth of the endocrine lesion. But the literature is confusing. It is not known whether the association is accidental or whether there is an etiological reason. Further studies are needed to investigate this scenario.
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Affiliation(s)
- Alba Manuel-Vazquez
- From the Department of General and Digestive Surgery, University Hospital of Guadalajara, Guadalajara, Spain
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Development and Validation of a Multi-institutional Preoperative Nomogram for Predicting Grade of Dysplasia in Intraductal Papillary Mucinous Neoplasms (IPMNs) of the Pancreas: A Report from The Pancreatic Surgery Consortium. Ann Surg 2017; 267:157-163. [PMID: 28079542 DOI: 10.1097/sla.0000000000002015] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Previous nomogram models for patients undergoing resection of intraductal papillary mucinous neoplasms (IPMNs) have been relatively small single-institutional series. Our objective was to improve upon these studies by developing and independently validating a new model using a large multiinstitutional dataset. SUMMARY BACKGROUND DATA IPMNs represent the most common radiographically identifiable precursor lesions of pancreatic cancer. They are a heterogenous group of neoplasms in which more accurate markers of high-grade dysplasia or early invasive carcinoma could help avoid unnecessary surgery in 1 case and support potentially curative intervention (resection) in another. METHODS Prospectively maintained databases from 3 institutions were queried for patients who had undergone resection of IPMNs between 2005 and 2015. Patients were separated into main duct [main and mixed-type (MD)] and branch duct (BD) types based on preoperative imaging. Logistic regression modeling was used on a training subset to develop 2 independent nomograms (MD and BD) to predict low-risk (low- or intermediate-grade dysplasia) or high-risk (high-grade dysplasia or invasive carcinoma) disease. Model performance was then evaluated using an independent validation set. RESULTS We identified 1028 patients who underwent resection for IPMNs [MD: n = 454 (44%), BD: n = 574 (56%)] during the 10-year study period. High-risk disease was present in 487 patients (47%). Patients with high-risk disease comprised 71% and 29% of MD and BD groups, respectively (P <0.0001). MD and BD nomograms were developed on the training set [70% of total (n = 720); MD: n = 318, BD: n = 402] and validated on the test set [30% (n = 308); MD: n = 136, BD: n = 172]. The presence of jaundice was almost exclusively associated with high-risk disease (57 of 58 patients, 98%). Cyst size >3.0 cm, solid component/mural nodule, pain symptoms, and weight loss were significantly associated with high-risk disease. C-indices were 0.82 and 0.81 on training and independent validation sets, respectively; Brier scores were 0.173 and 0.175, respectively. CONCLUSIONS For patients with suspected IPMNs, we present an independently validated model for the prediction of high-risk disease.
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Efficacy, Safety, and Outcomes of Endoscopic Retrograde Cholangiopancreatography With Per-Oral Pancreatoscopy: A Multicenter Experience. J Clin Gastroenterol 2017; 51:e101-e105. [PMID: 28059943 DOI: 10.1097/mcg.0000000000000796] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Per-oral pancreatoscopy can be used for both evaluation and treatment of pancreatic duct stones during endoscopic retrograde cholangiopancreatography, evaluating and treating pancreatic duct strictures of indeterminate etiology, and visual inspection and direct biopsy of pancreatic duct mucosa for diagnosis of intraductal papillary mucinous neoplasm (IPMN). We aim to describe the efficacy, safety, and outcomes of pancreatoscopy in a large, multicenter series of patients. MATERIALS AND METHODS A multicenter retrospective review was conducted of all patients who underwent per-oral pancreatoscopy at 2 large tertiary-care medical centers. Review of relevant medical records, laboratory data, imaging studies, endoscopic procedure notes, telephone follow-up notes, and progress notes was performed. RESULTS Thirty-three patients underwent 41 pancreatoscopy procedures. Indications included: 20 (48.8%) for diagnosis and treatment of pancreatic duct stones, 16 (39%) for investigation of IPMN, and 5 (12.2%) for evaluation of pancreatic duct strictures.In 20 procedures performed for stone disease, complete pancreatic duct clearance was achieved in 17 of 20 (85%) cases. Strictures were successfully dilated in 5 of 5 (100%) procedures. Direct visualization and biopsy demonstrated IPMN in 11 of 11 (100%) cases. Adverse events occurred in 3 of 41 (7.3%) of procedures, all of which were mild. CONCLUSIONS In this large series, we demonstrate that in patients with difficult to manage stone disease, strictures and possible malignant ductal pathology, pancreatoscopy is an effective and safe tool that can facilitate both diagnosis and effective therapy. Adverse events in our study were mild and within acceptable limits, further demonstrating that this is a safe procedure that should be offered to appropriate patients.
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Pak LM, D'Angelica MI, DeMatteo RP, Kingham TP, Balachandran VP, Jarnagin WR, Allen PJ. Natural History of Patients Followed Radiographically with Mucinous Cysts of the Pancreas. J Gastrointest Surg 2017; 21:1599-1605. [PMID: 28516310 PMCID: PMC5693653 DOI: 10.1007/s11605-016-3338-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 11/23/2016] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the outcome of patients presumed to have mucinous cysts of the pancreas who were initially selected for radiographic surveillance. METHODS Patients with a pancreatic cyst and a measured cyst fluid carcinoembryonic antigen (CEA) ≥192 ng/mL were included. Patients were stratified by those who underwent initial resection and those who were recommended for radiographic surveillance. The natural history of these two groups was examined. RESULTS From 1999 to 2014, 227 patients were identified who had a cyst fluid CEA ≥192 ng/mL (median 961, range 192-300,000 ng/mL). Immediate resection was performed on 63 patients (28%). Initial radiographic surveillance was recommended for 164 patients; 87% did not have main pancreatic duct dilation, and 87% met consensus criteria for radiographic surveillance. After a median follow-up of 56 months, 48 of the 164 patients (29%) had undergone resection. Ultimately, there were three cases (2%) of high-grade dysplasia and two cases of invasive carcinoma (1%) within these 164 patients selected for observation. Three of the five cases of either high-grade dysplasia or invasive carcinoma were among the 22 patients followed outside of consensus guidelines. CONCLUSIONS Appropriately selected patients with mucinous pancreatic cysts can be safely followed with serial surveillance with a low risk of malignant progression.
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Affiliation(s)
- Linda M Pak
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-896, New York, NY, 10065, USA
| | - Michael I D'Angelica
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-896, New York, NY, 10065, USA
| | - Ronald P DeMatteo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-896, New York, NY, 10065, USA
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-896, New York, NY, 10065, USA
| | - Vinod P Balachandran
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-896, New York, NY, 10065, USA
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-896, New York, NY, 10065, USA
| | - Peter J Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-896, New York, NY, 10065, USA.
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Brunner M, Weber GF, Kersting S, Grützmann R. [Branch duct intraductal papillary mucinous neoplasm - contra resection]. Chirurg 2017; 88:918-926. [PMID: 28871376 DOI: 10.1007/s00104-017-0495-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Due to improvements in imaging modalities the diagnosis of branch duct intraductal papillary mucinous neoplasms (BD-IPMN) has been significantly increased in recent years. A BD-IPMN is frequently diagnosed as an incidental finding in asymptomatic patients. The optimal management of BD-IPMN is the subject of controversial discussions. Numerous studies have shown that an individualized therapeutic strategy with a follow-up observation of most BD-IPMNs is feasible and safe, considering age, comorbidities and patient preference. An accurate evaluation of BD-IPMN with a detailed anamnesis, high-resolution imaging techniques and endoscopic ultrasound is necessary. Symptomatic patients as well as patients with so-called high-risk stigmata should undergo resection. Asymptomatic patients with so-called worrisome features can either undergo surveillance or surgical resection, taking age and comorbidities into account. For BD-IPMN patients without high-risk stigmata and worrisome features and showing no symptoms, surveillance of the pancreatic lesion is the preferred approach. The high prevalence of BD-IPMN, limitations in differential diagnostics, an overestimation of the risk of malignancy due to an overrepresentation of symptomatic and suspected BD-IPMN in resected cohorts, an overestimated role of BD-IPMN as precursor lesions for pancreatic carcinoma and evidence of the safety of follow-up surveillance, underline the enormous importance of surveillance. Based on this and considering the background of a notable mortality and morbidity of pancreatic surgery, aggressive management with prophylactic surgical resection is not justified for all BD-IPMN, in particular for low-risk lesions.
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Affiliation(s)
- M Brunner
- Klink für Allgemein- und Viszeralchirurgie, Universitätsklinikum der Friedrich-Alexander-Universität, Krankenhausstraße 12, 91054, Erlangen, Deutschland
| | - G F Weber
- Klink für Allgemein- und Viszeralchirurgie, Universitätsklinikum der Friedrich-Alexander-Universität, Krankenhausstraße 12, 91054, Erlangen, Deutschland
| | - S Kersting
- Klink für Allgemein- und Viszeralchirurgie, Universitätsklinikum der Friedrich-Alexander-Universität, Krankenhausstraße 12, 91054, Erlangen, Deutschland
| | - Robert Grützmann
- Klink für Allgemein- und Viszeralchirurgie, Universitätsklinikum der Friedrich-Alexander-Universität, Krankenhausstraße 12, 91054, Erlangen, Deutschland.
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Aronsson L, Andersson R, Ansari D. Intraductal papillary mucinous neoplasm of the pancreas - epidemiology, risk factors, diagnosis, and management. Scand J Gastroenterol 2017; 52:803-815. [PMID: 28446039 DOI: 10.1080/00365521.2017.1318948] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Intraductal papillary mucinous neoplasm (IPMN) is one of the most common cystic neoplasms of the pancreas. It is a heterogeneous disease and can be divided into ductal types and morphological subtypes. The incidence of IPMN is increasing, likely due to the widespread use of cross-sectional imaging and a growing elderly population. IPMN poses an increasing demand on the health care system. Current guidelines provide indications for surgery and recommendations for surveillance, but management of IPMN is still challenging in routine clinical practice. In this article, we review current knowledge about IPMN and provide future directions for improving diagnosis and management.
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Affiliation(s)
- Linus Aronsson
- a Department of Clinical Sciences Lund, Surgery , Lund University, Skane University Hospital , Lund , Sweden
| | - Roland Andersson
- a Department of Clinical Sciences Lund, Surgery , Lund University, Skane University Hospital , Lund , Sweden
| | - Daniel Ansari
- a Department of Clinical Sciences Lund, Surgery , Lund University, Skane University Hospital , Lund , Sweden
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Tanaka M, Fernández-Del Castillo C, Kamisawa T, Jang JY, Levy P, Ohtsuka T, Salvia R, Shimizu Y, Tada M, Wolfgang CL. Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology 2017; 17:738-753. [PMID: 28735806 DOI: 10.1016/j.pan.2017.07.007] [Citation(s) in RCA: 1013] [Impact Index Per Article: 144.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 07/12/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023]
Abstract
The management of intraductal papillary mucinous neoplasm (IPMN) continues to evolve. In particular, the indications for resection of branch duct IPMN have changed from early resection to more deliberate observation as proposed by the international consensus guidelines of 2006 and 2012. Another guideline proposed by the American Gastroenterological Association in 2015 restricted indications for surgery more stringently and recommended physicians to stop surveillance if no significant change had occurred in a pancreatic cyst after five years of surveillance, or if a patient underwent resection and a non-malignant IPMN was found. Whether or not it is safe to do so, as well as the method and interval of surveillance, has generated substantial debate. Based on a consensus symposium held during the meeting of the International Association of Pancreatology in Sendai, Japan, in 2016, the working group has revised the guidelines regarding prediction of invasive carcinoma and high-grade dysplasia, surveillance, and postoperative follow-up of IPMN. As the working group did not recognize the need for major revisions of the guidelines, we made only minor revisions and added most recent articles where appropriate. The present guidelines include updated information and recommendations based on our current understanding, and highlight issues that remain controversial or where further research is required.
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Affiliation(s)
- Masao Tanaka
- Department of Surgery, Shimonoseki City Hospital, Shimonoseki, Japan.
| | | | - Terumi Kamisawa
- Department of Gastroenterology, Komagome Metropolitan Hospital, Tokyo, Japan
| | - Jin Young Jang
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Philippe Levy
- Pôle des Maladies de l'Appareil Digestif, Service de Gastroentérologie-Pancréatologie, Hopital Beaujon, Clichy Cedex, France
| | - Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Yasuhiro Shimizu
- Dept. of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Christopher L Wolfgang
- Cameron Division of Surgical Oncology and The Sol Goldman Pancreatic Cancer Research Center, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
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Ankeny JS, Court CM, Hou S, Li Q, Song M, Wu D, Chen JF, Lee T, Lin M, Sho S, Rochefort MM, Girgis MD, Yao J, Wainberg ZA, Muthusamy VR, Watson RR, Donahue TR, Hines OJ, Reber HA, Graeber TG, Tseng HR, Tomlinson JS. Circulating tumour cells as a biomarker for diagnosis and staging in pancreatic cancer. Br J Cancer 2017; 114:1367-75. [PMID: 27300108 PMCID: PMC4984454 DOI: 10.1038/bjc.2016.121] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 02/18/2016] [Accepted: 04/08/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Current diagnosis and staging of pancreatic ductal adenocarcinoma (PDAC) has important limitations and better biomarkers are needed to guide initial therapy. We investigated the performance of circulating tumour cells (CTCs) as an adjunctive biomarker at the time of disease presentation. METHODS Venous blood (VB) was collected prospectively from 100 consecutive, pre-treatment patients with PDAC. Utilising the microfluidic NanoVelcro CTC chip, samples were evaluated for the presence and number of CTCs. KRAS mutation analysis was used to compare the CTCs with primary tumour tissue. CTC enumeration data was then evaluated as a diagnostic and staging biomarker in the setting of PDAC. RESULTS We found 100% concordance for KRAS mutation subtype between primary tumour and CTCs in all five patients tested. Evaluation of CTCs as a diagnostic revealed the presence of CTCs in 54/72 patients with confirmed PDAC (sensitivity=75.0%, specificity=96.4%, area under the curve (AUROC)=0.867, 95% CI=0.798-0.935, and P<0.001). Furthermore, a cut-off of ⩾3 CTCs in 4 ml VB was able to discriminate between local/regional and metastatic disease (AUROC=0.885; 95% CI=0.800-0.969; and P<0.001). CONCLUSION CTCs appear to function well as a biomarker for diagnosis and staging in PDAC.
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Affiliation(s)
- J S Ankeny
- Department of Surgery, University of California Los Angeles, 575 Westwood Plaza, Los Angeles, CA 90095, USA.,Veteran's Health Administration, Greater Los Angeles, Department of Surgery, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA
| | - C M Court
- Department of Surgery, University of California Los Angeles, 575 Westwood Plaza, Los Angeles, CA 90095, USA.,Veteran's Health Administration, Greater Los Angeles, Department of Surgery, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA
| | - S Hou
- Department of Surgery, University of California Los Angeles, 575 Westwood Plaza, Los Angeles, CA 90095, USA.,Department of Molecular and Medical Pharmacology, Crump Institute for Molecular Imaging, California NanoSystems Institute, University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, CA 90095-1770, USA
| | - Q Li
- Department of Molecular and Medical Pharmacology, Crump Institute for Molecular Imaging, California NanoSystems Institute, University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, CA 90095-1770, USA
| | - M Song
- Department of Molecular and Medical Pharmacology, Crump Institute for Molecular Imaging, California NanoSystems Institute, University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, CA 90095-1770, USA
| | - D Wu
- Department of Molecular and Medical Pharmacology, Crump Institute for Molecular Imaging, California NanoSystems Institute, University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, CA 90095-1770, USA
| | - J F Chen
- Department of Molecular and Medical Pharmacology, Crump Institute for Molecular Imaging, California NanoSystems Institute, University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, CA 90095-1770, USA
| | - T Lee
- California NanoSystems Institute, University of California, 570 Westwood Plaza, Los Angeles, CA 90095, USA
| | - M Lin
- Department of Molecular and Medical Pharmacology, Crump Institute for Molecular Imaging, California NanoSystems Institute, University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, CA 90095-1770, USA
| | - S Sho
- Department of Surgery, University of California Los Angeles, 575 Westwood Plaza, Los Angeles, CA 90095, USA.,Veteran's Health Administration, Greater Los Angeles, Department of Surgery, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA
| | - M M Rochefort
- Department of Surgery, University of California Los Angeles, 575 Westwood Plaza, Los Angeles, CA 90095, USA
| | - M D Girgis
- Department of Surgery, University of California Los Angeles, 575 Westwood Plaza, Los Angeles, CA 90095, USA
| | - J Yao
- Department of Molecular and Medical Pharmacology, Crump Institute for Molecular Imaging, California NanoSystems Institute, University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, CA 90095-1770, USA
| | - Z A Wainberg
- UCLA Center for Pancreatic Diseases, 575 Westwood Plaza, Los Angeles, CA 90095, USA.,Department of Hematology/Oncology, University of California Los Angeles, 575 Westwood Plaza, Los Angeles, CA 90095, USA
| | - V R Muthusamy
- UCLA Center for Pancreatic Diseases, 575 Westwood Plaza, Los Angeles, CA 90095, USA.,Department of Gastroenterology, University of California Los Angeles, 575 Westwood Plaza, Los Angeles, CA 90095, USA
| | - R R Watson
- UCLA Center for Pancreatic Diseases, 575 Westwood Plaza, Los Angeles, CA 90095, USA.,Department of Gastroenterology, University of California Los Angeles, 575 Westwood Plaza, Los Angeles, CA 90095, USA
| | - T R Donahue
- Department of Surgery, University of California Los Angeles, 575 Westwood Plaza, Los Angeles, CA 90095, USA.,UCLA Center for Pancreatic Diseases, 575 Westwood Plaza, Los Angeles, CA 90095, USA
| | - O J Hines
- Department of Surgery, University of California Los Angeles, 575 Westwood Plaza, Los Angeles, CA 90095, USA.,UCLA Center for Pancreatic Diseases, 575 Westwood Plaza, Los Angeles, CA 90095, USA
| | - H A Reber
- Department of Surgery, University of California Los Angeles, 575 Westwood Plaza, Los Angeles, CA 90095, USA.,UCLA Center for Pancreatic Diseases, 575 Westwood Plaza, Los Angeles, CA 90095, USA
| | - T G Graeber
- Department of Molecular and Medical Pharmacology, Crump Institute for Molecular Imaging, California NanoSystems Institute, University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, CA 90095-1770, USA
| | - H R Tseng
- Department of Molecular and Medical Pharmacology, Crump Institute for Molecular Imaging, California NanoSystems Institute, University of California, Los Angeles, 570 Westwood Plaza, Los Angeles, CA 90095-1770, USA
| | - J S Tomlinson
- Department of Surgery, University of California Los Angeles, 575 Westwood Plaza, Los Angeles, CA 90095, USA.,Veteran's Health Administration, Greater Los Angeles, Department of Surgery, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA.,UCLA Center for Pancreatic Diseases, 575 Westwood Plaza, Los Angeles, CA 90095, USA
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46
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Zhang L, Rao SX, Xu XF, Wang DS, Jin DY, Zeng MS. Value of apparent diffusion coefficient for predicting malignancy of intraductal papillary mucinous neoplasms of the pancreas. Diagn Interv Radiol 2017; 22:308-13. [PMID: 27283593 DOI: 10.5152/dir.2016.15354] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE We aimed to explore the potential value of the whole tumor apparent diffusion coefficient (ADC) for discriminating between benign and malignant intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. METHODS Forty-two patients underwent 1.5 T magnetic resonance imaging that included diffusion-weighted imaging (DWI, b=0.500 s/mm2). The mean, minimum, and maximum ADC values were measured for the whole tumor. The differences between benign and malignant IPMNs were calculated for the mean ADC, ADC-min, and ADC-max values. Receiver operating characteristics (ROC) analysis was conducted to evaluate their potential diagnostic performance. RESULTS Fifteen of 25 benign IPMNs demonstrated low or iso-signal intensity on DWI with a b value of 500 s/mm2 compared with normal pancreatic parenchyma, whereas all malignant IPMNs demonstrated high signal intensity. The mean value of ADC was significantly higher in benign IPMNs compared with malignant IPMNs (3.39×10-3 mm2/s vs. 2.39×10-3 mm2/s, P < 0.001), with an area under the ROC curve (AUC) of 0.92 (95% confidence interval [CI], 0.79-0.98). The ADC-min value of malignant IPMNs was also significantly lower than that of benign IPMNs (1.24×10-3 mm2/s vs. 2.58×10-3 mm2/s, P < 0.001), with an AUC of 0.94 (95% CI, 0.82-0.99). No marked difference was found between benign and malignant IPMNs for the ADC-max value (3.89×10-3 mm2/s vs. 3.78×10-3 mm2/s, P = 0.299). CONCLUSION Lower mean and minimum ADC values of the whole tumor might be potential predictors of malignant IPMNs of the pancreas.
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Affiliation(s)
- Lei Zhang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China.
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47
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Megibow AJ, Baker ME, Morgan DE, Kamel IR, Sahani DV, Newman E, Brugge WR, Berland LL, Pandharipande PV. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2017; 14:911-923. [PMID: 28533111 DOI: 10.1016/j.jacr.2017.03.010] [Citation(s) in RCA: 191] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 02/27/2017] [Accepted: 03/13/2017] [Indexed: 12/12/2022]
Abstract
The ACR Incidental Findings Committee (IFC) presents recommendations for managing pancreatic cysts that are incidentally detected on CT or MRI. These recommendations represent an update from the pancreatic component of the JACR 2010 white paper on managing incidental findings in the adrenal glands, kidneys, liver, and pancreas. The Pancreas Subcommittee-which included abdominal radiologists, a gastroenterologist, and a pancreatic surgeon-developed this algorithm. The recommendations draw from published evidence and expert opinion, and were finalized by informal iterative consensus. Algorithm branches successively categorize pancreatic cysts based on patient characteristics and imaging features. They terminate with an ascertainment of benignity and/or indolence (sufficient to discontinue follow-up), or a management recommendation. The algorithm addresses most, but not all, pathologies and clinical scenarios. Our goal is to improve quality of care by providing guidance on how to manage incidentally detected pancreatic cysts.
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Affiliation(s)
- Alec J Megibow
- Department of Radiology, NYU-Langone Medical Center, New York, New York.
| | - Mark E Baker
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio
| | - Desiree E Morgan
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ihab R Kamel
- Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Dushyant V Sahani
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Elliot Newman
- Department of Surgery, NYU-Langone Medical Center, New York, New York
| | - William R Brugge
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lincoln L Berland
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Pari V Pandharipande
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
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48
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Predictive Factors for the Metachronous Development of High-risk Lesions in the Remnant Pancreas After Partial Pancreatectomy for Intraductal Papillary Mucinous Neoplasm. Ann Surg 2017; 263:1180-7. [PMID: 26334637 DOI: 10.1097/sla.0000000000001368] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify factors predicting the development of high-risk lesions in the remnant pancreas after surgery for intraductal papillary mucinous neoplasm (IPMN). BACKGROUND IPMN has unique features, including multifocality, adenoma-carcinoma sequence, and the development of distinct pancreatic ductal adenocarcinoma (PDAC) in the same pancreas. Careful attention should, therefore, be paid to the metachronous occurrence of high-risk lesions, including high-grade dysplasia or invasive carcinoma (HGD/INV) of IPMN and concomitant PDAC in the remnant pancreas after partial pancreatectomy for IPMN. METHODS Clinicopathologic and surveillance data for 195 patients who underwent partial pancreatectomy for IPMN were reviewed retrospectively. RESULTS Thirteen patients exhibited metachronous development of high-risk lesions including 6 HGD/INV and 7 concomitant PDACs in the remnant pancreas. The 5- and 10-year cumulative incidences of metachronous high-risk lesions in the remnant pancreas were 7.8% and 11.8%, respectively. Twelve of 13 patients had high-risk lesions at the time of initial surgery, and 10 of the 13 IPMNs were located in the distal pancreas. The IPMN subtypes initially resected were gastric in 6 patients, intestinal in 5, and pancreatobililary in the remaining 2. Univariate and multiple regression analyses identified pathologic results of HGD/INV and IPMN located in the distal pancreas as independent predictive factors for metachronous HGD/INV of IPMN, and the pancreatobiliary subtype of IPMN and presence of concomitant PDAC for metachronous PDAC. CONCLUSIONS Patients undergoing partial pancreatectomy for IPMN are at high risk of developing lesions requiring surgery in the remnant pancreas, and close, long-term surveillance should be considered in these patients.
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49
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Are the Current Guidelines for the Surgical Management of Intraductal Papillary Mucinous Neoplasms of the Pancreas Adequate? A Multi-Institutional Study. J Am Coll Surg 2017; 224:461-469. [DOI: 10.1016/j.jamcollsurg.2016.12.031] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 01/31/2023]
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50
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Moris M, Wallace MB. Intraductal papillary mucinous neoplasms and mucinous cystadenomas: current status and recommendations. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:358-367. [PMID: 28112959 DOI: 10.17235/reed.2017.4630/2016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The real prevalence of pancreatic cystic lesions remains unknown. The malignant potential of some of these lesions remains a cause for significant concern. Thus, it is mandatory to develop a strategy to clearly discriminate those cysts with a potential for malignant transformation from those that do not carry any significant risk. Intraductal papillary mucinous neoplasms and mucinous cystadenomas are mucinous cystic neoplasms with a known malignant potential that have gained greater recognition in recent years. However, despite the numerous studies that have been carried out, their differential diagnosis among other cysts subtypes and their therapeutic approach continue to be a challenge for clinicians. This review contains a critical approach of the current recommendations and management strategies regarding intraductal papillary mucinous neoplasms and mucinous cystadenomas, as well as highlighting the limitations exposed in current guidelines.
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