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Zhu Y, Mao Y, Wang J, Wang Z, Chen X. Main pancreatic duct involved IPMN without high-risk factors: how to judge the degree of malignancy based on MPD dilation? Medicine (Baltimore) 2024; 103:e39323. [PMID: 39151506 DOI: 10.1097/md.0000000000039323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2024] Open
Abstract
The aim of this study was to evaluate the cutoff value for identifying malignance in main pancreatic duct (MPD)-involved intraductal papillary mucinous neoplasm (IPMN) with an MPD diameter ranging from 5 to 10 mm. Clinical-radiological characteristics of 142 patients, including MPD-involved IPMNs (n = 53) and branch-duct (BD)-IPMNs (n = 89) were analyzed. Logistic regression analysis was used to determine the risk factors of malignant IPMNs and invasive carcinoma. ROC curves were used to identify different cutoffs in terms of preoperative MPD values to predict the presence of invasive carcinoma as well as malignant IPMNs, and the prediction performance was evaluated. For MPD-involved IPMNs (5 mm < MPD < 10 mm), MPD diameter of 7.5 mm for discriminating malignant IPMNs (area under curve [AUC] = 0.67) and 7.7 mm for discriminating invasive IPMNs (AUC = 0.56) were found to be the optimal cutoff values at receiver operating characteristic curve (ROC) analysis. MPD > 7.5 mm and carbohydrate antigen19-9 (Ca19-9) > 37 U/ml were found to be predictors of malignant IPMNs at univariate, and MPD > 7.5 mm was a predictor in multivariate analysis in MPD-involved IPMNs. The AUC of the ROC curve of MPD (7.5 mm) combined with Ca19-9 in identifying malignant IPMNs was 0.73 in MPD-involved IPMNs. MPD (7.5 mm) combined with Ca19-9 performed well in identifying malignant IPMNs in MPD-involved IPMNs.
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Affiliation(s)
- Yong Zhu
- Department of Radiology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Yingfan Mao
- Department of Radiology, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Jianhua Wang
- Department of Radiology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Zhongqiu Wang
- Department of Radiology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Xiao Chen
- Department of Radiology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, Jiangsu Province, China
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Das KK, Scheiman JM. Surveillance of Intraductal Papillary Mucinous Neoplasms: When Is Enough, Actually Enough? Gastroenterology 2023; 165:827-829. [PMID: 37479192 DOI: 10.1053/j.gastro.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/23/2023]
Affiliation(s)
- Koushik K Das
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
| | - James M Scheiman
- Division of Gastroenterology, Michigan Medicine, Ann Arbor, Michigan.
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Chidambaram S, Kawka M, Gall TM, Cunningham D, Jiao LR. Can we predict the progression of premalignant pancreatic cystic tumors to ductal adenocarcinoma? Future Oncol 2022; 18:2605-2612. [PMID: 35730473 DOI: 10.2217/fon-2021-1545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the most prevalent malignant pancreatic tumor. Few studies have shown how often PDACs arise from cystic precursor lesions. This special report aims to summarize the evidence on the progression of precancerous lesions to PDAC. A review of the literature found four studies that discussed pancreatic intraepithelial lesions (PanINs), three that discussed mucinous cystic neoplasms (MCN) and five that discussed intraductal papillary neoplasms (IPMNs). PanINs were the most common precursors lesion, with approximately 80% of PDACs originating from this lesion. The lack of evidence characterizing the features of PDAC precursor cystic lesions potentially leads to a subset of patients undergoing surgery unnecessarily. Advancements in molecular techniques could allow the study of cystic lesions at a genetic level, leading to more personalized management.
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Affiliation(s)
- Swathikan Chidambaram
- Department of Surgery & Cancer, Hammersmith Hospital Campus, Imperial College, London, W12 0HS, UK
- Imperial College London, Exhibition Road, South Kensington, London, SW7 2BU, UK
| | - Michal Kawka
- Imperial College London, Exhibition Road, South Kensington, London, SW7 2BU, UK
| | - Tamara Mh Gall
- Department of Surgery & Cancer, Hammersmith Hospital Campus, Imperial College, London, W12 0HS, UK
- Imperial College London, Exhibition Road, South Kensington, London, SW7 2BU, UK
| | - David Cunningham
- Department of Academic Surgery, The Royal Marsden Hospital, 203 Fulham Road, London, SW3 6JJ, UK
| | - Long R Jiao
- Imperial College London, Exhibition Road, South Kensington, London, SW7 2BU, UK
- Department of Academic Surgery, The Royal Marsden Hospital, 203 Fulham Road, London, SW3 6JJ, UK
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Das KK, Mullady DK. Main Pancreatic Duct Dilation in IPMN: When (and Where) to Get "Worried"? Clin Gastroenterol Hepatol 2022; 20:272-275. [PMID: 33581356 DOI: 10.1016/j.cgh.2021.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Koushik K Das
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel K Mullady
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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Pulvirenti A, Margonis GA, Morales-Oyarvide V, McIntyre CA, Lawrence SA, Goldman DA, Gonen M, Weiss MJ, Ferrone CR, He J, Brennan MF, Cameron JL, Lillemoe KD, Kingham TP, Balachandran V, Qadan M, D’Angelica MI, Jarnagin WR, Wolfgang CL, Castillo CFD, Allen PJ. Intraductal Papillary Mucinous Neoplasms: Have IAP Consensus Guidelines Changed our Approach?: Results from a Multi-institutional Study. Ann Surg 2021; 274:e980-e987. [PMID: 31804389 PMCID: PMC8503800 DOI: 10.1097/sla.0000000000003703] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the influence of consensus guidelines on the management of intraductal papillary mucinous neoplasms (IPMN) and the subsequent changes in pathologic outcomes. BACKGROUND Over time, multiple guidelines have been developed to identify high-risk IPMN. We hypothesized that the development and implementation of guidelines should have increased the percentage of resected IPMN with high-risk disease. METHODS Memorial Sloan-Kettering (MSK), Johns Hopkins (JH), and Massachusetts General Hospital (MGH) databases were queried for resected IPMN (2000-2015). Patients were categorized into main-duct (MD-IPMN) versus branch-duct (BD-IPMN). Guideline-specific radiographic/endoscopic features were recorded. High-risk disease was defined as high-grade dysplasia/carcinoma. Fisher's exact test was used to detect differences between institutions. Logistic regression evaluated differences between time-points [preguidelines (pre-GL, before 2006), Sendai (SCG, 2006-2012), Fukuoka (FCG, after 2012)]. RESULTS The study included 1210 patients. The percentage of BD-IPMN with ≥1 high-risk radiographic feature differed between centers (MSK 69%, JH 60%, MGH 45%; P < 0.001). In MD-IPMN cohort, the presence of radiographic features such as solid component and main pancreatic duct diameter ≥10 mm also differed (solid component: MSK 38%, JH 30%, MGH 18%; P < 0.001; duct ≥10 mm: MSK 49%, JH 32%, MGH 44%; P < 0.001). The percentage of high-risk disease on pathology, however, was similar between institutions (BD-IPMN: P = 0.36, MD-IPMN: P = 0.48). During the study period, the percentage of BD-IPMN resected with ≥1 high-risk feature increased (52% pre-GL vs 67% FCG; P = 0.005), whereas the percentage of high-risk disease decreased (pre-GL vs FCG: 30% vs 20%). For MD-IPMN, there was not a clear trend towards guideline adherence, and the rate of high-risk disease was similar over the time (pre-GL vs FCG: 69% vs 67%; P = 0.63). CONCLUSION Surgical management of IPMN based on radiographic criteria is variable between institutions, with similar percentages of high-risk disease. Over the 15-year study period, the rate of BD-IPMN resected with high-risk radiographic features increased; however, the rate of high-risk disease decreased. Better predictors are needed.
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MESH Headings
- Adenocarcinoma, Mucinous/diagnostic imaging
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/surgery
- Adenocarcinoma, Papillary/diagnostic imaging
- Adenocarcinoma, Papillary/pathology
- Adenocarcinoma, Papillary/surgery
- Adult
- Aged
- Aged, 80 and over
- Carcinoma, Pancreatic Ductal/diagnostic imaging
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Pancreatic Ductal/surgery
- Female
- Humans
- Male
- Middle Aged
- Neoplasm Grading
- Neoplasm Staging
- Pancreatic Neoplasms/diagnostic imaging
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/surgery
- Practice Guidelines as Topic
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Affiliation(s)
| | - Georgios A Margonis
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Caitlin A McIntyre
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sharon A Lawrence
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Debra A Goldman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mithat Gonen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Matthew J Weiss
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jin He
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Murray F Brennan
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John L Cameron
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vinod Balachandran
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - William R Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Christopher L Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Peter J Allen
- Department of Surgery, Hepatopancreatobiliary Service, Duke, University School of Medicine, Durham, NC
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A nomogram for predicting pancreatic mucinous cystic neoplasm and serous cystic neoplasm. Abdom Radiol (NY) 2021; 46:3963-3973. [PMID: 33748881 DOI: 10.1007/s00261-021-03038-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To develop and validate a nomogram for the preoperative prediction of pancreatic serous cystic neoplasm (SCN) and mucinous cystic neoplasm (MCN) based on multidetector computed tomography (MDCT). MATERIALS AND METHODS In this retrospective study, the data of 227 patients with SCN and MCN were analyzed. Each patient underwent MDCT and surgical resection. A multivariable logistic regression model was developed using a training set consisting of 129 patients with SCN and 38 patients with MCN who were admitted between October 2012 and April 2019. The model was validated in 60 consecutive patients, 44 of whom had SCN and 16 of whom had MCN, admitted between May 2019 and April 2020. The regression model was adopted to establish a nomogram. Nomogram performance was determined by its discriminative ability and clinical utility. RESULT The multivariable logistic regression model included sex, size, location, shape, cyst characteristic, and cystic wall thickening. The individualized prediction nomogram showed good discrimination in the training sample (AUC 0.89; 95% CI 0.83-0.95) and in the validation sample (AUC 0.81; 95% CI 0.70-0.94). If the threshold probability is between 0.03 and 0.9, and > 0.93 in the prediction model, using the nomogram to predict SCN and MCN is more beneficial than the treat-all-patients as SCN scheme or the treat-all-patients as MCN scheme. The prediction model showed better discrimination than the radiologists' diagnosis (AUC = 0.68). CONCLUSION The nomogram could predict SCN and MCN preoperatively and may aid clinical decision-making.
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Pancreatic cyst characterization: maximum axial diameter does not measure up. HPB (Oxford) 2021; 23:1105-1112. [PMID: 33317934 DOI: 10.1016/j.hpb.2020.10.026] [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: 08/18/2020] [Revised: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Unidimensional size is commonly used to risk stratify pancreatic cysts (PCs) despite inconsistent performance. The current study aimed to determine if unidimensional size, demonstrated by maximum axial diameter (MAD), is an appropriate surrogate measurement for volume and surface area. METHODS Patients with cross-sectional imaging of PCs from 2012 to 2013 were identified. Cyst MAD, volume, and surface area were measured using quantitative imaging software. Non-pseudocystic PCs >1 cm were selected for inclusion to assess MAD correlation with volume and surface area. Cysts imaged twice >1 year apart were selected to evaluate volumetric growth rate. RESULTS In total, 195 cysts were included. Overall, MAD was strongly correlated with volume (r = 0.83) and surface area (r = 0.93). However, cysts 1-2 cm and 2-3 cm were weakly correlated with volume and surface area: r = 0.78, 0.57 and 0.82, 0.61, respectively. Cyst volumes and surface areas varied widely within unidimensional size groups with 51% and 40% of volumes and surface areas overlapping unidimensional size groups, respectively. Estimated changes in volume poorly predicted measured changes in volume with 42% of cysts having >100% absolute percent difference. CONCLUSIONS Pancreatic cyst volume and surface area may be useful adjunct measurements to risk stratify patients and surveil cyst changes and deserves further study.
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Goh BKP, Park RHS, Koh YX, Teo JY, Tan EK, Cheow PC, Thng CH, Low AS, Tan DM, Chow PKH, Chan CY, Chung AYF, Ooi LLPJ. Changing trends in the clinicopathological features, practices and outcomes in the surgical management for cystic lesions of the pancreas and impact of the international guidelines: Single institution experience with 462 cases between 1995-2018. Pancreatology 2020; 20:1786-1790. [PMID: 33008749 DOI: 10.1016/j.pan.2020.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/08/2020] [Accepted: 09/23/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The impact on clinical practice of the international guidelines including the Sendai Guidelines (SG06) and Fukuoka Guidelines (FG12) on the management of cystic lesions of the pancreas (CLP) has not been well-studied. The primary aim was to examine the changing trends and outcomes in the surgical management of CLP in our institution over time and to determine the impact of these guidelines on our institution practice. METHODS 462 patients with surgically-treated CLP were retrospectively reviewed and classified under the 2 guidelines. The cohort was divided into 3 time periods: 1998-2006, 2007-2012 and 2013 to 2018. RESULTS Comparison across the 3 time periods demonstrated significantly increasing frequency of older patients, asymptomatic CLP, male gender, smaller tumor size, elevated Ca 19-9, use of magnetic resonance imaging (MRI) and use of endoscopic ultrasound (EUS) prior to surgery. There was also significantly increasing frequency of adherence to the international guidelines as evidenced by the increasing proportion of HRSG06 and HRFG12 CLP with a corresponding lower proportion of LRSG06 and LRFG12 being resected. This resulted in a significantly higher proportion of resected CLP whereby the final pathology confirmed that a surgery was actually indicated. CONCLUSIONS Over time, there was increasing adherence to the international guidelines for the selection of patients for surgical resection as evidenced by the significantly increasing proportion of HRSG06 and HRFG06 CLPs undergoing surgery. This was associated with a significantly higher proportion of patients with a definitive indication for surgery. These suggested that over time, there was a continuous improvement in our selection of appropriate CLP for surgical treatment.
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Affiliation(s)
- Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke National University of Singapore Medical School, Singapore.
| | - Rachel H S Park
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ye-Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke National University of Singapore Medical School, Singapore
| | - Jin-Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke National University of Singapore Medical School, Singapore
| | - Ek-Khoon Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke National University of Singapore Medical School, Singapore
| | - Peng-Chung Cheow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke National University of Singapore Medical School, Singapore
| | - Choon-Hua Thng
- Department of Oncologic Imaging, National Cancer Center Singapore, Singapore
| | - Albert S Low
- Department of Radiology, Singapore General Hospital, Singapore
| | - Damien M Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Pierce K H Chow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke National University of Singapore Medical School, Singapore
| | - Chung-Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke National University of Singapore Medical School, Singapore
| | - Alexander Y F Chung
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke National University of Singapore Medical School, Singapore
| | - London L P J Ooi
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; Duke National University of Singapore Medical School, Singapore
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Significance of Uncinate Duct Dilatation in IPMNs: A New High-risk Criterion? Ann Surg 2020; 275:e789-e795. [PMID: 33201115 DOI: 10.1097/sla.0000000000004307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the significance of UDD in IPMNs. BACKGROUND The uncinate process of the pancreas has an independent ductal drainage system. International consensus guidelines of IPMNs still consider it as a branch-duct, even though it is the main drainage system for the uncinate process. METHODS A retrospective review of all surgically treated IPMNs at our institution after 2008 was performed. Preoperative radiological studies were reviewed by an abdominal radiologist who was blinded to the pathological results. In addition to the Fukuoka criteria, presence of UDD was recorded. Using multivariate analysis, the pathological significance of UDD in predicting advanced neoplasia [high grade dysplasia or invasive carcinoma (HGD/IC)] was determined. RESULTS Two hundred sixty patients were identified (mean age at diagnosis was 68 years and 49% were females): 122 (47%) had HGD/IC. UDD was noted in 59 (23%), of which 36 (61%) had HGD/IC (P < 0.003). On multivariate analysis, UDD was an independent predictor of HGD/IC (odds ratio = 2.99, P < 0.04). Subgroup analysis on patients with IPMNs confined to the dorsal portion of the gland (n = 161), also demonstrated UDD to be a significant predictor of HGD/IC in those remote lesions (odds ratio: 4.41, P = 0.039). CONCLUSIONS This is the largest study to evaluate the significance of UDD in IPMNs and shows it to be a high-risk feature. This association persisted for remote IPMNs limited to the dorsal pancreas, suggesting UDD may be associated with an aggressive phenotype even in remote IPMN lesions.
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Deng S, Fan Z, Gong Y, Cheng H, Jin K, Qian Y, Xiao Z, Liu Y, Wang R, Zheng Y, Ni Q, Yu X, Liu C, Luo G. Clinical implication of serum CA125 for the prediction of malignancy in mucinous cystic neoplasms of the pancreas. Exp Ther Med 2020; 20:158. [PMID: 33093896 PMCID: PMC7571373 DOI: 10.3892/etm.2020.9287] [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] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/06/2020] [Indexed: 02/06/2023] Open
Abstract
Mucinous cystic neoplasms (MCNs) of the pancreas have malignant potential. Carbohydrate antigen 125 (CA125) is a common widely used biomarker for cancers. However, the role of CA125 in predicting the malignant change of MCNs is currently unidentified. Patients with resected and pathologically confirmed MCN were identified from a prospectively maintained database. The predictive role of serum CA125 in assessing malignant change of MCNs was analyzed and compared with serum carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA). This study included 164 patients with MCN (low/moderate grade, 153 cases; high grade and invasive, 11 cases). The serum levels of CA125 in the high grade and invasive group (45.1±42.1 U/ml) was significantly higher than those in the low/moderate grade group (21.0±46.2 U/ml, P=0.006). The area under the receiver operating characteristic (ROC) curve of CA125 (0.75) for predicting malignancy of MCNs was higher than that of CA19-9 (0.68) or CEA (0.72). The prediction value of CA125 was improved when combined with CEA (CA125 alone, sensitivity 36.4%, specificity 90.6%, accuracy 86.6%; combined with CEA, sensitivity 45.5%, specificity 88.2%, accuracy 85.0%). It was concluded that serum CA125 shows value in predicting the malignant change of MCNs, especially when combined with serum CEA.
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Affiliation(s)
- Shengming Deng
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Zhiyao Fan
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Yitao Gong
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - He Cheng
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Kaizhou Jin
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Yunzhen Qian
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Zhiwen Xiao
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Yu Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Ruijie Wang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Yuwei Zheng
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China
| | - Quanxing Ni
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Chen Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Guopei Luo
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
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11
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Regenet N, Sauvanet A, Muscari F, Meunier B, Mariette C, Adham M, Moutardier V, Delpero JR, Regimbeau JM, Pessaux P, Paye F, Sa Cunha A, Ansquer C. The value of 18F-FDG positron emission tomography to differentiate benign from malignant intraductal papillary mucinous neoplasms: A prospective multicenter study. J Visc Surg 2020; 157:387-394. [DOI: 10.1016/j.jviscsurg.2020.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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12
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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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13
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Advances in the management of pancreatic cystic neoplasms. Curr Probl Surg 2020; 58:100879. [PMID: 34144739 DOI: 10.1016/j.cpsurg.2020.100879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 08/09/2020] [Indexed: 12/11/2022]
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14
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Park RHS, Lim GRS, Wu JJY, Koh YX, Teo JY, Cheow PC, Chan CY, Ooi LLPJ, Chung AYF, Goh BKP. Validation of the clinical utility of 4 guidelines in the initial triage of mucinous cystic lesions of the pancreas based on cross-sectional imaging: Experience with 188 surgically-treated patients. Eur J Surg Oncol 2020; 46:2114-2121. [PMID: 32828582 DOI: 10.1016/j.ejso.2020.07.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/10/2020] [Accepted: 07/19/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Over the years, several guidelines have been introduced to guide management of mucinous pancreatic cystic neoplasms (mPCN). In this study, we aimed to evaluate and compare the clinically utility of the Sendai-06, Fukuoka-12, Fukuoka-17 and European-18 guidelines in predicting malignancy of mPCN. METHODS One hundred and eighty-eight patients with mucinous cystic neoplasms (MCN) or intraductal papillary mucinous neoplasm (IPMN) who underwent surgery were retrospectively reviewed and classified under the 4 guidelines. Malignancy was defined as high grade dysplasia and invasive carcinoma. RESULTS Raised CA19-9>37U/ml, enhancing mural nodule≥5 mm and main pancreatic duct≥10 mm were significantly associated with malignancy on multivariate analysis. Increasing number of high risk features, absolute indications (European-18), worrisome risk or relative indications (European-18) were significantly associated with an increased likelihood of malignancy. The positive predictive values (PPV) of high risk features for Sendai-06, Fukuoka-12, Fukuoka-17 and absolute indications (European-18) for malignancy were 53%, 76%, 78% and 78% respectively. The negative predictive values (NPV) of the Sendai-06, Fukuoka-12 and Fukuoka-17 were 100%, while that of the European-18 was 92%. Risk of malignancy for patients with ≥4 worrisome features (Fukuoka-17) and ≥3 relative indications (European-18) was 66.7% and 75.0% respectively. CONCLUSIONS All 4 guidelines studied were useful in the initial triage of mPCN for the risk stratification of malignancy. The Fukuoka-17 had the highest PPV and NPV.
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Affiliation(s)
- Rachel H S Park
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia Level 5, 20 College Road, Singapore, 169856, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore, 117597, Singapore
| | - Grace R S Lim
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia Level 5, 20 College Road, Singapore, 169856, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore, 117597, Singapore
| | - Jania J Y Wu
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia Level 5, 20 College Road, Singapore, 169856, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore, 117597, Singapore
| | - Ye-Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia Level 5, 20 College Road, Singapore, 169856, Singapore; Duke NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Jin-Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia Level 5, 20 College Road, Singapore, 169856, Singapore; Duke NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Peng-Chung Cheow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia Level 5, 20 College Road, Singapore, 169856, Singapore; Duke NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Chung-Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia Level 5, 20 College Road, Singapore, 169856, Singapore; Duke NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - London L P J Ooi
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia Level 5, 20 College Road, Singapore, 169856, Singapore; Duke NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Alexander Y F Chung
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia Level 5, 20 College Road, Singapore, 169856, Singapore; Duke NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Academia Level 5, 20 College Road, Singapore, 169856, Singapore; Duke NUS Medical School, 8 College Road, Singapore, 169857, Singapore.
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15
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Caravati A, Andrianello S, Pollini T, Biancotto M, Balduzzi A, Malleo G, Salvia R, Marchegiani G. Branch Duct Intraductal Papillary Mucinous Neoplasms: Recommendations for Follow-Up and Surgery. Scand J Surg 2020; 109:34-41. [PMID: 32009571 DOI: 10.1177/1457496919900414] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Pancreatic cysts are increasingly diagnosed, mainly during abdominal imaging performed for other reasons. Between pancreatic cystic neoplasm, intraductal papillary mucinous neoplasms are the most common pre-malignant entities. Intraductal papillary mucinous neoplasms involving side branches overall harbor a low risk of malignancy, and in the recent past, a progressively more conservative approach has been consolidated. Purpose of this report is to summarize the evidence supporting the current practice for the management of branch duct intraductal papillary mucinous neoplasm and to offer a useful practical guide from first observation to post-operative follow-up. MATERIALS AND METHODS Review of the most important scientific literature on intraductal papillary mucinous neoplasms was made. In this review article, we also report the experience of a high volume center in managing Pancreatic cystic neoplasms. RESULTS The correct management during surveillance still is a matter of debate, since many guidelines have been published suggesting different clinical approaches. Recently, follow-up discontinuation has also been proposed in selected cases. CONCLUSION Despite significant improvements made by the increase of evidence, selecting surgical candidates because of an increased risk of malignant progression remains an unsolved issue and a hot topic for pancreatologists.
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Affiliation(s)
- A Caravati
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - S Andrianello
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - T Pollini
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - M Biancotto
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - A Balduzzi
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - G Malleo
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - R Salvia
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - G Marchegiani
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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16
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Keane MG, Dadds HR, El Sayed G, Luong TV, Davidson BR, Fusai GK, Thorburn D, Pereira SP. Clinical and radiological features that predict malignant transformation in cystic lesions of the pancreas: a retrospective case note review. ACTA ACUST UNITED AC 2020; 1:4. [PMID: 32322783 PMCID: PMC7176489 DOI: 10.12688/amrcopenres.12860.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: Pancreatic cystic lesions (PCL) are being detected with increasing frequency. Current methods of stratifying risk of malignant transformation are imperfect. This study aimed to determine the frequency of pancreatic malignancy in patients with PCL and define clinical and radiological features that predict malignant transformation in patients managed by surgery and/or surveillance. Methods: A retrospective cohort of adults who were evaluated in a tertiary hepatopancreaticobiliary centre between January 2000 - December 2013 with a confirmed PCL and followed up for at least 5 years. All cystic lesions were discussed at a weekly multidisciplinary meeting. Results: Of the 1,090 patients diagnosed with a PCL, 768 patients were included in the study: 141 patients were referred for immediate pancreatic resection, 570 entered surveillance while 57 had a malignant PCL which was unresectable at diagnosis (n=47) or were unfit for surgery (n=10). In those who were resected following presentation, malignancy was present in 38%. During follow-up 2% of those entering a surveillance programme underwent malignant transformation. Clinical and radiological features associated with a high-risk PCL included older age, symptoms, associated solid component or dilated main pancreatic duct. In intraductal papillary mucinous neoplasms, larger size was not a feature of malignant transformation (benign vs. malignant 30mm vs. 23mm; P= 0.012). Conclusion: The sensitivity of standard diagnostic tests leading to immediate surgery for high-risk PCL (malignant or mucinous) was 92% but with a specificity of just 5%. Surveillance of PCL without high-risk features within a multidisciplinary meeting was associated with a low incidence of cancer development, supporting the use of worrisome clinical and radiological features in the initial stratification of PCL.
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Affiliation(s)
- Margaret G Keane
- Institute for Liver and Digestive Health, University College London, London, NW3 2QG, UK.,Department of Gastroenterology, University College London Hospitals NHS Trust, London, UK
| | - Hannah R Dadds
- Institute for Liver and Digestive Health, University College London, London, NW3 2QG, UK
| | - Ghassan El Sayed
- Department of Gastroenterology, University College London Hospitals NHS Trust, London, UK
| | - Tu Vinh Luong
- Institute for Liver and Digestive Health, University College London, London, NW3 2QG, UK.,Department of Cellular Pathology, University College London, London, UK
| | - Brian R Davidson
- Institute for Liver and Digestive Health, University College London, London, NW3 2QG, UK.,Department of HPB Surgery, Royal Free Hospital, London, NW3 2QG, UK
| | - Guiseppe K Fusai
- Institute for Liver and Digestive Health, University College London, London, NW3 2QG, UK.,Department of HPB Surgery, Royal Free Hospital, London, NW3 2QG, UK
| | - Douglas Thorburn
- Institute for Liver and Digestive Health, University College London, London, NW3 2QG, UK
| | - Stephen P Pereira
- Institute for Liver and Digestive Health, University College London, London, NW3 2QG, UK.,Department of Gastroenterology, University College London Hospitals NHS Trust, London, UK
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17
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Yang J, Guo X, Zhang H, Zhang W, Song J, Xu H, Ma X. Differential diagnosis of pancreatic serous cystadenoma and mucinous cystadenoma: utility of textural features in combination with morphological characteristics. BMC Cancer 2019; 19:1223. [PMID: 31842793 PMCID: PMC6915993 DOI: 10.1186/s12885-019-6421-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/02/2019] [Indexed: 02/05/2023] Open
Abstract
Background Texture analysis of medical images has been reported to be a reliable method for differential diagnosis of neoplasms. This study was to investigate the performance of textural features and the combined performance of textural features and morphological characteristics in the differential diagnosis of pancreatic serous and mucinous cystadenomas. Methods We retrospectively reviewed 59 patients with pancreatic serous cystadenoma and 32 patients with pancreatic mucinous cystadenoma at our hospital. A three-dimensional region of interest (ROI) around the margin of the lesion was drawn manually in the CT images of each patient, and textural parameters were retrieved from the ROI. Textural features were extracted using the LifeX software. The least absolute shrinkage and selection operator (LASSO) method was applied to select the textural features. The differential diagnostic capabilities of morphological features, textural features, and their combination were evaluated using receiver operating characteristic (ROC) analysis, and the area under the receiver operating characteristic curve (AUC) was used as the main indicator. The diagnostic accuracy based on the AUC value is defined as follows: 0.9–1.0, excellent; 0.8–0.9, good; 0.7–0.8, moderate; 0.6–0.7, fair; 0.5–0.6, poor. Results In the differential diagnosis of pancreatic serous and mucinous cystadenomas, the combination of morphological characteristics and textural features (AUC 0.893, 95% CI 0.816–0.970) is better than morphological characteristics (AUC 0.783, 95% CI 0.665–0.900) or textural features (AUC 0.777, 95% CI 0.673–0.880) alone. Conclusions In conclusion, our preliminary results highlighted the potential of CT texture analysis in discriminating pancreatic serous cystadenoma from mucinous cystadenoma. Furthermore, the combination of morphological characteristics and textural features can significantly improve the diagnostic performance, which may provide a reliable method for selecting patients with surgical intervention indications in consideration of the different treatment principles of the two diseases.
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Affiliation(s)
- Jing Yang
- Department of Biotherapy, Cancer Center, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, People's Republic of China
| | - Xinli Guo
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Hao Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Weiwei Zhang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jinen Song
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Hui Xu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xuelei Ma
- Department of Biotherapy, Cancer Center, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, People's Republic of China.
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18
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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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19
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Carmicheal J, Patel A, Dalal V, Atri P, Dhaliwal AS, Wittel UA, Malafa MP, Talmon G, Swanson BJ, Singh S, Jain M, Kaur S, Batra SK. Elevating pancreatic cystic lesion stratification: Current and future pancreatic cancer biomarker(s). Biochim Biophys Acta Rev Cancer 2019; 1873:188318. [PMID: 31676330 DOI: 10.1016/j.bbcan.2019.188318] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/25/2019] [Accepted: 10/25/2019] [Indexed: 02/06/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an incredibly deadly disease with a 5-year survival rate of 9%. The presence of pancreatic cystic lesions (PCLs) confers an increased likelihood of future pancreatic cancer in patients placing them in a high-risk category. Discerning concurrent malignancy and risk of future PCL progression to cancer must be carefully and accurately determined to improve survival outcomes and avoid unnecessary morbidity of pancreatic resection. Unfortunately, current image-based guidelines are inadequate to distinguish benign from malignant lesions. There continues to be a need for accurate molecular and imaging biomarker(s) capable of identifying malignant PCLs and predicting the malignant potential of PCLs to enable risk stratification and effective intervention management. This review provides an update on the current status of biomarkers from pancreatic cystic fluid, pancreatic juice, and seromic molecular analyses and discusses the potential of radiomics for differentiating PCLs harboring cancer from those that do not.
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Affiliation(s)
- Joseph Carmicheal
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Asish Patel
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Vipin Dalal
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Pranita Atri
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Amaninder S Dhaliwal
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Uwe A Wittel
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Mokenge P Malafa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Geoffrey Talmon
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Benjamin J Swanson
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Shailender Singh
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Maneesh Jain
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sukhwinder Kaur
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Surinder K Batra
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA; Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA; Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA.
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20
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Simpson RE, Cockerill NJ, Yip-Schneider MT, Ceppa EP, House MG, Zyromski NJ, Nakeeb A, Al-Haddad MA, Schmidt CM. Clinical criteria for integrated molecular pathology in intraductal papillary mucinous neoplasm: less is more. HPB (Oxford) 2019; 21:574-581. [PMID: 30293868 DOI: 10.1016/j.hpb.2018.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 08/13/2018] [Accepted: 09/03/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND For pancreatic cysts with negative cytology, Integrated Molecular Pathology (IMP) is a malignancy risk score integrating clinical criteria with pancreatic cyst fluid DNA profiling. Aside from main pancreatic duct (MPD) diameter, integrated clinical criteria are not International Consensus Guidelines High-Risk Stigmata. We predicted exclusion of clinical criteria except MPD diameter could simplify the IMP and better distinguish invasive/malignant disease. METHODS Records of >1100 patients with IPMN were reviewed retrospectively. Sensitivity, specificity, and accuracy of conventional IMP for invasive/malignant disease was compared to DNA profile including only MPD ≥10mm (IMP-10.) Invasive outcomes were invasive-IPMN/adenocarcinoma on surgical pathology, pathologic or radiographic evidence of invasive/metastatic disease during surveillance. Malignant outcomes included high grade dysplastic IPMN (HGD-IPMN). RESULTS 225 patients who met study criteria underwent 283 IMP evaluations: 98 followed by surgery, 185 followed by ≥ 23 months surveillance. IMP-10 had greater specificity (90.1% vs. 73.7%) and accuracy (89.8% vs. 74.2%) for invasive disease compared to IMP in surgery + surveillance patients, but lower sensitivity (77.8% vs. 88.9%). Trends were similar in surgery patients alone and malignant outcome analyses. CONCLUSION IMP-10 excludes less-reliable clinical factors resulting in greater accuracy in predicting invasive/malignant disease and fewer patients with benign disease being recommended for surgery.
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Affiliation(s)
- Rachel E Simpson
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN 46202, USA
| | - Nathan J Cockerill
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN 46202, USA
| | - Michele T Yip-Schneider
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN 46202, USA; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, 550 University Blvd., Indianapolis, IN 46202, USA
| | - Eugene P Ceppa
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN 46202, USA; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, 550 University Blvd., Indianapolis, IN 46202, USA
| | - Michael G House
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN 46202, USA
| | - Nicholas J Zyromski
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN 46202, USA
| | - Attila Nakeeb
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN 46202, USA
| | - Mohammad A Al-Haddad
- Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, 550 University Blvd., Indianapolis, IN 46202, USA; Indiana University School of Medicine, Department of Medicine, Division of Gastroenterology, 702 Rotary Cir., Suite 225, Indianapolis, IN 46202, USA
| | - C M Schmidt
- Indiana University School of Medicine, Department of Surgery, 545 Barnhill Dr., Indianapolis, IN 46202, USA; Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, 550 University Blvd., Indianapolis, IN 46202, USA; Indiana University School of Medicine, Department of Biochemistry/Molecular Biology, 635 Barnhill Dr., Medical Sciences Building Rm 4053, Indianapolis, IN 46202, USA; Walther Oncology Center, 950 W. Walnut St., Indianapolis, IN 46202, USA; Indiana University Simon Cancer Center, 535 Barnhill Dr., Indianapolis, IN 46202, USA.
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21
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Sharib JM, Fonseca AL, Swords DS, Jaradeh K, Bracci PM, Firpo MA, Hatcher S, Scaife CL, Wang H, Kim GE, Mulvihill SJ, Maitra A, Koay EJ, Kirkwood KS. Surgical overtreatment of pancreatic intraductal papillary mucinous neoplasms: Do the 2017 International Consensus Guidelines improve clinical decision making? Surgery 2018; 164:1178-1184. [DOI: 10.1016/j.surg.2018.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/24/2018] [Accepted: 07/10/2018] [Indexed: 12/17/2022]
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22
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Growth in Branch Duct IPMN Undergoing Surveillance: Unsafe at Any Speed? Clin Gastroenterol Hepatol 2018; 16:1401-1403. [PMID: 29775796 DOI: 10.1016/j.cgh.2018.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/04/2018] [Indexed: 02/07/2023]
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23
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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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The 2012 International Consensus Guidelines of Intraductal Papillary Mucinous Neoplasms of the Pancreas (Fukuoka Criteria) Predict the Malignant Potential, Even in Actual Clinical Situations. Pancreas 2018; 47:285-290. [PMID: 29401172 DOI: 10.1097/mpa.0000000000001001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The aim of the present study was to validate the use of the 2012 International Consensus Guidelines for intraductal papillary mucinous neoplasm (IPMN) (Fukuoka criteria) in patients without findings of obstructive jaundice and/or an enhanced solid component. METHODS This retrospective study included patients who underwent pancreatectomy for IPMN between October 2002 and September 2016. The sensitivity, specificity, and positive and negative predictive values for malignancy were calculated for each feature of high-risk stigmata. RESULTS Of the 135 patients who underwent surgery for IPMN, 50 (37.0%) had low/intermediate-grade dysplasia, 25 (18.5%) had high-grade dysplasia, and the remaining 60 (44.5%) had invasive carcinoma. A malignant potential was, thus, present in 63% of all resected cases. Considering an actual clinical situation, the predictors for malignant potential were assessed in 62 patients without findings of obstructive jaundice and/or an enhanced solid component. A multivariate analysis revealed that the Fukuoka criteria were the only independent factor for predicting the malignant potential (odds ratio, 5.69; P = 0.036). CONCLUSIONS The present study suggested that malignant potential can be accurately detected by faithfully keeping to the Fukuoka criteria. Using these criteria enables us to identify patients with malignant potential, even in the actual clinical situations.
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Marchegiani G, Andrianello S, Perri G, Bonamini D, De Robertis R, Malleo G, Bassi C, Salvia R. Vanishing Pancreatic Cysts during Follow-Up: Another Step Towards De-Emphasizing Cyst Size as a Major Clinical Predictor of Malignancy. Dig Surg 2017; 35:508-513. [PMID: 29232660 DOI: 10.1159/000485199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 11/09/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION In the management of pancreatic cystic neoplasms (PCN), size plays a crucial role as the expression of disease progression. While many evidences regarding the natural history of growing pancreatic cysts exist, almost no data are available regarding cysts with a reduction in size. METHODS Radiological and clinical data from patients of the dedicated pancreatic cysts outpatient clinic of the Department of General and Pancreatic Surgery, University of Verona Hospital were retrospectively reviewed. Patients diagnosed with PCNs reducing in size during follow-up were reviewed. RESULTS From a total of 3,146 patients, we identified 12 (0.38%) vanishing/reducing cysts without a history of pancreatitis. Most of them were presumed IPMN (66.6%). The median follow-up was 69 months and the median cyst's size 30 mm (range 10-49). Most of the patients (75%) experienced a reduction in cyst size (median reduction of 8 mm, range 6-22) after a median time of 12 months (range 6-63), 3 patients experienced a complete disappearance of the cyst. CONCLUSION Cyst size reduction during follow-up is a rare phenomenon of unknown explanation. It adds to the debate regarding the role of size as a clinical predictor whenever a definite diagnosis of a PCN cannot be reached.
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Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefano Andrianello
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Deborah Bonamini
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | | | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Morales-Oyarvide V, Fong ZV, Fernández-Del Castillo C, Warshaw AL. Intraductal Papillary Mucinous Neoplasms of the Pancreas: Strategic Considerations. Visc Med 2017; 33:466-476. [PMID: 29344522 DOI: 10.1159/000485014] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Intraductal papillary mucinous neoplasms (IPMN) are cystic neoplasms with the potential for progression to pancreatic cancer. Recognized by the global medical community just over two decades ago, IPMN have gained great epidemiological and clinical relevance thanks to the widespread use of cross-sectional abdominal imaging, which has led to a surge in the number of incidental pancreatic cysts being diagnosed. As our understanding of this disease has improved, we now know that some IPMN have a very elevated risk of cancer and require surgical resection, while others are low-risk lesions and can be followed. The approach to IPMN must therefore strike a balance between preventing the over-utilization of surgery and the timely recognition and treatment of patients with high-risk lesions. Several clinical, radiographic, and laboratory parameters have been proposed to risk-stratify IPMN, leading to the publication of management guidelines that do not always converge in their recommendations. The goal of this clinical therapeutic review is to describe the strategic approach to IPMN at the Massachusetts General Hospital, and how our current understanding, management algorithm, and future directions have been informed by research efforts at our institution and other centers.
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Affiliation(s)
- Vicente Morales-Oyarvide
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Zhou W, Xu Y, Rong Y, Wu W, Kuang T, Xin B, Zhu H, Lou W, Wang D. Validation of Sendai and Fukuoka consensus guidelines in predicting malignancy in patients with preoperatively diagnosed mucinous pancreatic cystic neoplasms. J Surg Oncol 2017; 117:409-416. [PMID: 29044541 DOI: 10.1002/jso.24882] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 09/18/2017] [Indexed: 01/04/2023]
Affiliation(s)
- Wentao Zhou
- Department of General Surgery, Zhong Shan Hospital, Fudan University, Shanghai, China
| | - Yadong Xu
- Department of Pancreatic Surgery, Zhong Shan Hospital, Fudan University, Shanghai, China
| | - Yefei Rong
- Department of General Surgery, Zhong Shan Hospital, Fudan University, Shanghai, China
| | - Wenchuan Wu
- Department of Pancreatic Surgery, Zhong Shan Hospital, Fudan University, Shanghai, China
| | - Tiantao Kuang
- Department of General Surgery, Zhong Shan Hospital, Fudan University, Shanghai, China
| | - Baobao Xin
- Department of General Surgery, Zhong Shan Hospital, Fudan University, Shanghai, China
| | - Hongxu Zhu
- Department of General Surgery, Zhong Shan Hospital, Fudan University, Shanghai, China
| | - Wenhui Lou
- Department of Pancreatic Surgery, Zhong Shan Hospital, Fudan University, Shanghai, China
| | - Dansong Wang
- Department of General Surgery, Zhong Shan Hospital, Fudan University, Shanghai, China
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Basar O, Brugge WR. My Treatment Approach: Pancreatic Cysts. Mayo Clin Proc 2017; 92:1519-1531. [PMID: 28890216 DOI: 10.1016/j.mayocp.2017.06.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/21/2017] [Accepted: 06/06/2017] [Indexed: 12/12/2022]
Abstract
Our treatment approach for either symptomatic or incidentally found pancreatic cysts continues to improve. The true incidence of pancreatic cysts is not known, and pancreatic cystic neoplasms, especially intraductal papillary mucinous neoplasms, are currently most commonly diagnosed and resected. This is a result of increasing awareness, widespread availability of imaging, and better understanding of the nature of pancreatic cysts as well. Recent studies on molecular analysis and devices such as microbiopsy forceps help us better define and select the treatment approach to alleviate symptoms and to prevent malignant tumors while avoiding unnecessary surgery.
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Affiliation(s)
- Omer Basar
- Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA.
| | - William R Brugge
- Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Gambitta P, Aseni P, Fontana P, Bareggi E, Forti E, Tringali A, Molteni F, Vertemati M. Advantage of endoscopic-ultrasound-fine-needle aspiration associated to Sendai clinical guidelines in detecting the malignant risk in patients with undetermined pancreatic cysts: Long-term follow-up. INTERNATIONAL JOURNAL OF HEPATOBILIARY AND PANCREATIC DISEASES 2017. [DOI: 10.5348/ijhpd-2016-62-oa-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Aims: Contradictory information exists on whether different clinical guidelines are effective in detecting the malignant risk in patients with pancreatic cysts. We have retrospectively evaluated the accuracy and the long-term outcome in patients with pancreatic cysts with a diameter ≥ 2 cm when indication for surgery was established by clinical evaluation of their malignant risk according to Sendai Clinical Guidelines associated to endoscopic-ultrasound-fine-needle aspiration.
Material and Methods: Patients with pancreatic cysts with a diameter ≥2 cm were evaluated for their potential malignant risk by endoscopic-ultrasound-fine-needle aspiration associated to the clinical evaluation by Sendai Clinical Guidelines. Long-term outcome and comparison in patients survival as well as the accuracy in detecting malignancies were evaluated with the combined clinical and endoscopic evaluation.
Results: Two hundred eighteen patients with pancreatic cysts were observed during a nine-year period of the study and 74 of them (33.9%) presenting with a pancreatic cyst ≥2 cm were eligible for the study. Fourteen malignant neoplasms (18.9%) were detected. The accuracy in detecting malignancy of combined clinical and endoscopic evaluation was very high (0.99). The five-year survival rates for patients who underwent surgery with benign and malignant pancreatic cysts and for patients in observational follow-up were similar (70% and 85%). The cohort of patients with malignant pancreatic cysts with ductal adenocarcinoma showed a five-year survival rate of 41%.
Conclusion: Endoscopic ultrasound fine-needle aspiration associated to Sendai clinical guidelines showed a high accuracy in detecting malignant risk in patients with pancreatic cysts with a diameter ≥ 2 cm. allowing appropriate selection for surgical treatment with satisfactory long-term survival.
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Affiliation(s)
- Pietro Gambitta
- Unità Operativa di Gastroenterologia ed Endoscopia Digestiva Ospedale Luigi Sacco, Milano, Italy
| | - Paolo Aseni
- Dipartimento di Emergenza Urgenza Medicina d'Urgenza e Pronto Soccorso, ASST, Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Paola Fontana
- Unità Operativa di Gastroenterologia ed Endoscopia Digestiva Ospedale Luigi Sacco, Milano, Italy
| | - Emilia Bareggi
- Unità Operativa di Gastroenterologia ed Endoscopia Digestiva Ospedale Luigi Sacco, Milano, Italy
| | - Edoardo Forti
- Endoscopia Digestiva e Interventistica, Ospedale Niguarda Ca' Granda, Milano, Italy
| | - Alberto Tringali
- Endoscopia Digestiva e Interventistica, Ospedale Niguarda Ca' Granda, Milano, Italy
| | - Francesco Molteni
- Università Statale di Milano, Dipartimento di Scienze Sociali e Politiche, Milano, Italy
| | - Maurizio Vertemati
- Dipartimento di Scienze Biomediche e Cliniche "L. Sacco" Università degli Studi di Milano, Italy
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Abstract
With increased utilization and ongoing advancements in cross-sectional abdominal imaging, the identification of a pancreatic cyst has become a frequent finding. While many pancreatic cysts are associated with a benign clinical course, others may transform into pancreatic ductal adenocarcinoma. However, distinguishing a benign from a malignant pancreatic cyst or pancreatic cyst with malignant potential on the basis of standard clinical findings, imaging parameters and ancillary studies can be challenging. Hence, a significant interest within the past decade has been the identification of novel biomarkers to accurately classify and prognosticate a pancreatic cyst. Within this review, we discuss novel DNA, miRNA, protein and metabolite biomarkers, and their relevance in clinical practice. In addition, we focus on future areas of research that have the potential to change pancreatic cyst management.
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Abstract
Pancreatic cysts, especially incidental asymptomatic ones seen on noninvasive imaging such as CT or MR imaging, remain a clinical challenge. The etiology of such cysts may range from benign cysts without any malignant potential such as pancreatic pseudocysts and serous cystadenomas to premalignant or frankly malignant cysts such as mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, cystic degeneration associated with solid tumors such as pancreatic ductal adenocarcinoma or pancreatic endocrine neoplasms, and solid pseudopapillary neoplasms. The clinical challenge in 2017 is to accurately preoperatively diagnose them and their malignant potential before deciding about surgery, surveillance or doing nothing. This review will focus on the currently available clinical guidelines for doing so.
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Affiliation(s)
- James J Farrell
- Yale Center for Pancreatic Diseases, Interventional Endoscopy, Yale School of Medicine, New Haven, CT, USA. .,Section of Digestive Diseases, Yale University School of Medicine, LMP 1080, 15 York Street, New Haven, CT, 06510-3221, USA.
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Basar O, Brugge WR. Pancreatic cyst guidelines: Which one to live by? Gastrointest Endosc 2017; 85:1032-1035. [PMID: 28411756 DOI: 10.1016/j.gie.2016.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 11/02/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Omer Basar
- Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William R Brugge
- Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
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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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Re. Validation of the 2012 International Consensus Guidelines Using Computed Tomography and Magnetic Resonance Imaging. Ann Surg 2017; 266:e51. [PMID: 28257323 DOI: 10.1097/sla.0000000000001378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Evaluation of the 2015 AGA guidelines on pancreatic cystic neoplasms in a large surgically confirmed multicenter cohort. Endosc Int Open 2017; 5:E201-E208. [PMID: 28317015 PMCID: PMC5352566 DOI: 10.1055/s-0042-122010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and study aims The American Gastroenterological Association (AGA) recently published guidelines for the management of asymptomatic pancreatic cystic neoplasms (PCNs). We aimed to evaluate the diagnostic characteristics of the AGA guidelines in appropriately recommending surgery for malignant PCNs. Patients and methods A retrospective multicenter study was performed of patients who underwent endoscopic ultrasound (EUS) for evaluation of PCNs who ultimately underwent surgical resection from 2004 - 2014. Demographics, EUS characteristics, fine-needle aspiration (FNA) results, type of resection, and final pathologic diagnosis were recorded. Patients were categorized into 2 groups (surgery or surveillance) based on what the AGA guidelines would have recommended. Performance characteristics for the diagnosis of cancer or high-grade dysplasia (HGD) on surgical pathology were calculated. Results Three hundred patients underwent surgical resection for PCNs, of whom the AGA guidelines would have recommended surgery in 121 (40.3 %) and surveillance in 179 (59.7 %) patients. Among patients recommended for surgery, 45 (37.2 %) had cancer, whereas 76 (62.8 %) had no cancer/HGD. Among patients recommended for surveillance, 170 (95.0 %) had no cancer/HGD; however, 9 (5.0 %) patients had cancer that would have been missed. For the finding of cancer/HGD on surgical pathology, the AGA guidelines had 83.3 % sensitivity (95 % CI 70.7 - 92.1), 69.1 % specificity (95 % CI 62.9 - 74.8), 37.2 % positive predictive value (95 % CI 28.6 - 46.4), 95.0 % negative predictive value (95 % CI 90.7 - 97.7), and 71.7 % accuracy (95 % CI 67.4 - 74.6). Conclusions The 2015 AGA guidelines would have resulted in 60 % fewer patients being referred for surgical resection, and accurately recommended surveillance in 95 % of patients with asymptomatic PCNs. Future prospective studies are required to validate these guidelines. Meeting presentations: Presented in part at Digestive Diseases Week 2016.
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Singhi AD, Nikiforova MN, McGrath K. DNA testing of pancreatic cyst fluid: is it ready for prime time? Lancet Gastroenterol Hepatol 2016; 2:63-72. [PMID: 28404017 DOI: 10.1016/s2468-1253(16)30084-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/15/2016] [Accepted: 08/15/2016] [Indexed: 12/19/2022]
Abstract
Pancreatic cysts are a clinical quandary in both diagnosis and management. Although many cysts, such as pseudocysts and serous cystadenomas, are benign and can be monitored clinically, mucinous cysts, such as intraductal papillary mucinous neoplasms and mucinous cystic neoplasms, have the potential to progress to pancreatic cancer. Considering the poor prognosis of pancreatic cancer, the detection of a pancreatic cyst can be a source of anxiety for both the patient and physician. This diagnosis in turn can lead to expensive, invasive, and even harmful surveillance and treatment options. As a consequence, several national and international guidelines for the management of pancreatic cysts have been developed over the past decade. However, these guidelines rely on standard clinical assessment, radiographical imaging, and ancillary fluid studies that have insufficient sensitivity and specificity. The application of DNA-based molecular techniques has emerged as an adjunct to the assessment of pancreatic cysts. The cellular content of pancreatic cyst fluid aspirate is often suboptimal for analysis, but DNA isolated from lysed or exfoliated cells within the cyst can be analysed for genetic abnormalities. Moreover, whole exome sequencing and targeted sequencing of the major pancreatic cysts has identified unique mutational profiles for cyst type and genetic alterations that coincide with the development of pancreatic cancer. In this Review, we discuss the major cystic lesions of the pancreas and their underlying molecular pathology, current management guidelines for pancreatic cysts, and integration of DNA-based molecular testing within this field.
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Affiliation(s)
- Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Marina N Nikiforova
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kevin McGrath
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Scourtas A, Dudley JC, Brugge WR, Kadayifci A, Mino-Kenudson M, Pitman MB. Preoperative characteristics and cytological features of 136 histologically confirmed pancreatic mucinous cystic neoplasms. Cancer Cytopathol 2016; 125:169-177. [PMID: 27926784 DOI: 10.1002/cncy.21806] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/11/2016] [Accepted: 11/10/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Mucinous cystic neoplasms (MCNs) of the pancreas present a management conundrum. The majority are benign but all are resected due to their malignant potential. Recent studies have recommended nonsurgical management. In the current study, the authors analyzed the preoperative imaging, cytology, and cyst fluid characteristics of 136 histologically confirmed MCNs to assess predictors of a high-risk (HR) cyst for surgical triage. METHODS MCNs resected at the Massachusetts General Hospital between 1990 and 2014 formed the study cohort. Patient demographics, cyst size, and mural nodules (MNs) by endoscopic ultrasound, cytology, and cyst fluid carcinoembryonic antigen and amylase levels were correlated with histological grade. A HR cyst was defined as high-grade dysplasia or invasive carcinoma on histology. Performance characteristics were assessed for each parameter, with a cyst size ≥3 cm or a MN on imaging and malignant cytology considered to be "true-positive" results for predicting malignancy. RESULTS Only 15 of the 136 cysts had HR histology (11%). On average, patients with HR cysts were older than those with low-risk cysts (55 years vs 49 years, respectively). High-grade cytology was the most accurate predictor of malignancy (95%) followed by MN and cyst size together (88%) and MN alone (83%). The average carcinoembryonic antigen level (in ng/mL) increased with the grade of dysplasia but the ranges overlapped between low risk and HR cysts. CONCLUSIONS To the authors' knowledge, the current study is the largest series to date analyzing the cytological features of histologically confirmed MCN. Cytology is insensitive but very specific for detecting a HR MCN and outperformed imaging for the detection of HR MCN. Endoscopic ultrasound-guided fine-needle aspiration and cytology should be performed on any clinically suspected MCN that is being considered for conservative management. Cancer Cytopathol 2017;125:169-177. © 2016 American Cancer Society.
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Affiliation(s)
- Aristana Scourtas
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan C Dudley
- Department of Pathology, Stanford University Medical Center, Palo Alto, California
| | - William R Brugge
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Abdurrahman Kadayifci
- Division of Gastroenterology, Gaziantep University School of Medicine, Gaziantep, Turkey
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
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Kaiser J, Fritz S, Klauss M, Bergmann F, Hinz U, Strobel O, Schneider L, Büchler MW, Hackert T. Enucleation: A treatment alternative for branch duct intraductal papillary mucinous neoplasms. Surgery 2016; 161:602-610. [PMID: 27884612 DOI: 10.1016/j.surg.2016.09.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 09/06/2016] [Accepted: 09/16/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND Small, asymptomatic, branch-duct intraductal papillary mucinous neoplasms of the pancreas are often kept under surveillance despite their malignant potential. The management of branch-duct intraductal papillary mucinous neoplasm is controversial with regard to indications and extent of any operative intervention. The present study aimed to evaluate enucleation as an alternative operative approach for branch-duct intraductal papillary mucinous neoplasms to exclude and prevent malignancy. METHODS For branch-duct intraductal papillary mucinous neoplasms of <30 mm in diameter and an acceptable distance from the main pancreatic duct, enucleation was considered as the operative approach of choice. All patients scheduled for enucleation of branch-duct intraductal papillary mucinous neoplasm on the basis of these features between January 2004 and September 2014 were analyzed. Among these, patients with successful enucleation were compared with those who were scheduled for enucleation but converted intraoperatively to pancreatic resection (intention-to-treat analysis). End points were hospital morbidity and mortality as well as histopathology and functional outcome at a mean follow-up of 32 months. RESULTS In the study, 115 patients with presumed branch-duct intraductal papillary mucinous neoplasm and the intention to perform pancreatic enucleation were included; 87 enucleations were performed in 74 patients. In 41 patients, enucleation was converted to a pancreatic resection (procedure-specific success rate 64%); indications for conversion included location or size (46%), presence of multicystic lesions (39%), or involvement of the main pancreatic duct (15%). Of the 74 patients with enucleation, 64 branch-duct intraductal papillary mucinous neoplasms revealed low- (85%), 11% moderate dysplasia-, and 4% high-grade dysplasia on histology. Among converted resections, 6 intraductal papillary mucinous neoplasms revealed high-grade dysplasia or invasive carcinoma (15%). Intention-to-treat analysis with patients converted to pancreatic resection showed that enucleations resulted in less blood loss (100 vs 400 mL) and a shorter operation time (146 vs 255 minutes; P < .001 each). Postoperative morbidity including postoperative pancreatic fistula was similar in both groups. No mortality occurred after enucleation; after formal resection, 1 patient died due to multiorgan failure. Both hospital stay (10 vs 14 days) and rates of postoperative endocrine and exocrine dysfunction rates were less after enucleation (P < .02 each). Intraductal papillary mucinous neoplasm-specific recurrence rates (3% vs 6%) were similar in both groups. CONCLUSION Enucleation is a safe procedure that can be performed successfully in a high proportion of branch-duct intraductal papillary mucinous neoplasms and should be considered instead of standard resections as an important function-preserving alternative. Limitations may occur due to malignancy, size, localization, multilocularity, or main-duct involvement requiring conversion to a formal, anatomic resection. Beside the advantages in the short-term course, functional outcome seems to be superior after enucleation, and intraductal papillary mucinous neoplasm-specific recurrence rates are not increased compared with standard resections, at least at a mean follow-up of 32 months.
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Affiliation(s)
- Joerg Kaiser
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Stefan Fritz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; Department of General and Visceral Surgery, Katharinenhospital, Stuttgart, Germany
| | - Miriam Klauss
- Department of Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany
| | - Frank Bergmann
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Lutz Schneider
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
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Outcome of long interval radiological surveillance of side branch pancreatic duct-involved intraductal papillary mucinous neoplasm in selected patients. HPB (Oxford) 2016; 18:879-885. [PMID: 27591177 PMCID: PMC5094481 DOI: 10.1016/j.hpb.2016.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 06/05/2016] [Accepted: 06/13/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Side branch IPMN (SB-IPMN) of the pancreas has a malignancy rate between 10 and 20%. We hypothesized that surveillance at longer intervals on selected patients with SB-IPMN might be indicated. METHODS This is a retrospective study of prospectively collected data of 276 patients presenting from 2000 to 2010. After 2007, we opted to screen our patients with longer intervals, initially at 12 months then 24 months using MR if no "worrisome features" were present. RESULTS Complete data sets for 261 patients were analysed and patients were aged 78 (40-91) years. 232 patients had sole SB-IPMN while 92% were incidental (n = 209) and 8% were symptomatic (n = 24). Single SB-IPMN accounted for 84% (n = 195) of all cases; maximum diameter of 15.5 (5-60) mm. The median follow up duration was 46 (32-53) months. Short interval radiological surveillance (3-9 months) was 39% (n = 90), while long interval surveillance (12-36 months) was performed in 61% (n = 142). The rate of pancreatic resection, due to concern for the development of pancreatic cancer, in the short and long interval surveillance groups was 4.4% (n = 4) and 3.5% (n = 5) respectively; p = 0.78. CONCLUSION Our data suggests no difference in outcome between long and short interval MR surveillance of SB-IPMN patients.
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Ma GK, Goldberg DS, Thiruvengadam N, Chandrasekhara V, Kochman ML, Ginsberg GG, Vollmer CM, Ahmad NA. Comparing American Gastroenterological Association Pancreatic Cyst Management Guidelines with Fukuoka Consensus Guidelines as Predictors of Advanced Neoplasia in Patients with Suspected Pancreatic Cystic Neoplasms. J Am Coll Surg 2016; 223:729-737.e1. [DOI: 10.1016/j.jamcollsurg.2016.07.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 07/21/2016] [Accepted: 07/22/2016] [Indexed: 01/08/2023]
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Hsiao CY, Yang CY, Wu JM, Kuo TC, Tien YW. Utility of the 2006 Sendai and 2012 Fukuoka guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas: A single-center experience with 138 surgically treated patients. Medicine (Baltimore) 2016; 95:e4922. [PMID: 27661043 PMCID: PMC5044913 DOI: 10.1097/md.0000000000004922] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This study aimed to evaluate the utility of the 2006 Sendai and 2012 Fukuoka guidelines for differentiating malignant intraductal papillary mucinous neoplasm (IPMN) of the pancreas from benign IPMN.Between January 2000 and March 2015, a total of 138 patients underwent surgery and had a pathologically confirmed pancreatic IPMN. Clinicopathological parameters were reviewed, and all patients were classified according to both the 2006 Sendai and 2012 Fukuoka guidelines. Univariate and multivariate analyses were used for identifying significant factors associated with malignancy in IPMN.There were 9 high-grade dysplasia (HGD) and 37 invasive cancers (ICs) in the 138 patients. The positive predictive value (PPV) and negative predictive value (NPV) of the Sendai and Fukuoka guidelines for HGD/IC was 35.1%, 43.3%, 100%, and 85.4%, respectively. Of the 36 patients with worrisome features using the Fukuoka guideline, 7 patients had HGD/IC in their IPMNs. According to the multivariate analysis, jaundice, tumors of ≥3 cm, presence of mural nodule on imaging, and aged <65 years were associated with HGD/IC in patients with IPMN.The Sendai guideline had a better NPV, but the Fukuoka guideline had a better PPV. We suggest that patients with worrisome features based on the Fukuoka guideline be aggressively managed.
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Affiliation(s)
| | | | | | | | - Yu-Wen Tien
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan, ROC
- Correspondence: Yu-Wen Tien, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Rd, Taipei 10002, Taiwan, ROC (e-mail: )
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Basar O, Brugge WR. Which guidelines should be used for branch-duct intraductal papillary mucinous neoplasms? Gastrointest Endosc 2016; 84:446-9. [PMID: 27530478 DOI: 10.1016/j.gie.2016.04.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 04/27/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Omer Basar
- Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Gastroenterology, Hacettepe Medical School, Ankara, Turkey
| | - William R Brugge
- Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
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Intraductal Papillary Mucinous Neoplasm of the Pancreas: Current State of the Art and Ongoing Controversies. Ann Surg 2016; 263:908-17. [PMID: 26727096 DOI: 10.1097/sla.0000000000001567] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
With the widespread use and advances in radiographic imaging, Intraductal Papillary Mucinous Neoplasms (IPMNs) of the pancreas are identified with increasing frequency. Although many studies have addressed its biology and treatment, true understanding of its natural history continues to elude us. Its malignant potential places careproviders in a clinical dilemma of balancing the morbidity of pancreatectomy against the risk of malignant transformation while under continuous surveillance. Recently, there have been conflicting data published in the literature, generating more uncertainty in the field. In this article, we critically analyze the contrasting consensus guidelines from the International Association of Pancreatology and the American Gastroenterology Association, and address lingering questions and controversies. We also synthesize newly published data in the context of current standard of care, and provide a comprehensive review and recommendations for the clinical diagnosis, treatment, and follow-up strategy in the management of patients with Intraductal Papillary Mucinous Neoplasms.
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Imaging comparison of tubular and colloid pancreatic adenocarcinoma arising from intraductal papillary mucinous neoplasm on multidetector CT. Clin Imaging 2016; 40:1195-1199. [PMID: 27596236 DOI: 10.1016/j.clinimag.2016.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/04/2016] [Accepted: 08/12/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE This study aims to compare tubular pancreatic ductal adenocarcinoma (tPDAC) and colloid subtype pancreatic ductal adenocarcinoma (cPDAC) associated with intraductal papillary mucinous neoplasms (IPMNs) on computed tomography. METHODS An institutional review board-approved retrospective study included patients with either IPMN tPDAC or cPDAC. Enhancing mural nodules (MN), solid component (SC), main pancreatic duct (MPD) diameter, and abrupt change in MPD caliber were evaluated. RESULTS A total of 22 patients with cPDAC and 17 patients with tPDAC showed no significant difference in MPD size. MN and SC were seen in cPDAC/tPDAC in 55%/18% and 9%/53%, respectively. Abrupt change in MPD caliber was seen in cPDAC/tPDAC at 18%/59%. CONCLUSION cPDAC and tPDAC differ in the frequency of MN, SC, and changes in MPD caliber.
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Goh BKP, Teo JY, Allen JC, Tan DMY, Chan CY, Lee SY, Tai DWM, Thng CH, Cheow PC, Chow PKH, Ooi LLPJ, Chung AYF. Preoperative platelet-to-lymphocyte ratio improves the performance of the international consensus guidelines in predicting malignant pancreatic cystic neoplasms. Pancreatology 2016; 16:888-92. [PMID: 27421563 DOI: 10.1016/j.pan.2016.06.660] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/08/2016] [Accepted: 06/24/2016] [Indexed: 12/11/2022]
Abstract
INTRODUCTION To determine if neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were predictive of malignancy in pancreatic cystic neoplasms (PCN) and if these improved the performance of the international consensus guidelines (ICG) in the initial triage of these patients. METHODS 318 patients with surgically-treated suspected PCN were retrospectively reviewed. Malignant neoplasms were defined as neoplasms harbouring invasive carcinoma. The optimal cut-off for NLR and PLR were determined by plotting the receiver operating characteristics (ROC) curves of NLR/PLR in predicting malignant PCN and utilizing the Youden index. RESULTS The optimal NLR and PLR cut-offs were determined to be 3.33 and 205, respectively. Univariate analyses demonstrated that symptomatic PCNs, age, obstructive jaundice, presence of solid component, dilatation of main pancreatic duct ≥10 mm, high NLR and high PLR were predictive of a malignant PCN. Multivariate analyses demonstrated that obstructive jaundice, presence of solid component, MPD ≥10 mm and high PLR but not NLR were independent predictors of a malignant PCN. A high PLR significantly predicted invasive carcinoma in patients classified within the ICG(HR) group. Comparison between the ROC curves of the ICG versus ICG plus high PLR in predicting malignant PCN demonstrated a significant improvement in the accuracy of the ICG when PLR was included [AUC 0.784 (95% CI: 0.740-0.829) vs AUC 0.822 (95% CI: 0.772-0.872) (p = 0.0032)]. CONCLUSIONS High PLR is an independent predictor of malignancy in PCN. The addition of PLR as a criterion to the ICG improved the accuracy of these guidelines in detecting invasive neoplasms.
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Affiliation(s)
- Brian K P Goh
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore.
| | - Jin-Yao Teo
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore
| | | | - Damien M Y Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Chung-Yip Chan
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore
| | - Ser-Yee Lee
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore
| | - David W M Tai
- Division of Medical Oncology, National Cancer Centre, Singapore
| | - Choon-Hua Thng
- Department of Diagnostic Imaging, National Cancer Centre, Singapore
| | - Peng-Chung Cheow
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore
| | - Pierce K H Chow
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore
| | - London L P J Ooi
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore
| | - Alexander Y F Chung
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore
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Main-duct Intraductal Papillary Mucinous Neoplasm: High Cancer Risk in Duct Diameter of 5 to 9 mm. Ann Surg 2016; 262:875-80; discussion 880-1. [PMID: 26583679 DOI: 10.1097/sla.0000000000001462] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The 2012 international consensus guidelines for the management of intraductal papillary mucinous neoplasms (IPMN) recommend surgical treatment in main-duct IPMN patients with a main pancreatic duct (MPD) diameter of ≥10 mm. Aim of the present study was to analyze cancer risk in patients with an MPD diameter of less than 10 mm. METHODS All consecutive patients (prospective data protocol) with histological proof of IPMN who underwent surgery between January 2004 and December 2013 were included in the study. Clinical characteristics, particularly preoperative imaging with regard to morphology of the MPD, were correlated with final histopathology. RESULTS Among a total of 605 patients who underwent surgery for IPMN, there were 320 patients with MPD involvement, 238 patients with mixed-type IPMN, and 82 patients with main-duct IPMN alone. The total malignancy rate including high-grade dysplasia and invasive carcinoma in IPMNs with MPD involvement was 68%. When the MPD diameter was 5 to 9 mm, malignancy rate was 59%, whereas in MPD diameter more than 10 mm, it was 73%. No statistical correlations were observed between MPD diameter and clinical and/or IPMN features such as age, cyst location, mural nodules, serum tumor markers, or bilirubin. CONCLUSIONS Main-duct IPMNs with a MPD between 5 and 9 mm already bear a significant risk of malignancy. Therefore, surgical treatment is clearly indicated in patients with a MPD diameter of ≥5 mm and the 2012 guidelines should be discussed and adapted with regard to this topic.
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Utomo WK, Looijenga LH, Bruno MJ, Hansen BE, Gillis A, Biermann K, Peppelenbosch MP, Fuhler GM, Braat H. A MicroRNA Panel in Pancreatic Cyst Fluid for the Risk Stratification of Pancreatic Cysts in a Prospective Cohort. MOLECULAR THERAPY. NUCLEIC ACIDS 2016; 5:e350. [PMID: 28131248 PMCID: PMC5023405 DOI: 10.1038/mtna.2016.61] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 06/21/2016] [Indexed: 12/20/2022]
Abstract
A subset of pancreatic cystic neoplasms are regarded as precursor lesions of pancreatic cancer, but only a minority of all pancreatic cystic neoplasms will undergo malignant transformation. MicroRNAs are increasingly recognized as molecular targets in carcinogenesis. Previously, a 9-microRNA (miR) signature was suggested to discriminate between high risk and low risk pancreatic cystic neoplasm. In this study, we aimed to validate this 9-miR panel in a prospective cohort. Total miR was isolated from pancreatic cyst fluid and expression of miR18a, miR24, miR30a-3p, miR92a, miR99b, miR106b, miR142-3p, miR342-3p, and miR532-3p was analyzed by singleplex Taqman MicroRNA Assay. A total of 62 patient samples were analyzed. During follow-up, 24 (38.7%) patients underwent resection, of which 6 (9.7%) patients showed at least high grade dysplasia. A logistic regression model presented a “predicted risk” score which significantly differed between low and high risk cysts, either including all patients or only those with histological confirmation of diagnosis. Using a set cut-off of 50%, the sensitivity of the model for the total cohort was 10.0%, specificity 100.0%, positive predicted value 100.0%, negative predicted value 85.2%, and diagnostic accuracy of 85.5%. Thus, while observing a significant difference between low and high risk cysts, clinical implementation of this biomarker panel is as yet unlikely to be beneficial in the management of pancreatic cysts.
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Affiliation(s)
- W K Utomo
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | - L H Looijenga
- Department of Pathology, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | - B E Hansen
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | - Ajm Gillis
- Department of Pathology, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | - K Biermann
- Department of Pathology, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | - M P Peppelenbosch
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, The Netherlands
| | - G M Fuhler
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, The Netherlands.
| | - H Braat
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, The Netherlands
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Predictors for Surgical Referral in Patients With Pancreatic Cystic Lesions Undergoing Endoscopic Ultrasound: Results From a Large Multicenter Cohort Study. Pancreas 2016; 45:51-7. [PMID: 26262589 DOI: 10.1097/mpa.0000000000000386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Endoscopic ultrasound (EUS) plays an integral role in the evaluation of pancreatic cysts lesions (PCLs). The aim of the study was to determine predictors of surgical referral in patients with PCLs undergoing EUS. METHODS We performed a multicenter retrospective study of patients undergoing EUS for evaluation of PCLs. Demographics, EUS characteristics, and fine-needle aspiration results were recorded. Patients were categorized into surgery or surveillance groups on the basis of post-EUS recommendations. Univariate and multivariate analyses were performed to identify predictors of surgical referral. RESULTS 1804 patients were included. 1301 patients were recommended to undergo surveillance and 503 patients were referred for surgical evaluation, of which 360 patients underwent surgery. Multivariate analysis revealed the following 5 independent predictors of surgical referral: symptoms of weight loss on presentation (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.44-5.03), EUS findings of associated solid mass (OR, 7.34; 95% CI, 3.81-14.16), main duct communication (OR, 4.13; 95% CI, 1.71-9.98), multilocular macrocystic morphology (OR, 2.79; 95% CI, 1.78-4.38), and fine-needle aspiration findings of mucin on cytology (OR, 3.06; 95% CI, 1.94-4.82). CONCLUSIONS This study identifies factors associated with surgical referral in patients with PCLs undergoing EUS. Future studies should focus on creation of risk stratification models to determine the need for surgery or enrollment in surveillance programs.
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Sheng Y, Bian Y, Wang L. Distinguishing benign from malignant main duct intraductal papillary mucinous neoplasms of the pancreas by multislice helical computed tomography. Shijie Huaren Xiaohua Zazhi 2015; 23:5809-5814. [DOI: 10.11569/wcjd.v23.i36.5809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Main duct intraductal papillary mucinous neoplasms (MD-IPMNs) of the pancreas are located in the dilated main pancreatic duct and associated with mucin overproduction. They may have a high degree of malignancy and lack specific clinical manifestations. With advantages of thin slice thickness, high resolution, multi-phase dynamic scan and multiple post-processing techniques, multislice helical computed tomography (MSCT) can accurately diagnose and differentiate malignant from benign MD-IPMNs. This paper will review the current advances in differentiating malignant from benign MD-IPMNs by MSCT.
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Tanaka M. International consensus on the management of intraductal papillary mucinous neoplasm of the pancreas. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:286. [PMID: 26697446 DOI: 10.3978/j.issn.2305-5839.2015.11.09] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
International consensus guidelines for the management of intraductal papillary mucinous neoplasm (IPMN) of the pancreas revised in 2012 (Fukuoka consensus) seem to be accepted well worldwide. Division of various factors to predict malignant transformation into two categories, i.e., "high-risk stigmata" and "worrisome features", is also accepted as practically useful for stratifying the risk factors. Our current interest resides in the development of noninvasive and/or invasive pancreatic cancer in areas of the pancreas distinct from IPMN. Invasive pancreatic cancers derived from and concomitant with IPMN should be distinguished to clarify the incidence of each entity, although some more definitive method for differentiation has to be devised in some cases where histological distinction is obscure. IPMN is a clue to early detection of pancreatic cancer. The optimal surveillance protocol for IPMN on observation should be determined in consideration of both of these different pancreatic cancers.
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Affiliation(s)
- Masao Tanaka
- Shimonoseki City Hospital, 1-13-1 Koyo-cho, Shimonoseki 750-8520, Japan
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