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Taya M, Hecht EM, Huang C, Lo GC. Pancreatic Cystic Lesions: Imaging Techniques and Diagnostic Features. Gastrointest Endosc Clin N Am 2023; 33:497-518. [PMID: 37245932 DOI: 10.1016/j.giec.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The detection of incidental pancreatic cystic lesions has increased over time. It is crucial to separate benign from potentially malignant or malignant lesions to guide management and reduce morbidity and mortality. The key imaging features used to fully characterize cystic lesions are optimally assessed by contrast-enhanced magnetic resonance imaging/magnetic resonance cholangiopancreatography, with pancreas protocol computed tomography offering a complementary role. While some imaging features have high specificity for a particular diagnosis, overlapping imaging features between diagnoses may require further investigation with follow-up diagnostic imaging or tissue sampling.
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Affiliation(s)
- Michio Taya
- Department of Radiology, New York Presbyterian - Weill Cornell Medicine, 520 East 70th Street, Starr 8a, New York, NY 10021, USA
| | - Elizabeth M Hecht
- Department of Radiology, New York Presbyterian - Weill Cornell Medicine, 520 East 70th Street, Starr 8a, New York, NY 10021, USA
| | - Chenchan Huang
- Department of Radiology, NYU Grossman School of Medicine, 560 1st Avenue, 2F, New York, NY 10016, USA
| | - Grace C Lo
- Department of Radiology, New York Presbyterian - Weill Cornell Medicine, 520 East 70th Street, Starr 8a, New York, NY 10021, USA.
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2
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Hu F, Hu Y, Wang D, Ma X, Yue Y, Tang W, Liu W, Wu P, Peng W, Tong T. Cystic Neoplasms of the Pancreas: Differential Diagnosis and Radiology Correlation. Front Oncol 2022; 12:860740. [PMID: 35299739 PMCID: PMC8921498 DOI: 10.3389/fonc.2022.860740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/04/2022] [Indexed: 12/18/2022] Open
Abstract
Although the probability of pancreatic cystic neoplasms (PCNs) being detected is raising year by year, their differential diagnosis and individualized treatment are still a challenge in clinical work. PCNs are tumors containing cystic components with different biological behaviors, and their clinical manifestations, epidemiology, imaging features, and malignant risks are different. Some are benign [e.g., serous cystic neoplasms (SCNs)], with a barely possible that turning into malignant, while others display a low or higher malignant risk [e.g., solid pseudopapillary neoplasms (SPNs), intraductal papillary mucinous neoplasms (IPMNs), and mucinous cystic neoplasms (MCNs)]. PCN management should concentrate on preventing the progression of malignant tumors while preventing complications caused by unnecessary surgical intervention. Clinically, various advanced imaging equipment are usually combined to obtain a more reliable preoperative diagnosis. The challenge for clinicians and radiologists is how to accurately diagnose PCNs before surgery so that corresponding surgical methods and follow-up strategies can be developed or not, as appropriate. The objective of this review is to sum up the clinical features, imaging findings and management of the most common PCNs according to the classic literature and latest guidelines.
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Affiliation(s)
- Feixiang Hu
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yue Hu
- Hefei Cancer Hospital, Chinese Academy of Sciences (CAS), Hefei, China
| | - Dan Wang
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai, China
| | - Xiaowen Ma
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yali Yue
- Children's Hospital, Fudan University, Shanghai, China
| | - Wei Tang
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wei Liu
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Puye Wu
- General Electric (GE) Healthcare, Shanghai, China
| | - Weijun Peng
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Tong Tong
- Department of Radiology, Fudan University Shanghai Cancer Center, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
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Gao J, Han F, Wang X, Duan S, Zhang J. Multi-Phase CT-Based Radiomics Nomogram for Discrimination Between Pancreatic Serous Cystic Neoplasm From Mucinous Cystic Neoplasm. Front Oncol 2021; 11:699812. [PMID: 34926238 PMCID: PMC8672034 DOI: 10.3389/fonc.2021.699812] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 11/15/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose This study aimed to develop and verify a multi-phase (MP) computed tomography (CT)-based radiomics nomogram to differentiate pancreatic serous cystic neoplasms (SCNs) from mucinous cystic neoplasms (MCNs), and to compare the diagnostic efficacy of radiomics models for different phases of CT scans. Materials and Methods A total of 170 patients who underwent surgical resection between January 2011 and December 2018, with pathologically confirmed pancreatic cystic neoplasms (SCN=115, MCN=55) were included in this single-center retrospective study. Radiomics features were extracted from plain scan (PS), arterial phase (AP), and venous phase (VP) CT scans. Algorithms were performed to identify the optimal features to build a radiomics signature (Radscore) for each phase. All features from these three phases were analyzed to develop the MP-Radscore. A combined model comprised the MP-Radscore and imaging features from which a nomogram was developed. The accuracy of the nomogram was evaluated using receiver operating characteristic (ROC) curves, calibration tests, and decision curve analysis. Results For each scan phase, 1218 features were extracted, and the optimal ones were selected to construct the PS-Radscore (11 features), AP-Radscore (11 features), and VP-Radscore (12 features). The MP-Radscore (14 features) achieved better performance based on ROC curve analysis than any single phase did [area under the curve (AUC), training cohort: MP-Radscore 0.89, PS-Radscore 0.78, AP-Radscore 0.83, VP-Radscore 0.85; validation cohort: MP-Radscore 0.88, PS-Radscore 0.77, AP-Radscore 0.83, VP-Radscore 0.84]. The combination nomogram performance was excellent, surpassing those of all other nomograms in both the training cohort (AUC, 0.91) and validation cohort (AUC, 0.90). The nomogram also performed well in the calibration and decision curve analyses. Conclusions Radiomics for arterial and venous single-phase models outperformed the plain scan model. The combination nomogram that incorporated the MP-Radscore, tumor location, and cystic number had the best discriminatory performance and showed excellent accuracy for differentiating SCN from MCN.
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Affiliation(s)
- Jiahao Gao
- Department of Radiology, Huashan Hospital North, Fudan University, Shanghai, China.,Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Fang Han
- Department of Radiology, Huashan Hospital North, Fudan University, Shanghai, China.,Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoshuang Wang
- Department of Radiology, Huashan Hospital North, Fudan University, Shanghai, China
| | - Shaofeng Duan
- Department of Life Sciences, GE Healthcare, Shanghai, China
| | - Jiawen Zhang
- Department of Radiology, Huashan Hospital North, Fudan University, Shanghai, China.,Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
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Tirkes T, Patel AA, Tahir B, Kim RC, Schmidt CM, Akisik FM. Pancreatic cystic neoplasms and post-inflammatory cysts: interobserver agreement and diagnostic performance of MRI with MRCP. Abdom Radiol (NY) 2021; 46:4245-4253. [PMID: 34014363 DOI: 10.1007/s00261-021-03116-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/28/2021] [Accepted: 05/06/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE We aimed to answer several clinically relevant questions; (1) the interobserver agreement, (2) diagnostic performance of MRI with MRCP for (a) branch duct intraductal papillary mucinous neoplasms (BD-IPMN), mucinous cystic neoplasms (MCN) and serous cystic neoplasms (SCN), (b) distinguishing mucinous (BD-IPMN and MCN) from non-mucinous cysts, and (c) distinguishing three pancreatic cystic neoplasms (PCN) from post-inflammatory cysts (PIC). METHODS A retrospective analysis was performed at a tertiary referral center for pancreatic diseases on 71 patients including 44 PCNs and 27 PICs. All PCNs were confirmed by surgical pathology to be 17 BD-IPMNs, 13 MCNs, and 14 SCNs. Main duct and mixed type IPMNs were excluded. Two experienced abdominal radiologists blindly reviewed all the images. RESULTS Sensitivity of two radiologists for BD-IPMN, MCN and SCN was 88-94%, 62-69% and 57-64%, specificity of 67-78%, 67-78% and 67-78%, and accuracy of 77-82%, 65-75% and 63-73%, respectively. There was 80% sensitivity, 63-73% specificity, 70-76% accuracy for distinguishing mucinous from non-mucinous neoplasms, and 73-75% sensitivity, 67-78% specificity, 70-76% accuracy for distinguishing all PCNs from PICs. There was moderate-to-substantial interobserver agreement (Cohen's kappa: 0.65). CONCLUSION Two experienced abdominal radiologists had moderate-to-high sensitivity, specificity, and accuracy for BD-IPMN, MCN, and SCN. The interobserver agreement was moderate-to-substantial. MRI with MRCP can help workup of incidental pancreatic cysts by distinguishing PCNs from PICs, and premalignant mucinous neoplasms from cysts with no malignant potential.
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Affiliation(s)
- Temel Tirkes
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N. University Blvd UH 0663, Indianapolis, IN, 46202, USA.
| | - Aashish A Patel
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N. University Blvd UH 0663, Indianapolis, IN, 46202, USA
| | - Bilal Tahir
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N. University Blvd UH 0663, Indianapolis, IN, 46202, USA
| | - Rachel C Kim
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Fatih M Akisik
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 N. University Blvd UH 0663, Indianapolis, IN, 46202, USA
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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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Zhou XH, Ma JK, Valluru B, Sharma K, Liu L, Hu JB. Diagnosis and differentiation of mature cystic teratoma of pancreas from its mimics: A case report. Medicine (Baltimore) 2020; 99:e23267. [PMID: 33217853 PMCID: PMC7676578 DOI: 10.1097/md.0000000000023267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Mature cystic teratoma originating in the pancreas is very unusual, often observed as an incidental finding during routine examinations or recognized perioperatively as the patients present with very unspecific clinical symptoms. The confirmatory diagnosis of a pancreatic cystic teratoma is generally made by histopathology after surgical excision. So, the preoperative diagnosis is very challenging, especially differentiation from the other pancreatic pathologies. PATIENT CONCERNS A 23-year-old woman was admitted to our hospital with a complaint of mild grade periumbilical abdominal pain. A pancreatic mass was revealed on a preliminary abdominal ultrasound examination. Her medical history was unremarkable with no long-standing illness or malignancy. DIAGNOSIS Mature cystic teratoma in the head of the pancreas. INTERVENTIONS Roux-enY choledochojejunostomy with gastrojejunostomy was performed, excising the tumor from the pancreatic head. OUTCOMES The postoperative course was uneventful; the patient was asymptomatic and has no evidence of recurrence on a 2-year follow up. CONCLUSIONS Pancreatic cystic teratoma is a benign, well-differentiated, and extremely rare congenital tumor. MRI is the choice of imaging modality and phase-GRE or fat suppression is the best technique for pre-operative diagnosis.
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Affiliation(s)
- Xin he Zhou
- Department of Radiology, the First Affiliated Hospital of Dali University
| | - Ji Kong Ma
- Department of Nephrology, Dali Bai Autonomous Prefecture People's Hospital Dali 671000, China
| | - Bimbadhar Valluru
- Department of Radiology, the First Affiliated Hospital of Dali University
| | - Kalyan Sharma
- Department of Radiology, the First Affiliated Hospital of Dali University
| | - Ling Liu
- Department of Radiology, the First Affiliated Hospital of Dali University
| | - Jin Bo Hu
- Department of Radiology, the First Affiliated Hospital of Dali University
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Yadav RK, Jiang X, Chen J. Differentiating benign from malignant pancreatic cysts on computed tomography. Eur J Radiol Open 2020; 7:100278. [PMID: 33163586 PMCID: PMC7607418 DOI: 10.1016/j.ejro.2020.100278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/11/2020] [Accepted: 09/23/2020] [Indexed: 12/19/2022] Open
Abstract
CT can distinguish between benign and premalignant or malignant pancreatic cysts. Solid component and septation were the only CT features that could differentiate benign from malignant cysts. Cyst wall enhancements on CT were more commonly observed in premalignant or malignant cysts than in benign cysts. CT is a necessary diagnostic modality to preoperatively detect and characterize pancreatic lesions.
Purpose It is important to identify features on computed tomography (CT) that can distinguish between benign and premalignant or malignant pancreatic cysts to avoid unnecessary surgeries. This study investigated the preoperative diagnostic evaluation of cystic pancreatic lesions to determine how advanced imaging and clinical factors should guide management. Methods In total, 53 patients with 27 benign and 26 premalignant or malignant cysts were enrolled. CT features of the cysts were compared using univariate and multivariate analyses. Results On univariate analysis, a solid component (p < 0.01), septation (p < 0.01), location (p < 0.01), border (p < 0.01), wall enhancement (p = 0.01), lesion margins (p < 0.01), pancreatic atrophy (p = 0.04), and a cystic wall (p < 0.01) were all significantly different between benign and premalignant or malignant cysts. On multivariate analysis, only a solid component (p < 0.01) and septation (p < 0.01) were significant. Conclusion A thin cystic wall, uniform homogeneity, a clear border, the presence of septation, pancreatic atrophy, and the absence of both wall enhancements and solid components were more frequently seen in benign cysts. A thick wall, lack of homogeneity, the presence of wall enhancements and solid components, absence of septation, only a small degree of pancreatic atrophy, and unclear borders were more frequent among premalignant or malignant cysts. The only CT features to differentiate benign from premalignant or malignant cysts were a solid component and septation.
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Key Words
- CEA, Carcinoembryonic antigen
- CPR, Curved planar reformation
- CTA, CT angiography
- DWI, Diffusion-weighted imaging
- ERCP, Endoscopic retrograde cholangiopancreatography
- FDG PET, Fluorodeoxyglucose PET
- FNA, Fine-needle aspiration
- HASTE, Half-Fourier acquisition single-shot turbo spin-echo
- IPMN, Intraductal papillary mucinous neoplasia
- MCA, Mucinous cystadenoma
- MCB, Mucinous cystic borderline tumor
- MCC, Mucinous cystadenocarcinoma
- MCN, Mucinous cystic neoplasm
- MPD, Main pancreatic duct
- MPR, Multi-planar reformation
- MRA, MR angiography
- MRCP, MR cholangiopancreatography
- MRI, Magnetic resonance imaging
- MSCT, Multi-slice helical computed tomography
- PACS, Picture archiving and communicating system
- PCN, Cystic neoplasms of the pancreas
- PDAC, Pancreatic ductal adenocarcinoma
- PET, Positron emission computed tomography
- Pancreatic cystic lesions
- Pancreatic ductal adenocarcinoma
- Pancreatic neoplasm
- ROI, Region of interest
- SCA, Serous cystadenoma
- SMA, Serous microcystic adenoma
- US, Ultrasonography
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Affiliation(s)
- Rajesh Kumar Yadav
- Second Affiliated Hospital, Department of Radiology, Sun Yat-sen University, Guangzhou 510000, China
- Corresponding author: Current Address: Novus Health Wellness, 4808 Munson St NW, OH 44718 USA.
| | - Xinhua Jiang
- Department of Radiology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
| | - Jianyu Chen
- Second Affiliated Hospital, Department of Radiology, Sun Yat-sen University, Guangzhou 510000, China
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Ozaki K, Ikeno H, Kaizaki Y, Maeda K, Higuchi S, Kosaka N, Kimura H, Gabata T. Pearls and pitfalls of imaging features of pancreatic cystic lesions: a case-based approach with imaging-pathologic correlation. Jpn J Radiol 2020; 39:118-142. [PMID: 32840742 DOI: 10.1007/s11604-020-01032-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022]
Abstract
A variety of neoplastic and non-neoplastic lesions of the pancreas can present with a predominantly cystic architecture. These lesions are increasingly being detected as incidental findings on routine cross-sectional imaging following technological advances in these techniques and their widespread use. The different histopathological behaviors show various common and uncommon imaging findings, and some cases show similar appearance in spite of different histopathology. Each lesion requires specific management because of the differing risk of progression to malignancy, and an accurate imaging diagnosis is crucial. The typical imaging characteristics that differentiate pancreatic cystic lesions have been well described and fully summarized. However, in addition to a small percentage of cases that shows uncommon imaging findings, a substantial percentage of cystic lesions shows overlapping imaging findings that can lead to radiological misdiagnosis. For appropriate diagnosis and optimal treatment strategy, it is important to know the uncommon and overlapping imaging findings of these lesions, in addition to familiarity with the typical aspects. In this article, we reconfirm the well-known characteristic imaging features of pancreatic cystic lesions and present several diagnostically challenging cases, focusing on the uncommon and overlapping imaging findings.
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Affiliation(s)
- Kumi Ozaki
- Department of Radiology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka-Shimoaizuki, Eiheiji, Fukui, 910-1193, Japan.
| | - Hiroshi Ikeno
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Yasuharu Kaizaki
- Department of Diagnostic Pathology, Fukui Prefectural Hospital, Fukui, Japan
| | - Kazuya Maeda
- Department of Surgery, Fukui Prefectural Hospital, Fukui, Japan
| | - Shohei Higuchi
- Department of Pathology, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Nobuyuki Kosaka
- Department of Radiology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka-Shimoaizuki, Eiheiji, Fukui, 910-1193, Japan
| | - Hirohiko Kimura
- Department of Radiology, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka-Shimoaizuki, Eiheiji, Fukui, 910-1193, Japan
| | - Toshifumi Gabata
- Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
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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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Abraham AS, Simon B, Eapen A, Sathyakumar K, Chandramohan A, Raju RS, Joseph P, Kodiatte TA, Gowri M. Role of Cross-sectional Imaging (CT/MRI) in Characterization and Distinguishing Benign from Malignant/Potentially Malignant Cystic Lesions of Pancreas. J Clin Imaging Sci 2020; 10:28. [PMID: 32494507 PMCID: PMC7265468 DOI: 10.25259/jcis_15_2020] [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] [Received: 02/11/2020] [Accepted: 04/21/2020] [Indexed: 12/21/2022] Open
Abstract
Objectives: The aim of the study was to evaluate the accuracy of computed tomography/magnetic resonance imaging (CT/MRI) in characterizing cystic lesions of the pancreas and in differentiating between benign and malignant/potentially malignant lesions. Material and Methods: A retrospective study was performed on patients with pancreatic cystic lesions who underwent pre-operative imaging and surgery between October 2004 and April 2017 at a tertiary care teaching hospital. The images were reviewed for specific characteristics and diagnoses recorded independently by two radiologists who were blinded to the histopathological examination (HPE) report. Radiological diagnostic accuracy was assessed with HPE as reference standard. Results: A total of 80 patients fulfilled the inclusion criteria (M: F = 27:53). The final HPE diagnoses were solid pseudopapillary neoplasm (32.5%), walled off necrosis/pseudocyst (27.5%), mucinous cystadenoma (15%), serous cystadenoma (11.25%), intraductal papillary mucinous neoplasm (8.75%), mucinous cystadenocarcinoma (2.5%), simple epithelial cyst (1.25%), and unspecified benign cystic lesion (1.25%). Observer1 correctly identified the diagnosis in 73.75% of cases while observer 2 did so in 72.5%. Sensitivity for distinguishing benign versus malignant/potentially malignant lesions was 85.1% for observer 1 and 80.9% for observer 2. On multivariate logistic regression analysis: Solid cystic morphology, presence of mural nodule, and female gender were associated with premalignant/malignant lesions. Conclusion: Cross-sectional imaging is a valuable tool for characterization of pancreatic cystic lesions within its limitations.
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Affiliation(s)
- Amy Sara Abraham
- Departments of Radiodiagnosis, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Betty Simon
- Departments of Radiodiagnosis, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Anu Eapen
- Departments of Radiodiagnosis, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Kirthi Sathyakumar
- Departments of Radiodiagnosis, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Anuradha Chandramohan
- Departments of Radiodiagnosis, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Ravish Sanghi Raju
- Departments of Hepatopancreaticobiliary Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Philip Joseph
- Departments of Hepatopancreaticobiliary Surgery, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Thomas Alex Kodiatte
- Departments of Pathology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Mahasampath Gowri
- Biostatistics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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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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12
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Rowan D, Pant M, Hagen C, Giorgadze T. Coexisting pancreatic serous cystadenoma and pancreatic ductal adenocarcinoma: A cytological-pathologic correlation with literature review. Ann Diagn Pathol 2019; 42:87-91. [PMID: 31382079 DOI: 10.1016/j.anndiagpath.2019.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 07/26/2019] [Indexed: 12/12/2022]
Abstract
Pancreatic serous cystadenoma (SCA) is a benign neoplastic lesion with a distinctive gross and microscopic appearance consisting of numerous thin-walled cysts lined by uniform epithelial cells with clear cytoplasm and small nuclei. The vast majority of serous cystadenomas are benign. Pancreatic SCA has rarely been reported in association with other pancreatic lesions. We present a challenging case in which a cystic and solid pancreatic mass was identified on imaging studies. FNA was performed and showed clusters of atypical cells with significant nuclear pleomorphism (>4:1), disorganized, overlapping nuclei, and prominent nucleoli. The FNA diagnosis was positive for malignancy, consistent with adenocarcinoma. The patient underwent neoadjuvant therapy and pancreaticoduodenectomy. Final pathology showed a serous cystadenoma associated with small foci of high-grade PanIN. The lack of invasive adenocarcinoma in the resection specimen was most likely due to complete response of the tumor to neoadjuvant chemoradiation therapy, but it is also possible that only high-grade PanIN was present initially. To our knowledge, this is the first reported case of SCA and high grade PanIN/PDAC that was assessed by FNA. We discuss the cytologic differential diagnosis and how to avoid potential pitfalls highlighted by this case.
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Affiliation(s)
- Daniel Rowan
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mamta Pant
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Catherine Hagen
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Tamara Giorgadze
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA.
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13
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Yang J, Guo X, Ou X, Zhang W, Ma X. Discrimination of Pancreatic Serous Cystadenomas From Mucinous Cystadenomas With CT Textural Features: Based on Machine Learning. Front Oncol 2019; 9:494. [PMID: 31245294 PMCID: PMC6581751 DOI: 10.3389/fonc.2019.00494] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 05/24/2019] [Indexed: 02/05/2023] Open
Abstract
Objectives: This study was designed to estimate the performance of textural features derived from contrast-enhanced CT in the differential diagnosis of pancreatic serous cystadenomas and pancreatic mucinous cystadenomas. Methods: Fifty-three patients with pancreatic serous cystadenoma and 25 patients with pancreatic mucinous cystadenoma were included. Textural parameters of the pancreatic neoplasms were extracted using the LIFEx software, and were analyzed using random forest and Least Absolute Shrinkage and Selection Operator (LASSO) methods. Patients were randomly divided into training and validation sets with a ratio of 4:1; random forest method was adopted to constructed a diagnostic prediction model. Scoring metrics included sensitivity, specificity, accuracy, and AUC. Results: Radiomics features extracted from contrast-enhanced CT were able to discriminate pancreatic mucinous cystadenomas from serous cystadenomas in both the training group (slice thickness of 2 mm, AUC 0.77, sensitivity 0.95, specificity 0.83, accuracy 0.85; slice thickness of 5 mm, AUC 0.72, sensitivity 0.90, specificity 0.84, accuracy 0.86) and the validation group (slice thickness of 2 mm, AUC 0.66, sensitivity 0.86, specificity 0.71, accuracy 0.74; slice thickness of 5 mm, AUC 0.75, sensitivity 0.85, specificity 0.83, accuracy 0.83). Conclusions: In conclusion, our study provided preliminary evidence that textural features derived from CT images were useful in differential diagnosis of pancreatic mucinous cystadenomas and serous cystadenomas, which may provide a non-invasive approach to determine whether surgery is needed in clinical practice. However, multicentre studies with larger sample size are needed to confirm these results.
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Affiliation(s)
- Jing Yang
- State Key Laboratory of Biotherapy, Department of Biotherapy, West China Hospital, Cancer Center, Sichuan University, Chengdu, China
| | - Xinli Guo
- West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Xuejin Ou
- State Key Laboratory of Biotherapy, Department of Biotherapy, West China Hospital, Cancer Center, Sichuan University, Chengdu, China
| | - Weiwei Zhang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xuelei Ma
- State Key Laboratory of Biotherapy, Department of Biotherapy, West China Hospital, Cancer Center, Sichuan University, Chengdu, China
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14
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Saleem DM, Haseeb WA, Parry AH, Irfan R, Muzaffar NM, Tariq G, Javed SO, Feroz I. Preoperative contrast-enhanced computed tomographic characterisation of pancreatic cystic lesions: A prospective study. SA J Radiol 2019; 23:1727. [PMID: 31754534 PMCID: PMC6837796 DOI: 10.4102/sajr.v23i1.1727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 03/31/2019] [Indexed: 01/17/2023] Open
Abstract
Background Characterisation of pancreatic cystic lesions has a direct role in their management and computed tomography is the mainstay of investigation for diagnosing and characterising them. Objectives The aim of this study was to prospectively assess the diagnostic accuracy of contrast-enhanced computed tomography (CECT) in preoperative characterisation of pancreatic cystic lesions with histopathology as the reference standard. Method A total of 38 patients with cystic pancreatic lesions diagnosed after clinical, laboratory and sonographic evaluation, irrespective of age, were preoperatively evaluated with CECT. Images were reviewed for the general characteristics of the lesions on pre-contrast and portal venous phase images and overall diagnostic accuracy calculated. Imaging findings were compared with histopathology, or cytology and/or intra-operative findings. Results Serous cystadenoma (SCA) was the most common cystic pancreatic lesion found in 31.6% of patients followed by mucinous cystadenoma (MCA) (26.3%), solid pseudo-papillary tumour (SPT) (21.1%) and intra-ductal papillary mucinous neoplasm (IPMN) (10.5%). Three patients (7.9%) had simple cysts and one patient (2.6%) had a lymphangioma. The diagnostic accuracy of CECT for pancreatic cystic lesions was found to be 72.5. Conclusion The diagnostic accuracy of computed tomography (CT) was high for SCA, IPMN and pancreatic cysts, and low for MCA and SPT. Combination of a multiloculated cystic lesion with locule size of less than 20 mm, septal enhancement with relative lack of wall enhancement, central scar and lobulated outline are highly specific for SCA. Unilocular or macro-cystic pattern with locule size of more than 20 mm, female gender and wall enhancement with smooth external contour are pointers towards MCA. Solid cystic pancreatic head lesions in young females may be suggestive of SPT. A dilated main pancreatic duct in a cystic lesion with internal septations may point towards IPMN. Fluid attenuation lesions with imperceptible non-enhancing wall indicate pancreatic cysts. Lastly, pseudocysts and neuroendocrine tumours with cystic components are great mimickers of pancreatic cystic lesions, and a history of pancreatitis and hormonal profile of patients should always be sought.
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Affiliation(s)
- Dar M Saleem
- Department of Radiodiagnosis, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Wani A Haseeb
- Department of Radiodiagnosis, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Arshed H Parry
- Department of Radiodiagnosis, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Robbani Irfan
- Department of Radiodiagnosis, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Najar M Muzaffar
- Department of Radiodiagnosis, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Gojwari Tariq
- Department of Radiodiagnosis, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Shah O Javed
- Department of Surgical Gastroenterology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Imza Feroz
- Department of Radiodiagnosis, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India
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15
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Madhani K, Yousaf M, Aamar A, Ooka K, Muniraj T, Aslanian H, Salem R, Farrell JJ. Impact of endoscopic ultrasound on diagnosis and management of presumed mucinous neoplasms when done for pancreatic cyst morphology change on non-invasive surveillance imaging. Endosc Int Open 2019; 7:E389-E395. [PMID: 30931368 PMCID: PMC6420337 DOI: 10.1055/a-0824-6240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 08/06/2018] [Indexed: 12/18/2022] Open
Abstract
Background and study aims Guidelines for management of presumed neoplastic pancreatic cysts have encouraged noninvasive imaging for low-risk surveillance, while reserving endoscopic ultrasound for worrisome features including morphologic change. We aim to study the impact of endoscopic ultrasound on diagnosis and management compared with non-invasive imaging. Patients and methods A single-institution pancreatic cyst database was retrospectively queried for patients who underwent endoscopic ultrasound for the indication of change in cyst morphology. Diagnoses were classified as presumed mucinous neoplasm with or without worrisome features or high-risk stigmata and non-mucinous lesions. Management decisions were defined a priori as surgical evaluation for patients with high-risk stigmata, positive cytology or mural nodule, or continued surveillance for all others. Results Between January 2013 and October 2016, 709 pancreas cyst endoscopic ultrasounds were performed of which 89 were for cyst morphology change seen on noninvasive imaging including 10 presumed pseudocysts, nine presumed serous cystadenomas, and 70 presumed mucinous cystic neoplasms. Cyst morphologic changes included increase in caliber of the main pancreatic duct (7 cases), increase in cyst size (68 cases), cyst ≥ 30 mm (10 cases), and presence of a solid nodule (1 case). Median cyst size increase was 5 mm with interquartile range of 4 mm over 2.1 ± 1.9 years. Endoscopic ultrasound done for morphologic change resulted in a change in diagnosis and management in 16 % and 13 % of cases, respectively. Conclusion Endoscopic ultrasound has a modest but clinically significant role in impacting diagnosis and management for presumed mucinous cystic neoplasms when performed for the indication of cyst morphology change.
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Affiliation(s)
- Kamraan Madhani
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Muhammad Yousaf
- Department of Digestive Diseases, Yale School of Medicine, New Haven, CT,Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, CT
| | - Ali Aamar
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Kohtaro Ooka
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Thiruvengadam Muniraj
- Department of Digestive Diseases, Yale School of Medicine, New Haven, CT,Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, CT
| | - Harry Aslanian
- Department of Digestive Diseases, Yale School of Medicine, New Haven, CT,Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, CT
| | - Ronald Salem
- Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, CT,Department of Surgical Oncology, Yale School of Medicine, New Haven, CT
| | - James J Farrell
- Department of Digestive Diseases, Yale School of Medicine, New Haven, CT,Yale Center for Pancreatic Disease, Yale School of Medicine, New Haven, CT,Corresponding author James J. Farrell, MD Section of Digestive DiseasesYale School of MedicineLMP 1080, 15 York StNew Haven, CT 06510-3221+1-203-737-1755
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16
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Tumor growth rate of pancreatic serous cystadenomas: Endosonographic follow-up with volume measurement to predict cyst enlargement. Pancreatology 2019; 19:122-126. [PMID: 30503637 DOI: 10.1016/j.pan.2018.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 09/07/2018] [Accepted: 11/16/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Serous cystadenomas are benign lesions of the pancreas. Usually they are diagnosed incidentally on cross-sectional imaging studies. Endosonography is a valuable tool in the diagnosis and follow-up of these cystic lesions. Given its benign nature, surgical resection is advised only in symptomatic patients. The interval and length of surveillance is not well established. METHODS A retrospective single center study was done. All the patients with a pancreatic serous cystadenoma sent for an endosonographic evaluation, between December 2008 and December 2015 were included. The lesions were follow-up endosonographically at least once, in a 12 months interval. Volume was measured with the formula π/6 × (d1 x d1 x d2). Two groups were evaluated: patients with a volume under 10 mL (Group 1) and those with a volume of 10 mL or more at presentation (Group 2). Growth rate between these two groups was compared. RESULTS Thirty-one patients were analyzed, with a mean age of 58.2 years. Patients were mainly women (87%). Twenty-four patients in Group 1 had a mean enlargement of 0.67 ml per year, whereas patients in Group 2 had a mean enlargement of 9.8 ml per year. The growth rate difference between these two groups was statistically significant (p = 0.0001). CONCLUSION Asymptomatic patients with pancreatic serous cystadenomas should be follow-up for enlargement. Small volume lesions have a low risk of enlargement compared with high volume and macrocystic serous cystadenomas. Volume at presentation is a feature to analyze when defining surveillance interval.
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17
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Jefferson B, Venkatraman I, Kumar RV, Ponnuswamy K, Anbukkarasi, Maduraimuthu P. Mucinous cystadenoma of pancreas with honeycombing appearance: Radiological-Pathological correlation. Indian J Radiol Imaging 2018; 28:327-329. [PMID: 30319210 PMCID: PMC6176663 DOI: 10.4103/ijri.ijri_469_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Most mucinous cystadenomas of pancreas are solitary and multilocular with a few large compartments. Serous cystadenomas usually have a polycystic or microcystic (honeycomb) pattern consisting of collection of cysts (usually >6) that range from few millimetres up to 2 cm in size. Here we present a case of mucinous cystadenoma of pancreas showing an unusual appearance of honeycombing (which has not been described so far) using imaging studies such as endoscopic ultrasound and computed tomography with histopathological confirmation of the diagnosis.
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Affiliation(s)
- Beno Jefferson
- Department of Radiodiagnosis, Sree Balaji Medical College and Hospital, Chromepet, Chennai, Tamil Nadu, India
| | - Indiran Venkatraman
- Department of Radiodiagnosis, Sree Balaji Medical College and Hospital, Chromepet, Chennai, Tamil Nadu, India
| | - R Vinoth Kumar
- Department of Medical Gastroenterology, Sree Balaji Medical College and Hospital, Chromepet, Chennai, Tamil Nadu, India
| | - Karkuzhali Ponnuswamy
- Department of Pathology, Sree Balaji Medical College and Hospital, Chromepet, Chennai, Tamil Nadu, India
| | - Anbukkarasi
- Department of Pathology, Sree Balaji Medical College and Hospital, Chromepet, Chennai, Tamil Nadu, India
| | - Prabakaran Maduraimuthu
- Department of Radiodiagnosis, Sree Balaji Medical College and Hospital, Chromepet, Chennai, Tamil Nadu, India
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18
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Alvarez-Sánchez MV, Napoléon B. New horizons in the endoscopic ultrasonography-based diagnosis of pancreatic cystic lesions. World J Gastroenterol 2018; 24:2853-2866. [PMID: 30018480 PMCID: PMC6048425 DOI: 10.3748/wjg.v24.i26.2853] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/28/2018] [Accepted: 06/16/2018] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cystic lesions (PCLs) are increasingly being identified because of the widespread use of high-resolution abdominal imaging. These cysts encompass a spectrum from malignant disease to benign lesions, and therefore, accurate diagnosis is crucial to determine the best management strategy, either surgical resection or surveillance. However, the current standard of diagnosis is not accurate enough due to limitations of imaging and tissue sampling techniques, which entail the risk of unnecessary burdensome surgery for benign lesions or missed opportunities of prophylactic surgery for potentially malignant PCLs. In the last decade, endoscopic innovations based on endoscopic ultrasonography (EUS) imaging have emerged, aiming to overcome the present limitations. These new EUS-based technologies are contrast harmonic EUS, needle-based confocal endomicroscopy, through-the-needle cystoscopy and through-the needle intracystic biopsy. Here, we present a comprehensive and critical review of these emerging endoscopic tools for the diagnosis of PCLs, with a special emphasis on feasibility, safety and diagnostic performance.
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Affiliation(s)
- María-Victoria Alvarez-Sánchez
- Instituto de Investigación Sanitaria Galicia Sur, Complejo Hospitalario Universitario de Pontevedra, Pontevedra 36003, Spain
| | - Bertrand Napoléon
- Department of Gastroenterology, Ramsay Générale de Santé Private Hospital Jean Mermoz, Lyon 69008, France
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19
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Abstract
Pancreatic cystic lesions are being detected with increasing frequency because of increased use and improved quality of cross-sectional imaging techniques. Pancreatic cystic lesions encompass non-neoplastic lesions (such as pancreatitis-related collections) and neoplastic tumors. Common cystic pancreatic neoplasms include serous cystadenomas, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, and solid pseudopapillary tumors. These cystic pancreatic neoplasms may have typical morphology, but at times show overlapping imaging features on cross-sectional examinations. This article reviews the classical and atypical imaging features of commonly encountered cystic pancreatic neoplasms and presents the limitations of current cross-sectional imaging techniques in accurately classifying pancreatic cystic lesions.
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Affiliation(s)
- Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Frank J Wessels
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
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20
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Abstract
Evidence-based guidelines on the management of pancreatic cystic neoplasms (PCN) are lacking. This guideline is a joint initiative of the European Study Group on Cystic Tumours of the Pancreas, United European Gastroenterology, European Pancreatic Club, European-African Hepato-Pancreato-Biliary Association, European Digestive Surgery, and the European Society of Gastrointestinal Endoscopy. It replaces the 2013 European consensus statement guidelines on PCN. European and non-European experts performed systematic reviews and used GRADE methodology to answer relevant clinical questions on nine topics (biomarkers, radiology, endoscopy, intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystic neoplasm, rare cysts, (neo)adjuvant treatment, and pathology). Recommendations include conservative management, relative and absolute indications for surgery. A conservative approach is recommended for asymptomatic MCN and IPMN measuring <40 mm without an enhancing nodule. Relative indications for surgery in IPMN include a main pancreatic duct (MPD) diameter between 5 and 9.9 mm or a cyst diameter ≥40 mm. Absolute indications for surgery in IPMN, due to the high-risk of malignant transformation, include jaundice, an enhancing mural nodule >5 mm, and MPD diameter >10 mm. Lifelong follow-up of IPMN is recommended in patients who are fit for surgery. The European evidence-based guidelines on PCN aim to improve the diagnosis and management of PCN.
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21
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Abstract
A variety of pancreatic and peripancreatic neoplasms may contain calcifications. We present a review of common to uncommon pancreatic neoplasms that may contain calcifications to include ductal adenocarcinoma, pancreatic neuroendocrine tumors, serous cystadenomas, solid pseudopapillary tumors, intraductal papillary mucinous neoplasms, mucinous cystic neoplasms, and lymphoepithelial cysts. In addition, duodenal mucinous adenocarcinoma can present as a peripancreatic mass that may contain calcification. Knowledge of the spectrum of calcification patterns can help the interpreting radiologist provide a meaningful differential.
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22
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Kim GE, Shin SS, Kim JW, Heo SH, Lim HS, Jun CH, Jeong YY. Incidental, Small (< 3 cm), Unilocular, Pancreatic Cysts: Factors That Predict Lesion Progression during Imaging Surveillance. Korean J Radiol 2017; 18:915-925. [PMID: 29089824 PMCID: PMC5639157 DOI: 10.3348/kjr.2017.18.6.915] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 05/30/2017] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To explore the features that predict size increase and development of potential malignant features in incidentally detected, unilocular cystic pancreatic lesions (CPLs) less than 3 cm in diameter, during subsequent follow-up. MATERIALS AND METHODS We retrieved data of patients diagnosed with unilocular CPLs less than 3 cm in diameter during the period from November 2003 through December 2014, using a computerized search. All serial CT and MR images were analyzed to identify the number, size, and location of CPLs; dilatation of the main pancreatic duct; and occurrence of worrisome features and high-risk stigmata of malignancy in the lesion. The characteristics of CPLs were compared between the increase (i.e., size increase during subsequent follow-up) and no-increase groups. For CPLs in the increase group, subgroup analysis was performed according to the lesion size at the last follow-up (< 3 cm vs. ≥ 3 cm). RESULTS Among 553 eligible patients, 132 (23.9%) had CPLs that increased in size, and 421 (76.1%) had CPLs that did not, during follow-up. Of the 132, 12 (9.1%) CPLs increased to diameters ≥ 3 cm at the final follow-up. Among the various factors, follow-up duration was a significant independent factor for an interval size increase of CPLs (p < 0.001). In the increase group, initial cyst size was a significant independent factor to predict later size increase to or beyond 3 cm in diameter (p < 0.001), and the initial cyst diameter ≥ 1.5 cm predicted such a growth with a sensitivity and specificity of 83% and 72%, respectively. No significant factors to predict the development of potential malignant features were identified. CONCLUSION Follow-up duration was associated with an interval size increase of CPLs. Among the growing CPLs, initial cyst size was associated with future lesion growth to and beyond 3 cm.
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Affiliation(s)
- Go Eun Kim
- Department of Radiology, Chonnam National University Hospital, Gwangju 61469, Korea
| | - Sang Soo Shin
- Department of Radiology, Chonnam National University Medical School, Gwangju 61469, Korea.,Center for Aging and Geriatrics, Chonnam National University Medical School, Gwangju 61469, Korea
| | - Jin Woong Kim
- Department of Radiology, Chonnam National University Medical School, Gwangju 61469, Korea
| | - Suk Hee Heo
- Department of Radiology, Chonnam National University Medical School, Gwangju 61469, Korea
| | - Hyo Soon Lim
- Department of Radiology, Chonnam National University Medical School, Gwangju 61469, Korea
| | - Chung Hwan Jun
- Department of Gastroenterology, Chonnam National University Medical School, Gwangju 61469, Korea
| | - Yong Yeon Jeong
- Department of Radiology, Chonnam National University Medical School, Gwangju 61469, Korea
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23
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Abstract
Pancreatic cystic neoplasms are discovered with increasing frequency. Accurate knowledge of the natural history of cystic neoplasms is crucial to develop useful and cost-effective strategies for surveillance and surgical resection. To date, the natural history of cystic neoplasms is still incomplete due to lack of adequate diagnostic accuracy in the absence of surgical pathology. Nevertheless, current evidence points to risk factors for malignant transformation to help clinical management. New biomarkers that accurately distinguish cyst neoplasms and those most likely to progress to cancer would help clarify the natural history of cystic neoplasms.
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Affiliation(s)
- Alexander Larson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Richard S Kwon
- Division of Gastroenterology and Hepatology, University of Michigan, 1500 E. Medical Center Drive, Taubman 3912, Ann Arbor, MI, 48109-5362, USA.
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24
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Chai N, Feng J, Guo Y, Li H, Ning B, Wang X, Wang Y, Wang Y, Zhai Y, Linghu E. Preliminary study of single-operator cholangioscopy for diagnosing pancreatic cystic lesions. Gastrointest Endosc 2017; 86:208-218. [PMID: 28185905 DOI: 10.1016/j.gie.2017.01.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 01/23/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Advances in imaging technology have improved the annual detection rate of pancreatic cystic lesions (PCLs), but the preoperative diagnosis of PCLs remains unclear. Thus, the usefulness of single-operator cholangioscopy (SOC) as a diagnostic imaging tool for PCLs is worth investigating. We performed an intracystic visual examination of PCLs using SOC to determine the diagnostic value of SOC for PCLs. METHODS In this retrospective observational study, PCLs were confirmed using a diagnostic imaging modality. Patients who underwent an EUS-guided through-the-needle fiberoptic pancreatic cystoscopy and SOC examination and those whose lesion type was definitively diagnosed were included (n = 43). If the cystic fluid was turbid, a physiologic saline solution was injected into the cyst, and a SOC fiberoptic probe was inserted through a 19-gauge needle to observe the wall of the intracystic cavity and its contents. The characteristics were recorded, and the cystic fluid and biopsy specimens were further assessed by performing liquid-based cytologic and histopathologic examinations. Particularly, histopathologic examinations were performed in patients who underwent surgery. RESULTS Intracystic characteristics of the confirmed cases of PCLs (43 patients) were identified through intracystic visual examination with SOC. The clarity of cyst fluid is a prerequisite for imaging by SOC. The tree-like branching pattern of blood vessel distribution may be a serous cystic neoplasm-specific characteristic. Intracystic papilla-like structure is an important characteristic for diagnosing mucinous cystic neoplasms. CONCLUSIONS The identified imaging characteristics such as blood vessel distribution on the intracystic wall and the contents of different PCLs observed under the SOC probe can provide useful information for diagnosing PCLs. SOC could be an important ancillary imaging test of PCLs by EUS.
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Affiliation(s)
- Ningli Chai
- Department of Gastroenterology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Jia Feng
- Department of Gastroenterology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yuhang Guo
- Department of Gastroenterology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Huikai Li
- Department of Gastroenterology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Bo Ning
- Department of Gastroenterology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Xiangdong Wang
- Department of Gastroenterology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Ying Wang
- Department of Gastroenterology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yonghua Wang
- Department of Gastroenterology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yaqi Zhai
- Department of Gastroenterology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Enqiang Linghu
- Department of Gastroenterology, Chinese People's Liberation Army General Hospital, Beijing, China
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25
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Pausawasdi N, Ratanachu-Ek T. Endoscopic ultrasonography evaluation for pancreatic cysts: Necessity or overkill? Dig Endosc 2017; 29:444-454. [PMID: 28321928 DOI: 10.1111/den.12873] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/16/2017] [Indexed: 02/06/2023]
Abstract
Incidental pancreatic cysts have become gradually more recognized in clinical practice as a result of increased use of transabdominal ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI). These lesions consist of inflammatory cysts (pseudocysts) and pancreatic cystic neoplasms (PCN) which have been classified as benign, premalignant and malignant. The diagnosis and management strategy of incidentally discovered pancreatic cysts can be challenging as the majority of them are PCN and CT or MRI alone may not be sufficient to provide an accurate diagnosis. Endoscopic ultrasound (EUS)-guided fine-needle aspiration provides a method to obtain cyst fluid for analysis and the recently developed EUS-based technology including contrast-enhanced ultrasound, cystoscopy and needle-based confocal laser endomicroscopy allows endosonographers to gain additional useful information. The current data suggest that EUS evaluation of pancreatic cysts offers some benefits especially in cases of inconclusive CT or MRI.
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Affiliation(s)
- Nonthalee Pausawasdi
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine Siriraj Hospital, Siriraj Endoscopy Center, Mahidol Univeristy, Bangkok, Thailand
| | - Thawee Ratanachu-Ek
- Department of Surgery, Digestive Endoscopy Center, Rajavithi Hospital, Bangkok, Thailand
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26
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Yu MH, Kim YJ, Park HS, Jung SI, Jeon HJ. Imaging Patterns of Intratumoral Calcification in the Abdominopelvic Cavity. Korean J Radiol 2017; 18:323-335. [PMID: 28246512 PMCID: PMC5313520 DOI: 10.3348/kjr.2017.18.2.323] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 10/20/2016] [Indexed: 12/12/2022] Open
Abstract
Intratumoral calcification is one of the most noticeable of radiologic findings. It facilitates detection and provides information important for correctly diagnosing tumors. In the abdominopelvic cavity, a wide variety of tumors have calcifications with various imaging features, though the majority of such calcifications are dystrophic in nature. In this article, we classify the imaging patterns of intratumoral calcification according to number, location, and morphology. Then, we describe commonly-encountered abdominopelvic tumors containing typical calcification patterns, focusing on their differentiable characteristics using the imaging patterns of intratumoral calcification.
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Affiliation(s)
- Mi Hye Yu
- Department of Radiology, Konkuk University Medical Center, Seoul 05030, Korea
| | - Young Jun Kim
- Department of Radiology, Konkuk University Medical Center, Seoul 05030, Korea
| | - Hee Sun Park
- Department of Radiology, Konkuk University Medical Center, Seoul 05030, Korea
| | - Sung Il Jung
- Department of Radiology, Konkuk University Medical Center, Seoul 05030, Korea
| | - Hae Jeong Jeon
- Department of Radiology, Konkuk University Medical Center, Seoul 05030, Korea
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Moris M, Wallace MB. Intraductal papillary mucinous neoplasms and mucinous cystadenomas: current status and recommendations. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:358-367. [PMID: 28112959 DOI: 10.17235/reed.2017.4630/2016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The real prevalence of pancreatic cystic lesions remains unknown. The malignant potential of some of these lesions remains a cause for significant concern. Thus, it is mandatory to develop a strategy to clearly discriminate those cysts with a potential for malignant transformation from those that do not carry any significant risk. Intraductal papillary mucinous neoplasms and mucinous cystadenomas are mucinous cystic neoplasms with a known malignant potential that have gained greater recognition in recent years. However, despite the numerous studies that have been carried out, their differential diagnosis among other cysts subtypes and their therapeutic approach continue to be a challenge for clinicians. This review contains a critical approach of the current recommendations and management strategies regarding intraductal papillary mucinous neoplasms and mucinous cystadenomas, as well as highlighting the limitations exposed in current guidelines.
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de Pretis N, Mukewar S, Aryal-Khanal A, Bi Y, Takahashi N, Chari S. Pancreatic cysts: Diagnostic accuracy and risk of inappropriate resections. Pancreatology 2017; 17:267-272. [PMID: 28117220 DOI: 10.1016/j.pan.2017.01.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 11/18/2016] [Accepted: 01/12/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic cystic neoplasms (PCN) frequently undergo surgery, given malignant potential. Pancreatic cyst surgery is associated with significant rates of morbidity and mortality. It is crucial to accurately characterize these lesions pre-operatively to avoid unnecessary surgery in patients with benign pancreatic cysts. AIM We aimed to assess the correlation between pre-operative (pre-op) diagnosis based on imaging and clinical presentation, and post-operative (post-op) diagnosis based on histopathology in patients undergone pancreatic cyst surgery. METHODS From January 2000 to January 2012, we randomly selected 2000 patients with ICD-9 code 211.6 and 577.2. Amongst these we identified 281 patients undergone pancreas surgery. Patients with no pre-op imaging or non-cyst indication for surgery were excluded (n = 107). Imaging details, demographics, pre-operative physician diagnosis and histopathologic details of pancreatic cysts were recorded in 174 patients. RESULTS There was a discrepancy between the pre- and post-operative pancreatic cyst diagnosis in 54 (31%) patients. There was no difference in the proportion of various imaging studies (CT, EUS or MRI) between patients with a correct and patients with an incorrect pre-op diagnosis. The pre-op diagnosis was confirmed at pathology in 87.5% of the presumed SCNs, in 80% of the presumed pseudocysts, in 73.3% of the presumed BD-IPMNs, in 66.7% of the presumed MD/mixed-IPMNs and in 53.6% of the presumed MCNs. The accuracy of the pre-operative diagnosis of presumed MCN was significantly lower compared to the non-MCN cysts (53.6% vs. 75%; p = 0.037). Fourteen percent of resections were performed for asymptomatic benign cysts, preoperatively suspected to be potentially pre-malignant cysts. CONCLUSION In nearly 1 out of 3 patients undergone pancreas cyst surgery, there is a discrepancy between pre- and post-op diagnosis. Pre-op diagnosis of presumed MCN is more likely to be incorrect, compared to the other cysts.
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Affiliation(s)
- N de Pretis
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - S Mukewar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - A Aryal-Khanal
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - Y Bi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States
| | - N Takahashi
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - S Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, United States.
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Chang YR, Park JK, Jang JY, Kwon W, Yoon JH, Kim SW. Incidental pancreatic cystic neoplasms in an asymptomatic healthy population of 21,745 individuals: Large-scale, single-center cohort study. Medicine (Baltimore) 2016; 95:e5535. [PMID: 28002329 PMCID: PMC5181813 DOI: 10.1097/md.0000000000005535] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Although incidental pancreatic cystic neoplasms are being diagnosed with increasing frequency, little is known about the accurate prevalence of pancreatic cysts in the general population. The aims of this study were to evaluate the crude prevalence rate of pancreatic cystic neoplasms in asymptomatic healthy adults, and calculate the age- and sex-adjusted nationwide prevalence rate.A total of 21,745 asymptomatic individuals who underwent abdominal computed tomography (CT) as a health screening examination were enrolled between 2003 and 2013 at the Seoul National University Hospital Healthcare System Gangnam Center. Nationwide population data of 2010 were collected from the National Statistical Office, Korea.Incidental pancreatic cystic neoplasms were found in 457 individuals whose mean age was 58.7 years. The types of neoplasms were reviewed by 2 separate designated radiologists and the final diagnosis was made as follows: intraductal papillary mucinous neoplasm: 376 (82%), serous cystic neoplasm: 19 (4%), mucinous cystic neoplasm: 7 (2%), and indeterminate cysts: 55 (12%). Eight cases underwent operation. The crude prevalence rate was 2.1% and the age- and sex-adjusted expected nationwide prevalence was 2.2%. The prevalence increased with age.Here, we reported the first large-scale study among the healthy population to find out the prevalence rate of pancreatic cystic neoplasms; the age- and sex-adjusted prevalence was 2.2%, and increased with age. Further investigations regarding the clinical implications of incidental pancreatic neoplasms are necessary.
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Affiliation(s)
- Ye Rim Chang
- Department of Surgery, Seoul National University College of Medicine, Seoul
- Department of Surgery, Dankook University College of Medicine, Cheonan
| | - Joo Kyung Park
- Department of Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul National University College of Medicine
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, Seoul
| | - Wooil Kwon
- Department of Surgery, Seoul National University College of Medicine, Seoul
| | - Jeong Hee Yoon
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul
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Association Between Advances in High-Resolution Cross-Section Imaging Technologies and Increase in Prevalence of Pancreatic Cysts From 2005 to 2014. Clin Gastroenterol Hepatol 2016; 14:585-593.e3. [PMID: 26370569 DOI: 10.1016/j.cgh.2015.08.038] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 08/18/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Increasingly, pancreatic cysts are discovered incidentally in patients undergoing cross-sectional imaging for nonpancreatic reasons. It is unclear whether this increase is caused by improved detection by progressively more sophisticated cross-sectional imaging techniques or by a true increase in prevalence. We aimed to determine the prevalence of incidental pancreatic cysts in patients undergoing magnetic resonance imaging (MRI) for nonpancreatic indications on successive, increasingly sophisticated MRI systems. Also, we compared prevalence based on the demographic characteristics of the patients. METHODS We collected data from MRIs performed at the Mayo Clinic in Florida during the sample months of January and February, from 2005 to 2014. Each patient's clinical chart was reviewed in chronological order to include the first 50 MRIs of each year (500 total). Patients were excluded if they had pancreatic disease including cysts, pancreatic surgery, pancreatic symptoms, pancreatic indication for the imaging study, or previous abdominal MRIs. An expert pancreatic MRI radiologist reviewed each image, looking for incidental pancreatic cysts. RESULTS Of the 500 patients analyzed, 208 patients (41.6%) were found to have an incidental cyst. A significant relationship was observed between pancreatic cysts and patient age (P < .0001), diabetes mellitus (P = .001), and nonpancreatic cancer (P = .01), specifically nonmelanoma skin cancer (P = .03) or hepatocellular carcinoma (P = .02). The multivariable model showed a strong association between hardware and software versions and detection of cysts (P < .0001); the old hardware detected pancreatic cysts in 30.3% of patients, whereas the newest hardware detected cysts in 56.3% of patients. CONCLUSIONS Based on an analysis of data collected from 2005 through 2014, newer versions of MRI hardware and software corresponded with higher numbers of pancreatic cysts detected. Older age, diabetes, and the presence of nonpancreatic cancer (specifically nonmelanoma skin cancer and hepatocarcinoma) were also associated with the presence of cysts.
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Zhang XP, Yu ZX, Zhao YP, Dai MH. Current perspectives on pancreatic serous cystic neoplasms: Diagnosis, management and beyond. World J Gastrointest Surg 2016; 8:202-211. [PMID: 27022447 PMCID: PMC4807321 DOI: 10.4240/wjgs.v8.i3.202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/17/2016] [Accepted: 02/17/2016] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cystic neoplasms have been increasingly recognized recently. Comprising about 16% of all resected pancreatic cystic neoplasms, serous cystic neoplasms are uncommon benign lesions that are usually asymptomatic and found incidentally. Despite overall low risk of malignancy, these pancreatic cysts still generate anxiety, leading to intensive medical investigations with considerable financial cost to health care systems. This review discusses the general background of serous cystic neoplasms, including epidemiology and clinical characteristics, and provides an updated overview of diagnostic approaches based on clinical features, relevant imaging studies and new findings that are being discovered pertaining to diagnostic evaluation. We also concisely discuss and propose management strategies for better quality of life.
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32
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Pulvirenti A, Marchegiani G, Malleo G, Borin A, Allegrini V, Bassi C, Salvia R. Cystic Neoplasm of the Pancreas. Indian J Surg 2016; 77:387-92. [PMID: 26722201 DOI: 10.1007/s12262-015-1363-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/30/2015] [Indexed: 01/04/2023] Open
Abstract
Cystic neoplasms of the pancreas (CNPs) are not considered as rare entities any more. Imaging-based population studies attested an overall prevalence of 2 %, but that becomes five times higher on individuals of more than 70 year old. This family of neoplasms includes a wide spectrum of benign, borderline, and malignant lesions whose actual biological behavior has not been completely clarified yet. Moreover, the management of CNPs still represents a challenge for gastrointestinal (GI) specialists. While many CNPs have an indolent behavior that justifies surveillance, others should be resected because of the risk of progression to invasive cancer. Due to the high morbidity related to pancreatic resections, the surgeon should balance very carefully the advantages of a radical resection with the risks of an unrequested dangerous procedure. We reviewed the current issues regarding CNPs, with a particular focus on the clinical and radiological features that are integrated in the current guidelines and that drive the management of these patients.
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Affiliation(s)
- Alessandra Pulvirenti
- Unit of General and Pancreatic Surgery, The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, P. Le L.A. Scuro 10, Verona, 37134 Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, P. Le L.A. Scuro 10, Verona, 37134 Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, P. Le L.A. Scuro 10, Verona, 37134 Italy
| | - Alex Borin
- Unit of General and Pancreatic Surgery, The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, P. Le L.A. Scuro 10, Verona, 37134 Italy
| | - Valentina Allegrini
- Unit of General and Pancreatic Surgery, The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, P. Le L.A. Scuro 10, Verona, 37134 Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, P. Le L.A. Scuro 10, Verona, 37134 Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, The Pancreas Institute, G.B. Rossi Hospital, University of Verona Hospital Trust, P. Le L.A. Scuro 10, Verona, 37134 Italy
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33
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Cystic neoplasms of the pancreas; findings on magnetic resonance imaging with pathological, surgical, and clinical correlation. ACTA ACUST UNITED AC 2015; 39:1088-101. [PMID: 24718661 DOI: 10.1007/s00261-014-0138-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pancreatic cysts are increasingly being identified by cross-sectional imaging studies. Pancreatic cystic lesions comprise a spectrum of underlying pathologies ranging from benign and pre-malignant lesions to frank malignancies. Magnetic resonance imaging with cholangiopancreatography is a non-invasive imaging modality used for the characterization of cystic pancreatic lesions. This article will review the most common pancreatic cystic neoplasms and the utility of MR imaging in the characterization of these cysts.
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Yoon WJ, Brugge WR. Endoscopic ultrasound and pancreatic cystic lesions-diagnostic and therapeutic applications. Endosc Ultrasound 2014; 1:75-9. [PMID: 24949341 PMCID: PMC4062214 DOI: 10.7178/eus.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 04/26/2012] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cystic lesions are being detected with an increasing frequency. Endoscopic ultrasound (EUS) provides both diagnostic and therapeutic means for pancreatic cystic lesions. Detailed imaging and EUS-guided fine-needle aspiration provide additional information on pancreatic cystic lesions. EUS-guided pseudocyst drainage has advantages over conventional drainage modalities. EUS-guided cyst ablation is a promising therapeutic modality.
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Affiliation(s)
- Won Jae Yoon
- Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - William R Brugge
- Harvard Medical School; Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Lin XZ, Wu ZY, Li WX, Zhang J, Xu XQ, Chen KM, Yan FH. Differential diagnosis of pancreatic serous oligocystic adenoma and mucinous cystic neoplasm with spectral CT imaging: initial results. Clin Radiol 2014; 69:1004-10. [PMID: 24919983 DOI: 10.1016/j.crad.2014.05.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Revised: 05/01/2014] [Accepted: 05/02/2014] [Indexed: 01/07/2023]
Abstract
AIM To investigate the imaging characteristics of pancreatic serous oligocystic adenoma (SOA) and mucinous cystic neoplasms (MCNs) using spectral computed tomography (CT) and to evaluate whether quantitative information derived from spectral imaging can improve the differential diagnosis of these diseases. MATERIALS AND METHODS From February 2010 to June 2013, 44 patients (24 SOAs and 20 MCNs) who underwent spectral CT imaging were included in the study. Conventional characteristics and quantitative parameters were compared between the two disease groups. Logistic regression was used for multiparametric analysis. The receiver-operating characteristic curve was used to evaluate the diagnostic performance of single parameter and multiparametric analysis. Two radiologists diagnosed the diseases blinded and independently, without and with the information of the statistical analysis. RESULTS Tumour location, contour, size, and monochromatic CT values at 40 keV to 70 keV, iodine concentration, and effective atomic number (effective-Z) in the late arterial phase were the independent factors correlated with category. Multiparametric analysis with logistic regression showed that tumour size, location, and contour were the most effective variations, and obtained an area under the ROC curve (AUC) of 0.934. With the knowledge of statistical analysis, the accuracy of the first reader increased from 70.5% to 86.4%, and the accuracy of the second reader increased from 81.8% to 90.9%. CONCLUSIONS Although CT spectral imaging provided additional information and multiparametric analysis obtained better performance than single-parameter analysis in differentiating MCNs from SOAs, multiparametric analysis with the combination of quantitative parameters derived from CT spectral imaging did not improve the diagnostic performance. Tumour size, location, and contour played an important role in differentiating MCNs from SOAs.
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Affiliation(s)
- X-Z Lin
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 2nd Ruijin Road, Shanghai 200025, China
| | - Z-Y Wu
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 2nd Ruijin Road, Shanghai 200025, China
| | - W-X Li
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 2nd Ruijin Road, Shanghai 200025, China
| | - J Zhang
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 2nd Ruijin Road, Shanghai 200025, China
| | - X-Q Xu
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 2nd Ruijin Road, Shanghai 200025, China
| | - K-M Chen
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 2nd Ruijin Road, Shanghai 200025, China
| | - F-H Yan
- Department of Radiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, 197 2nd Ruijin Road, Shanghai 200025, China.
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Dawoud MA, Youssef MA, Elbarbary AA. Role of multi-detector computed tomography in the evaluation of pancreatic tumors. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2014. [DOI: 10.1016/j.ejrnm.2013.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Characterization of pancreatic serous cystadenoma on dual-phase multidetector computed tomography. J Comput Assist Tomogr 2014; 38:258-63. [PMID: 24632937 DOI: 10.1097/rct.10.1097/rct.0b013e3182ab1556] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The objective of the study was to characterize pancreatic serous cystadenomas on dual-phase multidetector computed tomography in a surgical series. MATERIALS AND METHODS This is a retrospective review of preoperative dual-phase multidetector computed tomographic scans from 68 patients with surgically resected and pathologically confirmed pancreatic serous cystadenomas. RESULTS Pancreatic serous cystadenomas were most commonly found in the tail (39%). The mean (SD) axial dimension was 4.5 (2.7) cm. A total of 36% contained internal calcifications. Dilatation of the main pancreatic duct (14%) and pancreatic parenchymal atrophy (11%) were uncommon. The mean (SD) attenuation of components with the highest attenuation was 49.1 (35.0) Hounsfield units on the arterial phase and 48.5 (33.4) Hounsfield units on the portal venous phase. Only 20% of neoplasms demonstrated "classic" morphology, as defined by multiple thin nonenhancing septations, calcifications, as well as the absence of main pancreatic duct dilatation and vascular involvement. CONCLUSIONS Only 20% of surgically resected serous cystadenomas fulfilled classic morphology. Attenuation was helpful in differentiating serous cystadenomas from insulinomas and other cystic pancreatic masses, but it was not helpful in differentiation from pancreatic adenocarcinomas. Morphologic features were more helpful in differentiating serous cystadenomas from malignant masses.
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Ardengh JC, Lopes CV, de Lima-Filho ER, Kemp R, Dos Santos JS. Impact of endoscopic ultrasound-guided fine-needle aspiration on incidental pancreatic cysts. A prospective study. Scand J Gastroenterol 2014; 49:114-20. [PMID: 24188361 DOI: 10.3109/00365521.2013.854830] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Widespread use of imaging procedures has promoted a higher identification of incidental pancreatic cysts (IPCs). However, little is known as to whether endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) could change the management strategy of patients having IPCs. This study has aimed to evaluate the management impact of EUS-FNA on IPCs. MATERIAL AND METHODS Patients with pancreatic cysts (PCs) who were referred to EUS-FNA were recruited prospectively. The referring physicians were questioned about the management strategy for these patients before and after EUS-FNA. The impact of EUS-FNA on management was then evaluated. RESULTS A total of 302 PC patients were recruited. Of these, 159 (52.6%) patients had asymptomatic IPCs. The average size was 2.3 cm (range: 0.2-7.1 cm), and 110 patients having smaller than 3 cm sized cysts. Lesions were located in the pancreatic head in 96 (61%) cases, and most patients (94%) had only a single cyst. The final diagnoses, obtained by EUS-FNA (91) and surgery (68), were 93 (58%) benign lesions, 36 (23%) cysts with malignant potential, 14 (9%) noninvasive malignancies, 10 (6%) malignant precursor lesions (PanIN), and 6 (4%) invasive malignancies. Management strategy changed significantly after EUS-FNA in 114 (71.7%) patients: 43% of the cases were referred to surgery, 44% of the patients were discharged from surveillance, and 13% of the cases were given further periodical imaging tests. CONCLUSION EUS-FNA has a management impact in almost 72% of IPCs, with a major influence on the management strategy, either discharge rather than surgical resection or surgery rather than additional follow up.
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Affiliation(s)
- José Celso Ardengh
- Division of Surgery and Anatomy, Ribeirão Preto Medical School - University of São Paulo , São Paulo , Brazil
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Boot C. A review of pancreatic cyst fluid analysis in the differential diagnosis of pancreatic cyst lesions. Ann Clin Biochem 2013; 51:151-66. [PMID: 24097809 DOI: 10.1177/0004563213503819] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diagnosis and management of pancreatic cyst lesions is challenging as there is currently no investigation that offers both high diagnostic sensitivity and high specificity for the identification of potentially malignant lesions. Accurate classification of these lesions is vital in order to avoid unnecessary treatment of benign lesions and missed opportunities for early treatment of lesions that are malignant/pre-malignant. Pancreatic cyst fluid analysis has an important role in diagnosis, although all currently available investigations based on fluid analysis have significant limitations. Cytological analysis can reveal features that are specific for a certain class of cyst, but offers limited sensitivity in detecting malignant/pre-malignant cysts. Measurement of tumour markers, particularly carcinoembryonic antigen can also be informative. Concentrations of cyst fluid carcinoembryonic antigen tend to be higher in malignant/pre-malignant cysts, although there is a wide overlap between the various classes of cyst. A number of studies have suggested that diagnostic carcinoembryonic antigen cut-offs can be chosen that provide a high degree of specificity but limited sensitivity. Studies of the analytical validity of tumour marker assays in pancreatic cyst fluid analysis have highlighted discrepancies in some fluid specimens, which require further investigation. DNA analysis also has a role. In particular, K-Ras-2 mutational analysis appears to provide high specificity for detection of malignant/pre-malignant lesions. A number of diagnostic algorithms have been published, integrating use of available investigations in order to achieve the optimum discrimination of benign and potentially malignant cysts. Research into new biochemical markers and optimal use of available pancreatic cyst fluid analyses is ongoing.
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Affiliation(s)
- Christopher Boot
- Clinical Laboratory Services, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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40
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Zaheer A, Pokharel SS, Wolfgang C, Fishman EK, Horton KM. Incidentally detected cystic lesions of the pancreas on CT: review of literature and management suggestions. ACTA ACUST UNITED AC 2013; 38:331-41. [PMID: 22534872 DOI: 10.1007/s00261-012-9898-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To facilitate a better understanding of incidentally noted cystic pancreatic lesions, since these lesions often pose a challenge regarding appropriate management. METHODS This article reviews pathophysiology, prevalence, significance, and recommendations for management of the various pancreatic cystic lesions. Illustrative cases are demonstrated. RESULTS Diagnostic benign lesions can be left alone. Cross-sectional imaging can be used to follow-up benign appearing lesions and to stage more aggressive ones. Endoscopic ultrasound with fine needle aspiration and cyst fluid analysis can be performed on certain indeterminate lesions. Lesions with high malignant potential should undergo resection. CONCLUSIONS A better understanding of the variety of incidentally detected pancreatic cystic lesions can help direct appropriate management.
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Affiliation(s)
- Atif Zaheer
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 601 N. Caroline Street, JHOC 3235 A, Baltimore, MD 21231, USA.
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Salomao M, Remotti H, Allendorf JD, Poneros JM, Sethi A, Gonda TA, Saqi A. Fine-needle aspirations of pancreatic serous cystadenomas: improving diagnostic yield with cell blocks and α-inhibin immunohistochemistry. Cancer Cytopathol 2013; 122:33-9. [PMID: 23939868 DOI: 10.1002/cncy.21347] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 06/17/2013] [Accepted: 07/12/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND The diagnosis of serous cystadenoma (SCA), a rare benign pancreatic neoplasm, can alter the management of patients with pancreatic masses. Although characteristic imaging findings and fluid chemical analysis have been described, SCAs are not always recognized preoperatively. Furthermore, scant cellular yield on fine-needle aspiration (FNA) often leads to a nondiagnostic or nonspecific benign diagnosis. α-Inhibin (AI), a sensitive marker for SCA, is infrequently required for diagnosis in surgical specimens due to their characteristic histologic appearance. The objective of the current study was to determine whether AI staining can improve SCA diagnosis on FNA specimens. METHODS Fifteen confirmed cases of SCA with prior FNA specimens were selected for this study. FNAs were evaluated for cellularity, cellular arrangement, and cytomorphology. Resection specimens were reviewed. RESULTS Of the 15 FNA cases, approximately 75% demonstrated scant cellularity (11 of 15 cases). On smears, the cells were arranged as flat sheets, corresponding to strips of cells on cell block sections. The cells were small and round to cuboidal, with clear cytoplasm; occasional plasmacytoid cells and oncocytic cells were identified. Flattened cells, corresponding to attenuated epithelial cells lining macrocysts on the resections, were also noted. Stromal fragments were present in 5 FNAs and correlated with the hyalinized stroma in the resection specimens. AI immunostaining was positive in 88% of cases (7 of 8 of cases), thereby supporting the diagnosis of SCA. CONCLUSIONS The results of the current study indicate that low cellularity and bland cytology are inherent to SCAs. Performing cell blocks and AI staining on FNA specimens is useful for establishing the diagnosis of SCA. An immunohistochemical panel including AI, chromogranin, and synaptophysin may enhance the diagnostic accuracy of pancreatic FNA specimens.
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Affiliation(s)
- Marcela Salomao
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
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Imaging of indeterminate pancreatic cystic lesions: a systematic review. Pancreatology 2013; 13:436-42. [PMID: 23890144 DOI: 10.1016/j.pan.2013.05.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 03/15/2013] [Accepted: 05/24/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic cystic lesions are an increasing problem and investigation of these cysts can be fraught with difficulty. There is currently no gold standard for diagnosis or surveillance. This review was undertaken to determine the present reliability of the characterisation, assessment of malignant potential and diagnosis of pancreatic cystic lesions using available imaging modalities. METHODS A Medline search using the terms 'pancreatic', 'pancreas', 'cyst', 'cystic', 'lesions', 'imaging', 'PET'. 'CT', 'MRI' and 'EUS' was performed. Publications were screened to include studies examining the performance of CT, MRI, MRCP, EUS and 18-FDG PET in the determination of benign or malignant cysts, cyst morphology and specific diagnoses. RESULTS Nineteen studies were identified that met the inclusion criteria. 18-FDG PET had a sensitivity and specificity of 57.0-94.0% and 65.0-97.0% and an accuracy of 94% in determining benign versus malignant cysts. CT had a sensitivity and specificity of 36.3-71.4% and 63.9-100% in determining benign disease but had an accuracy of making a specific diagnosis of 39.0-44.7%. MRI had a sensitivity and specificity of 91.4-100.0% and 89.7% in assessing main pancreatic duct communication. CONCLUSION CT is a good quality initial investigation to be used in conjunction with clinical data. MRCP can add useful information regarding MPD communication but should be used judiciously. PET may have a role in equivocal cases to determine malignancy. Further examination of CT-PET in this patient group is warranted.
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SHERIDAN MB, MANOHARAN P. Neoplasms of the pancreas. IMAGING 2013. [DOI: 10.1259/imaging/20369618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Cho CS, Russ AJ, Loeffler AG, Rettammel RJ, Oudheusden G, Winslow ER, Weber SM. Preoperative classification of pancreatic cystic neoplasms: the clinical significance of diagnostic inaccuracy. Ann Surg Oncol 2013; 20:3112-9. [PMID: 23595223 DOI: 10.1245/s10434-013-2986-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND The potential for malignant transformation varies among pancreatic cystic neoplasms (PCN) subtypes. Imaging and cyst fluid analysis are used to identify premalignant or malignant cases that should undergo operative resection, but the accuracy of operative decision-making process is unclear. The objective of this study was to characterize misdiagnoses of PCN and determine how often operations are undertaken for benign, non-premalignant disease. METHODS A retrospective analysis of patients undergoing pancreatic resection for the preoperative diagnosis of PCN was undertaken. Preoperative and pathological diagnoses were compared to measure diagnostic accuracy. RESULTS Between 1999 and 2011, 74 patients underwent pancreatic resection for the preoperative diagnosis of PCN. Preoperative classification of mucinous vs. non-mucinous PCN was correct in 74%. The specific preoperative PCN diagnosis was correct in 47%, but half of incorrect preoperative diagnoses were clinically equivalent to the pathological diagnoses. The likelihood that the pathological diagnosis was of higher malignant potential than the preoperative diagnosis was 7%. In 20% of cases, the preoperative diagnosis was premalignant or malignant, but the pathological diagnosis was benign. Diagnostic accuracy and the rate of undercall diagnoses and overcall operations did not change with the use of EUS or during the time period of this analysis. CONCLUSIONS Precise, preoperative classification of PCN is frequently incorrect but results in appropriate clinical decision-making in three-quarters of cases. However, one in five pancreatic resections performed for PCN was for benign disease with no malignant potential. An appreciation for the rate of diagnostic inaccuracies should inform our operative management of PCN.
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Affiliation(s)
- Clifford S Cho
- Section of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, J4/703 Clinical Sciences Center, 600 Highland Avenue, Madison, WI, USA.
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Abstract
OBJECTIVE The purpose of this review is to outline the management guidelines for the care of patients with cystic pancreatic lesions. CONCLUSION The guidelines are as follows: Annual imaging surveillance is generally sufficient for benign serous cystadenomas smaller than 4 cm and for asymptomatic lesions. Asymptomatic thin-walled unilocular cystic lesions smaller than 3 cm or side-branch intraductal papillary mucinous neoplasms should be followed up with CT or MRI at 6 and 12 months interval after detection. Cystic lesions with more complex features or with growth rates greater than 1 cm/year should be followed more closely or recommended for resection if the patient's condition allows surgery. Symptomatic cystic lesions, neoplasms with high malignant potential, and lesions larger than 3 cm should be referred for surgical evaluation. Endoscopic ultrasound with fine-needle aspiration (FNA) biopsy can be used preoperatively to assess the risk of malignancy.
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Lane J, Vance A, Finelli D, Williams G, Ravichandran P. Dermoid cyst of the pancreas: a case report with literature review. J Radiol Case Rep 2012; 6:17-25. [PMID: 23365699 DOI: 10.3941/jrcr.v6i12.1152] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Pancreatic dermoid cysts represent a rare entity with 35 cases described in the world literature, including the present one. Pre-operative diagnosis is difficult, with definitive diagnosis usually taking place intra-operatively. We report the case of a 63 year old male with a symptomatic, 6 cm cystic mass in the body of the pancreas. The pre-operative evaluation suggested a cystic neoplasm, but was indeterminate as to whether the lesion was benign or malignant. The diagnosis of dermoid cyst was made intra-operatively with frozen section. Although the diagnosis could not be made pre-operatively this retrospective report highlights the difficulty in evaluating cystic pancreatic lesions by imaging and summarizes the current body of knowledge on this rare entity.
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Affiliation(s)
- Jason Lane
- Department of Pathology, Summa Health System, Akron, USA.
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Hilendarov AD, Deenichin GP, Velkova KG. Imaging investigation of pancreatic cystic lesions and proposal for therapeutic guidelines. World J Radiol 2012; 4:372-8. [PMID: 22937216 PMCID: PMC3430734 DOI: 10.4329/wjr.v4.i8.372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 05/30/2012] [Accepted: 04/07/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To propose a diagnostic algorithm for preoperatively predicting the need for surgical intervention.
METHODS: The study included 56 patients (27 men and 29 women) with a final diagnosis of cystic pancreatic lesions. The following materials were used: ultrasonic equipment with 3.5 and 7 MHz linear, convex and biopsical transducers. Multidetector computed tomography (MDCT) investigations were performed using a 16-slice scanner. Images were obtained following the oral administration of 200 mL water and 100 mL intravenous iopamidol (300 mg/mL) administered by pump injector at a rate of 3 mL/s (40 and 60 s post-injection, respectively) using 0.5 mm detectors, reconstructed at 1 mm (pancreatic phase) or 2 mm (portal venous phase) increments. The table feed was 10 mm per rotation. Images were acquired in the pancreatic and portal venous phases of contrast enhancement. The “Chiba” needles 18, 20, 22, 23 G and an automatic aspiration system were used in conjunction with the following methods of guiding the interventional procedures: (1)“free-hand” biopsy and puncture method under ultrasound (US) or computed tomography (CT) control; (2) guiding method using biopsical transducer.
RESULTS: All 56 patients in this study underwent at least two cuts imaging survey methods, such as US, CT or magnetic resonance imaging (MRI). The most common preoperative diagnostic examination was US scan - 56 patients (100%). MDCT studies were conducted in 49 (87.50%) and MRI in 13 (23.21%). More than half of patients surveyed (37) underwent some type of interventional procedure: 25-fine-needle aspiration and 29-fine needle aspiration biopsy (FNAB), as part of the examination. Thirty-four patients of all 56 patients underwent surgery because of histological evidence of malignancy after the FNAB for cystic lesions of the pancreas. Distal pancreatectomy with splenectomy was the most common operative approach in 13 patients, followed by Whipple resection in 11 and distal pancreatectomy without splenectomy in 7. Three patients were treated with total pancreatectomy due to the presence of a multifocal mucinous neoplasm. Comparing the diagnostic results of US examination with those of MDCT examination and histological verification true positive results were found in 31 patients, true negative in 11 patients, false positive in 5 and false negative in 9 patients. Accordingly we estimated the power of the diagnostic imaging methods for cystic lesions of the pancreas. A specificity of 68.75%, sensitivity of 79.48%, accuracy of 75.00%, positive predictive value of 86.11% and negative predictive value of 55% were obtained. The power increased after applying invasive procedures with immunohistochemical analysis of CEA and P-53 (Fig. 4). In 15 patients with cytological feature of malignant tumour cells, the tumour markers were positive. In our opinion the higher the percentage of reacting cells the higher the percent of malignancy. In patients with clear symptoms and/or clear imaging features of malignant or premalignant cystic neoplasm, the need for surgery was confirmed by histological verification in 34 (60.71%) of cases.
CONCLUSION: By using the proposed algorithm, cystic mucinous tumors of the pancreas were detected and proper operative interventions would have been rendered with fewer diagnostic examinations.
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Hawes RH, Clancy J, Hasan MK. Endoscopic ultrasound-guided fine needle aspiration in cystic pancreatic lesions. Clin Endosc 2012; 45:128-31. [PMID: 22866252 PMCID: PMC3401615 DOI: 10.5946/ce.2012.45.2.128] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 06/16/2012] [Accepted: 06/16/2012] [Indexed: 12/18/2022] Open
Abstract
Incidental pancreatic cysts are being increasingly recognized recently with incremented concern about health and frequent health check-up. Endoscopic ultrasound (EUS) has emerged as the principal modality for imaging pancreas for various pancreatic diseases including pancreatic cyst. But imaging alone cannot accurately identify the exact nature of the pancreatic cyst. EUS-guided fine needle aspiration is a useful adjunctive procedure to differentiate pancreatic cystic lesions. Cystic fluid analysis with cytologic evaluation is important to diagnose etiology of pancreatic cystic lesions, helping the clinician to more accurately assess the presence or potential for malignancy.
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Affiliation(s)
- Robert H Hawes
- Center for Interventional Endoscopy, Florida Hospital Orlando, Orlando, FL, USA
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Barresi L, Tarantino I, Granata A, Curcio G, Traina M. Pancreatic cystic lesions: How endoscopic ultrasound morphology and endoscopic ultrasound fine needle aspiration help unlock the diagnostic puzzle. World J Gastrointest Endosc 2012; 4:247-59. [PMID: 22720127 PMCID: PMC3377868 DOI: 10.4253/wjge.v4.i6.247] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 05/08/2012] [Accepted: 05/27/2012] [Indexed: 02/06/2023] Open
Abstract
Cystic lesions of the pancreas are being diagnosed with increasing frequency, covering a vast spectrum from benign to malignant and invasive lesions. Numerous investigations can be done to discriminate between benign and non-evolutive lesions from those that require surgery. At the moment, there is no single test that will allow a correct diagnosis in all cases. Endoscopic ultrasound (EUS) morphology, cyst fluid analysis and cytohistology with EUS-guided fine needle aspiration can aid in this difficult diagnosis.
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Affiliation(s)
- Luca Barresi
- Luca Barresi, Ilaria Tarantino, Antonino Granata, Gabriele Curcio, Mario Traina, Unit of Gastroenterology and Digestive Endoscopy, Mediterranean Institute for Transplantation and Advanced Specialized Therapies, 90146 Palermo, Italy
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Mottola JC, Sahni VA, Erturk SM, Swanson R, Banks PA, Mortele KJ. Diffusion-weighted MRI of focal cystic pancreatic lesions at 3.0-Tesla: preliminary results. ACTA ACUST UNITED AC 2012; 37:110-7. [PMID: 21512724 DOI: 10.1007/s00261-011-9737-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE To determine the utility of 3.0-Tesla diffusion-weighted (DW) magnetic resonance imaging (MRI) for focal cystic pancreatic lesion (FCPL) characterization. MATERIALS AND METHODS 55 FCPL (34 IPMN, 5 serous cystadenoma, and 16 inflammatory) were evaluated. Two radiologists reviewed in consensus DW-MRI images. Reference standard was obtained from patient history, cytological and histopathology data, FCPL fluid analysis, and follow-up imaging results. Signal intensity (SI) and apparent diffusion coefficient values (ADC) of FCPL and normal pancreas were measured. FCPL-to-pancreas SI and ADC ratios were also calculated. RESULTS Qualitatively, 11 of 21 non-mucinous vs. 4 of 34 mucinous lesions appeared hyperintense at b value of 1,000 s/mm(2) (P = 0.02). Three FCPL demonstrated restricted diffusion: all inflammatory. Significant differences in mean ADC between neoplastic vs. non-neoplastic (P = 0.009), and mucinous vs. non-mucinous (P = 0.013) lesions were demonstrated. FCPL-to-pancreas ADC and SI ratios demonstrated significant differences between neoplastic vs. non-neoplastic lesions [ADC, (P = 0.019); SI for b values 750 (P = 0.010) and 1,000 s/mm(2) (P = 0.017)] and mucinous vs. non-mucinous lesions [ADC (P = 0.018); SI for b values 750 (P = 0.013) and 1,000 s/mm(2) (P = 0.015)]. CONCLUSION Although mean ADC values and FCPL-to-pancreas SI and ADC ratios may be helpful in differentiating FCPL, characterization of individual FCPL by means of 3.0-Tesla DW-MRI appears limited.
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Affiliation(s)
- Jeffrey C Mottola
- Division of Abdominal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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