Intraductal Papillary Mucinous Neoplasm of Pancreas

Navigating Intraductal Papillary Mucinous Neoplasm Management through Fukuoka Consensus vs. European Evidence-Based Guidelines on Pancreatic Cystic Neoplasms-A Study on Two European Centers

This study addresses the critical need for the accurate diagnosis and management of intraductal papillary mucinous neoplasms (IPMNs), which are pancreatic cystic neoplasm types holding a substantial potential for malignancy. It evaluates the diagnostic effectiveness of the Fukuoka consensus guidelines and the European evidence-based guidelines in detecting high-grade dysplasia/invasive carcinoma in IPMNs, utilizing a retrospective analysis of 113 patients from two European medical centers. The methods include a comparative analysis of clinical, radiological, and endoscopic ultrasonography data, alongside an assessment of guideline-driven diagnostic performance. The results demonstrate that both guidelines offer similar accuracy in identifying severe disease stages in IPMNs, with certain clinical markers-such as jaundice, solid mass presence, and an increase in CA 19-9 levels-being pivotal in predicting the need for surgical intervention. This study concludes that while both guidelines provide valuable frameworks for IPMN management, there is an inherent need for further research to refine these protocols and improve patient-specific treatment strategies. This research contributes to the ongoing discourse on optimizing diagnostic and treatment paradigms for pancreatic cystic neoplasms, aiming to enhance clinical outcomes and patient care in this challenging medical field.

Deep Learning Applications in Pancreatic Cancer

Pancreatic cancer is one of the most lethal gastrointestinal malignancies. Despite advances in cross-sectional imaging, chemotherapy, radiation therapy, and surgical techniques, the 5-year overall survival is only 12%. With the advent and rapid adoption of AI across all industries, we present a review of applications of DL in the care of patients diagnosed with PC. A review of different DL techniques with applications across diagnosis, management, and monitoring is presented across the different pathological subtypes of pancreatic cancer. This systematic review highlights AI as an emerging technology in the care of patients with pancreatic cancer.

Are the screening guidelines for branch duct intraductal papillary mucinous neoplasms cost-effective in an Australian setting?

BACKGROUNDS

Intraductal papillary mucinous neoplasms (IPMN) are cystic neoplasms of the pancreatic ductal system. These incidental cystic lesions are increasingly found on radiological imaging and screened for malignant transformation. The Fukuoka consensus guidelines recommend screening with computed tomography, magnetic resonance imaging or endoscopic ultrasound. Branch duct IPMN (BD-IPMN) have significantly lower malignancy and mortality rates compared to main duct IPMN. Our aim was to assess the cost-effectiveness of guideline's recommendations for BD-IPMN screening of cysts between 2 and 3 cm in an Australian context.

METHODS

Markov model decision analysis was used to calculate the incremental cost-effectiveness ratio (ICER) of screening. The ICER was compared to a willingness to pay (WTP) threshold of $50 000. We performed scenario analysis to examine the effect of cyst size and non-linearity of malignancy rate on ICER. Probabilistic sensitivity analyses (PSA) were performed on our input parameters.

RESULTS

Screening resulted in 586 quality adjusted life years gained and a net present value of $20 379 939, resulting in a base-case ICER of $34 758. After scenario analysis for non-linearity of malignancy rate the ICER increases to $64 555, which is above the WTP threshold. PSA indicates that ICER is most susceptible to the pre-test malignancy rate.

CONCLUSION

This cost analysis demonstrates that screening of 2-3 cm BD-IPMN according to current guidelines is unlikely to be cost-effective in an Australian context. To determine the true ICER, a cost analysis on real-world data is required.

SDC1 and ITGA2 as novel prognostic biomarkers for PDAC related to IPMN

The existing biomarkers are insufficient for predicting the prognosis of pancreatic ductal adenocarcinoma (PDAC). Intraductal papillary mucinous neoplasm (IPMN) is a precursor to PDAC; therefore, identifying biomarkers from differentially expressed genes (DEGs) of PDAC and IPMN is a new and reliable strategy for predicting the prognosis of PDAC. In this study, four datasets were downloaded from the Gene Expression Omnibus database and standardized using the R package 'limma.' A total of 51 IPMN and 81 PDAC samples were analyzed, and 341 DEGs in PDAC and IPMN were identified; DEGs were involved in the extracellular matrix and tumor microenvironment. An acceptable survival prognosis was demonstrated by SDC1 and ITGA2, which were highly expressed during in vitro PDAC cell proliferation, apoptosis, and migration. SDC1high was enriched in interferon alpha (IFN-α) response and ITGA2high was primarily detected in epithelial-mesenchymal transition (EMT), which was verified using western blotting. We concluded that SDC1 and ITGA2 are potential prognostic biomarkers for PDAC associated with IPMN. Downregulation of SDC1 and ITGA2 expression in PDAC occurs via a mechanism involving possible regulation of IFN-α response, EMT, and immunity, which may act as new targets for PDAC therapy.

Improving Pancreatic Cyst Management: Artificial Intelligence-Powered Prediction of Advanced Neoplasms through Endoscopic Ultrasound-Guided Confocal Endomicroscopy

Despite the increasing rate of detection of incidental pancreatic cystic lesions (PCLs), current standard-of-care methods for their diagnosis and risk stratification remain inadequate. Intraductal papillary mucinous neoplasms (IPMNs) are the most prevalent PCLs. The existing modalities, including endoscopic ultrasound and cyst fluid analysis, only achieve accuracy rates of 65-75% in identifying carcinoma or high-grade dysplasia in IPMNs. Furthermore, surgical resection of PCLs reveals that up to half exhibit only low-grade dysplastic changes or benign neoplasms. To reduce unnecessary and high-risk pancreatic surgeries, more precise diagnostic techniques are necessary. A promising approach involves integrating existing data, such as clinical features, cyst morphology, and data from cyst fluid analysis, with confocal endomicroscopy and radiomics to enhance the prediction of advanced neoplasms in PCLs. Artificial intelligence and machine learning modalities can play a crucial role in achieving this goal. In this review, we explore current and future techniques to leverage these advanced technologies to improve diagnostic accuracy in the context of PCLs.

A Rare Case of a Pancreatic Intraductal Oncocytic Papillary Neoplasm Associated With Invasive Adenocarcinoma Presenting as a Gastric Mass

The World Health Organization recently recognized intraductal oncocytic papillary neoplasms of the pancreas (IOPNs) as distinct, pre-malignant pancreatic neoplasms. Due to their unique macroscopic and microscopic features, IOPNs are typically easy to diagnose and yield an indolent prognostic outcome. The diagnosis may be more complicated, and the prognosis may differ if an associated invasive carcinoma is present. Owing to the rarity of this entity, the available data is severely limited. Herein, we report a diagnostically challenging case of an IOPN associated with invasive carcinoma, initially presenting as a gastric mass with distinctive radiological and histopathological features.

A Comparison of Single Dimension and Volume Measurements in the Risk Stratification of Pancreatic Cystic Lesions

The incidence of pancreatic cystic lesions (PCLs) has been rising due to improvements in imaging. Of these, intraductal papillary mucinous neoplasms (IPMNs) are the most common and are thought to contribute to almost 20% of pancreatic adenocarcinomas. All major society guidelines for the management of IPMNs use size defined by maximum diameter as the primary determinant of whether surveillance or surgical resection is recommended. However, there is no consensus on how these measurements should be obtained or whether a single imaging modality is superior. Furthermore, the largest diameter may fail to capture the complexity of PCLs, as most are not perfectly spherical. This article reviews current PCL measurement techniques in CT, MRI, and EUS and posits volume as a possible alternative to the largest diameter.

A review of deep learning and radiomics approaches for pancreatic cancer diagnosis from medical imaging

PURPOSE OF REVIEW

Early and accurate diagnosis of pancreatic cancer is crucial for improving patient outcomes, and artificial intelligence (AI) algorithms have the potential to play a vital role in computer-aided diagnosis of pancreatic cancer. In this review, we aim to provide the latest and relevant advances in AI, specifically deep learning (DL) and radiomics approaches, for pancreatic cancer diagnosis using cross-sectional imaging examinations such as computed tomography (CT) and magnetic resonance imaging (MRI).

RECENT FINDINGS

This review highlights the recent developments in DL techniques applied to medical imaging, including convolutional neural networks (CNNs), transformer-based models, and novel deep learning architectures that focus on multitype pancreatic lesions, multiorgan and multitumor segmentation, as well as incorporating auxiliary information. We also discuss advancements in radiomics, such as improved imaging feature extraction, optimized machine learning classifiers and integration with clinical data. Furthermore, we explore implementing AI-based clinical decision support systems for pancreatic cancer diagnosis using medical imaging in practical settings.

SUMMARY

Deep learning and radiomics with medical imaging have demonstrated strong potential to improve diagnostic accuracy of pancreatic cancer, facilitate personalized treatment planning, and identify prognostic and predictive biomarkers. However, challenges remain in translating research findings into clinical practice. More studies are required focusing on refining these methods, addressing significant limitations, and developing integrative approaches for data analysis to further advance the field of pancreatic cancer diagnosis.

Uncinate Duct Dilatation Predicts Additional Risk for High-Grade Dysplasia or Invasive Carcinoma Among Fukuoka-Positive Intraductal Papillary Mucinous Neoplasms

OBJECTIVE

To determine whether uncinate duct dilatation (UDD) increases the risk of high-grade dysplasia or invasive carcinoma (HGD/IC) in Fukuoka-positive intraductal papillary mucinous neoplasms (IPMNs).

BACKGROUND

Though classified as a branch duct, the uncinate duct is the primary duct of the pancreatic ventral anlage. We hypothesized that UDD, like main duct dilatation, confers additional risk for HGD/IC.

METHODS

A total of 467 patients met inclusion criteria in a retrospective cohort study of surgically resected IPMNs at the Massachusetts General Hospital. We used multivariable logistic regression to analyze the association between UDD (defined as ≥4 mm) and HGD/IC, controlling for Fukuoka risk criteria. In a secondary analysis, the modeling was repeated in the 194 patients with dorsal branch duct IPMNs (BD-IPMNs) in the pancreatic neck, body, or tail.

RESULTS

Mean age at surgery was 70, and 229 (49%) patients were female. In total, 267 (57%) patients had only worrisome features and 200 (43%) had at least 1 high-risk feature. UDD was present in 164 (35%) patients, of whom 118 (73%) had HGD/IC. On multivariable analysis, UDD increased the odds of HGD/IC by 2.8-fold, even while controlling for Fukuoka risk factors (95% CI: 1.8-4.4, P <0.001). Prevalence of HGD/IC in all patients with UDD was 73%, compared with 74% in patients with high-risk stigmata and 73% in patients with main duct IPMNs. In the secondary analysis, UDD increased the odds of HGD/IC by 3.2-fold in patients with dorsal BD-IPMNs (95% CI: 1.3-7.7, P =0.010).

CONCLUSIONS

UDD confers additional risk for HGD/IC unaccounted for by current Fukuoka criteria. Further research can extend this study to Fukuoka-negative patients, including unresected patients.

STAT3 signaling in pancreatic ductal adenocarcinoma: a candidate therapeutic target

Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive cancer with a poor prognosis which is lethal in over 90% of cases despite the standard therapies. Mainly activated by Janus kinase 2 (JAK2), signal transducer and activator of transcription 3 (STAT3) is a key transcription factor, capable of exerting the expression of multitude of genes involved in survival. Moreover, STAT3 activity is regulated by the interleukin 28 receptor α (IL28RA) and glutathione s-transferase mu-3 (GSTM3), up-regulation of both contributes to the invasiveness of pancreatic cancer cells. In this regard, STAT3 overactivity has an important pathogenic role in the development of PDAC as it is associated with enhanced cell proliferation, survival, angiogenesis, and metastasis. STAT3-associated expression of vascular endothelial growth factor (VEGF) and matrix metalloproteinase 3 and 9 are implicated in the angiogenic and metastatic behavior of the PDAC. Multitude of evidence underline the protective role of STAT3 inhibition against PDAC both in cell cultures and in tumor grafts. However, specific inhibition of STAT3 was not feasible until recently, when a selective potent chemical STAT3 inhibitor, termed N4, were developed and it turned out to be highly effective against PDAC in vitro, as well as in vivo. This review aims to discuss the most recent advances in our understanding of STAT3 role in the pathogenesis of PDAC and its therapeutic applications.

Main-Duct Intraductal Papillary Mucinous Neoplasm Complicated by a Pancreaticogastric Fistula and a Pancreaticocholedocal Fistula

Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are a spectrum of benign to malignant epithelial neoplasms that are characterized by papillary proliferation, duct dilation, and cyst formation. A rare complication of IPMNs is fistula formation into adjacent organs such as the duodenum, biliary system, and stomach. Here, we report a case of IPMN with a pancreaticobiliary fistula and pancreaticogastric fistula. An 84-year-old woman with early Alzheimer's disease was diagnosed with IPMN of the pancreas. She deferred surgery given her age and remained asymptomatic for five years until presenting with cholangitis. She had been further evaluated and was found to have a pancreaticobiliary fistula, which was treated with biliary stent placement. Her subsequent admission involved the formation of a new pancreaticogastric fistula. This case highlights potential complications of excess mucin production from unresected IPMNs and demonstrates a guarded prognosis in elderly patients.

Artificial Intelligence in the Diagnosis and Treatment of Pancreatic Cystic Lesions and Adenocarcinoma

Pancreatic cancer is projected to become the second leading cause of cancer-related mortality in the United States by 2030. This is in part due to the paucity of reliable screening and diagnostic options for early detection. Amongst known pre-malignant pancreatic lesions, pancreatic intraepithelial neoplasia (PanIN) and intraductal papillary mucinous neoplasms (IPMNs) are the most prevalent. The current standard of care for the diagnosis and classification of pancreatic cystic lesions (PCLs) involves cross-sectional imaging studies and endoscopic ultrasound (EUS) and, when indicated, EUS-guided fine needle aspiration and cyst fluid analysis. However, this is suboptimal for the identification and risk stratification of PCLs, with accuracy of only 65-75% for detecting mucinous PCLs. Artificial intelligence (AI) is a promising tool that has been applied to improve accuracy in screening for solid tumors, including breast, lung, cervical, and colon cancer. More recently, it has shown promise in diagnosing pancreatic cancer by identifying high-risk populations, risk-stratifying premalignant lesions, and predicting the progression of IPMNs to adenocarcinoma. This review summarizes the available literature on artificial intelligence in the screening and prognostication of precancerous lesions in the pancreas, and streamlining the diagnosis of pancreatic cancer.

Pancreatic Intraductal Papillary Mucinous Neoplasms: A Narrative Review

Introduction

Intraductal papillary mucinous neoplasms (IPMNs) are the most frequent cystic pancreatic neoplasm. They derive from the main pancreatic duct or branch ducts.

Aim

This narrative review aims to present and compare the current guidelines on the management of IPMNs.

Materials and methods

We reviewed the most important scientific literature on the management of IPMNs.

Discussion

The clinical presentation of IPMNs is usually nonspecific; common symptoms are abdominal pain, weight loss, and jaundice. There are no sex differences, and the incidence increases with age. It is considered a premalignant lesion associated with synchronous or metachronous carcinomas. Multifocal sites within the pancreas and the presence of solid components, like mural nodules, are predictive factors for developing malignancy. Magnetic resonance imaging (MRI) is the imaging technique of choice. However, computed tomography (CT) and endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) can also contribute to the diagnosis. Resection is the optimal treatment for IPMNs that arise from the main duct, while several indications are suggested for the surgery on IPMNs of branch ducts.

Conclusion

The decision on surgery is not always a simple task and should be based on high-risk features of the neoplasm. In any case, re-examination and follow-up are highly recommended.

Pancreatic colloid adenocarcinoma arising from intraductal papillary mucinous neoplasm: Radiologic-pathologic correlation with cinematic rendering

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas have the potential for malignant progression into adenocarcinoma. Colloid or mucinous non-cystic carcinoma of the pancreas is an uncommon variant neoplasm that can arise within an intestinal type IPMN and have a relatively improved prognosis but may mimic the more lethal tubular or ductal adenocarcinoma. Colloid carcinoma is an infiltrating ductal epithelial neoplasm containing primarily extracellular stromal mucin pools and scant amount of centrally floating neoplastic cells. While several reports have evaluated the unique pathologic and immunohistochemical profile of colloid carcinomas, there has been limited radiologic-pathologic correlation in the literature. We report a case of an 83-year-old female who presented for evaluation of slowly progressive abdominal pain and was found to have colloid carcinoma arising from an IPMN. This is one of the first reports to correlate the multimodality radiology including cinematic rendering (CR) and histopathology features associated with this tumor. An enhanced understanding of the correlation between imaging appearance and specific histopathologic findings may aid in the early recognition and treatment of this rare neoplasm. Emphasis is placed on CR as this may help guide surgical management.

A Review of Endoscopic Ultrasound-Guided Chemoablative Techniques for Pancreatic Cystic Lesions

Pancreatic cystic lesions (PCLs) are known precursors to pancreatic cancer, one of the deadliest types of cancer worldwide. Surgical removal or pancreatectomies remain the central approach to managing precancerous high-risk PCLs. Endoscopic ultrasound (EUS)-guided therapeutic management of PCLs is a novel management strategy for patients with prohibitive surgical risks. Various ablation techniques have been explored in previous studies utilizing EUS-guided fine needle injection (FNI) of alcohol and chemotherapeutic agents. This review article focuses on EUS-FNI and chemoablation, encompassing the evolution of chemoablation, pancreatic cyst selection, chemotherapy drug selection, including novel agents, and a discussion of its safety and efficacy.

Intraductal papillary mucinous neoplasm mimicking a duodenal tumor

Intraductal papillary mucinous neoplasms of the pancreas are characterized by ductal dilatation, mucus secretion, and intraductal papillary growth. Intraductal papillary mucinous neoplasms can cause fistulation and extend to adjacent organs. However, they rarely present as large mass in the small bowel that causes bowel obstruction. Herein, we describe a case of intraductal papillary mucinous neoplasm that protruded into the duodenal lumen through the ampulla of Vater, presented as a large duodenal tumor, and developed duodenal obstruction. A 78-year-old woman was admitted to the emergency department with a 2-day history of vomiting and epigastric pain and 2 kg weight-loss in 2 months. Esophagogastroduodenoscopy showed a duodenal mass; however, the endoscope could not pass further, and visualization of the entire tumor was impossible. Computed tomography and magnetic resonance imaging revealed a heterogeneous enhancing mass measuring 8 cm in the second portion of the duodenum, which continued further as an intraductal mass of the pancreas. The main pancreatic duct was dilated, and the parenchyma was atrophied. The biopsy showed a well-differentiated adenocarcinoma and an intact overlying duodenal mucosa. Surgical option of treatment was offered to the patient; however, she refused it due to her advanced age and personal religious beliefs. Thus, we conclude that the experience and knowledge gathered through this patient regarding intraductal papillary mucinous neoplasms could provide further understanding of this disease and evolve subsequent patient care.

Microbiota in the Natural History of Pancreatic Cancer: From Predisposition to Therapy

Early microbiome insights came from gut microbes and their role among intestinal and extraintestinal disease. The latest evidence suggests that the microbiota is a true organ, capable of several interactions throughout the digestive system, attracting specific interest in the biliopancreatic district. Despite advances in diagnostics over the last few decades and improvements in the management of this disease, pancreatic cancer is still a common cause of cancer death. Microbiota can influence the development of precancerous disease predisposing to pancreatic cancer (PC). At the same time, neoplastic tissue shows specific characteristics in terms of diversity and phenotype, determining the short- and long-term prognosis. Considering the above information, a role for microbiota has also been hypothesized in the different phases of the PC approach, providing future revolutionary therapeutic insights. Microbiota-modulating therapies could open new issues in the therapeutic landscape. The aim of this narrative review is to assess the most updated evidence on microbiome in all the steps regarding pancreatic adenocarcinoma, from early development to response to antineoplastic therapy and long-term prognosis.

Pancreatic cancer in patient with groove pancreatitis: Potential pitfalls in diagnosis

Pancreatic cancer is among the leading causes of cancer death in the United States of America. Early detection and intervention are critical as a large majority of patients have either local or distant metastatic disease at the time of diagnosis. However, groove pancreatitis, a rare form of chronic pancreatitis, presents as a challenge for adequate and efficient differential diagnosis of pancreatic cancer as a result of similar clinical symptoms and imaging features. Furthermore, intraductal papillary mucinous neoplasms and pancreatic intraepithelial neoplasia are 2 of the precursor lesions that have been identified with pancreatic ductal adenocarcinoma. Intraductal papillary mucinous neoplasms are cystic tumors of the pancreas characterized by excessive mucin production in either the main pancreatic duct or its branches. Conversely, pancreatic intraepithelial neoplasia are microscopic lesions in the smaller pancreatic ducts. In this article, we report the case of a 46-year-old male with a diagnosis of groove pancreatitis, main duct intraductal papillary mucinous neoplasm, and pancreatic intraepithelial neoplasia whose tumor was excised by means of a Whipple procedure. We focus on optimizing diagnosis and treatment through the application of radiological modalities.

Three-Year Observation of Glucose Metabolism After Pancreaticoduodenectomy: A Single-Center Prospective Study in Japan

CONTEXT

The glucose tolerance of patients changes considerably from before to after pancreaticoduodenectomy wherein approximately half of the pancreas is resected.

OBJECTIVE

The aim of this prospective study was to investigate the incidence of and risk factors for diabetes after pancreaticoduodenectomy.

METHODS

This study is a part of an ongoing prospective study, the Kindai Prospective Study on Metabolism and Endocrinology after Pancreatectomy (KIP-MEP) study. Of the 457 patients enrolled to date, 96 patients without diabetes who underwent pancreaticoduodenectomy were investigated in this study. Preoperatively, 1 month post-pancreaticoduodenectomy, and every 6 months thereafter, the glucose metabolism and endocrine function were evaluated using the 75 g oral glucose tolerance test. Various other metabolic, endocrine, and exocrine indices were also examined over a period of up to 36 months.

RESULTS

Of the 96 patients analyzed in this study, 33 were newly diagnosed with diabetes. The cumulative diabetes incidence at 36 months following pancreaticoduodenectomy was 53.8%. The preoperative insulinogenic index and ΔC-peptide in the glucagon stimulation test were significantly lower in the progressors to diabetes than in the nonprogressors. Multivariate Cox regression analysis demonstrated that the insulinogenic index was the only significant risk factor for new-onset diabetes.

CONCLUSION

The majority of patients developed new-onset diabetes after pancreaticoduodenectomy, and a low value of the insulinogenic index was suggested to be a risk factor for diabetes. Preoperative assessment for the prediction of the onset of diabetes serves as useful information for patients and is important for postoperative glycemic control and diabetes management in patients who require pancreaticoduodenectomy.

Risk prediction of pancreatic cancer using AI analysis of pancreatic subregions in computed tomography images

Early detection of Pancreatic Ductal Adenocarcinoma (PDAC) is complicated as PDAC remains asymptomatic until cancer advances to late stages when treatment is mostly ineffective. Stratifying the risk of developing PDAC can improve early detection as subsequent screening of high-risk individuals through specialized surveillance systems reduces the chance of misdiagnosis at the initial stage of cancer. Risk stratification is however challenging as PDAC lacks specific predictive biomarkers. Studies reported that the pancreas undergoes local morphological changes in response to underlying biological evolution associated with PDAC development. Accurate identification of these changes can help stratify the risk of PDAC. In this retrospective study, an extensive radiomic analysis of the precancerous pancreatic subregions was performed using abdominal Computed Tomography (CT) scans. The analysis was performed using 324 pancreatic subregions identified in 108 contrast-enhanced abdominal CT scans with equal proportion from healthy control, pre-diagnostic, and diagnostic groups. In a pairwise feature analysis, several textural features were found potentially predictive of PDAC. A machine learning classifier was then trained to perform risk prediction of PDAC by automatically classifying the CT scans into healthy control (low-risk) and pre-diagnostic (high-risk) classes and specifying the subregion(s) likely to develop a tumor. The proposed model was trained on CT scans from multiple phases. Whereas using 42 CT scans from the venous phase, model validation was performed which resulted in ~89.3% classification accuracy on average, with sensitivity and specificity reaching 86% and 93%, respectively, for predicting the development of PDAC (i.e., high-risk). To our knowledge, this is the first model that unveiled microlevel precancerous changes across pancreatic subregions and quantified the risk of developing PDAC. The model demonstrated improved prediction by 3.3% in comparison to the state-of-the-art method that considers the global (whole pancreas) features for PDAC prediction.

Intraductal Papillary Mucinous Neoplasm Arising from Heterotopic Pancreas in Stomach: A Case Report and Review of Literature

Heterotopic pancreas is generally an asymptomatic condition which is found incidentally at surgery, endoscopy, or autopsy. Intraductal papillary mucinous neoplasm (IPMN) arising from heterotopic pancreas is extremely rare. In this study, we report a patient with IPMN arising from heterotopic pancreas. A 28-year-old man presented to our department with epigastric pain for 20 days. Physical examination revealed no abnormal findings. Computed tomography (CT) revealed an intramural cystic-solid mass on the gastric wall. Endoscopic ultrasonography (EUS) revealed a hypoechoic, heterogeneous, and multilobulated lesion with septa. Cyst fluid analysis based on EUS guided fine needle aspiration (EUS-FNA) indicated that the concentration of carcinoembryonic antigen (CEA) was 492 ng/ml. The patient received Billroth I subtotal gastrectomy, and then a 4.6 cm mass from the lesser curvature of the stomach was removed. Finally, the patient was diagnosed as IPMN with low grade dysplasia in an ectopic pancreas based on histopathological analysis. This report described the clinical, radiologic, endoscopic and histologic features of IPMN arising from heterotopic pancreas in a 28-year-old man involving the stomach. All pathologists involved in the diagnosis and clinicians involved in the treatment should be aware of this kind of tumor pattern to improve the correct identification, diagnosis and management of patients.

Acute Pancreatitis Secondary to Newly Diagnosed Intraductal Papillary Mucinous Neoplasm

Acute pancreatitis (AP) is a common gastrointestinal cause of hospital admissions and is prevalent in the United States. AP etiologies include alcohol use, cholelithiasis, hypertriglyceridemia, hypercalcemia, autoimmune phenomena, medications, or idiopathic. Rarely, intraductal papillary mucinous neoplasms can cause AP, as we present in this case report.

Clinical Applications of Classical and Novel Biological Markers of Pancreatic Cancer

The incidence and prevalence of pancreatic adenocarcinoma have increased in recent years. Pancreatic cancer is the seventh leading cause of cancer death, but it is projected to become the second leading cause of cancer-related mortality by 2040. Most patients are diagnosed in an advanced stage of the disease, with very limited 5-year survival. The discovery of different tissue markers has elucidated the underlying pathophysiology of pancreatic adenocarcinoma and allowed stratification of patient risk at different stages and assessment of tumour recurrence. Due to the invasive capacity of this tumour and the absence of screening markers, new immunohistochemical and serological markers may be used as prognostic markers for recurrence and in the study of possible new therapeutic targets because the survival of these patients is low in most cases. The present article reviews the currently used main histopathological and serological markers and discusses the main characteristics of markers under development.

An update on EUS-guided ablative techniques for pancreatic cystic lesions

Pancreatic cystic lesions (PCLs) are increasingly being recognized due to improvements and widespread use of cross-sectional imaging. With an estimated prevalence of 15% in general population, incidentally discovered PCLs represent a dilemma in management. While pancreatectomies offer a chance of cure, the morbidity is considerable in patients with high surgical risks. More recently, EUS-guided approaches for cyst ablation are being offered in clinical trials for the management of PCLs. EUS-chemoablation studies have progressed from first investigating safety and efficacy of EUS-guided alcohol lavage to single-agent paclitaxel ablation. Recent studies have shown that alcohol lavage may not be required, and long-term resolution can be achieved by chemoablation alone. EUS-guided lauromacrogol ablation and EUS-guided radiofrequency ablation (RFA) are new techniques that have shown promising results in a few small studies. Overall, the current literature suggests that EUS-guided paclitaxel ablation has better cyst resolution rates compared to other existing minimally invasive techniques including ethanol injection, lauromacrogol ablation, or RFA. This article will review EUS-guided PCL ablation approaches and future directions the field is headed into.

Predicting pancreatic ductal adenocarcinoma using artificial intelligence analysis of pre-diagnostic computed tomography images

BACKGROUND

Early stage diagnosis of Pancreatic Ductal Adenocarcinoma (PDAC) is challenging due to the lack of specific diagnostic biomarkers. However, stratifying individuals at high risk of PDAC, followed by monitoring their health conditions on regular basis, has the potential to allow diagnosis at early stages.

OBJECTIVE

To stratify high risk individuals for PDAC by identifying predictive features in pre-diagnostic abdominal Computed Tomography (CT) scans.

METHODS

A set of CT features, potentially predictive of PDAC, was identified in the analysis of 4000 raw radiomic parameters extracted from pancreases in pre-diagnostic scans. The naïve Bayes classifier was then developed for automatic classification of CT scans of the pancreas with high risk for PDAC. A set of 108 retrospective CT scans (36 scans from each healthy control, pre-diagnostic, and diagnostic group) from 72 subjects was used for the study. Model development was performed on 66 multiphase CT scans, whereas external validation was performed on 42 venous-phase CT scans.

RESULTS

The system achieved an average classification accuracy of 86% on the external dataset.

CONCLUSIONS

Radiomic analysis of abdominal CT scans can unveil, quantify, and interpret micro-level changes in the pre-diagnostic pancreas and can efficiently assist in the stratification of high risk individuals for PDAC.

Spontaneous Infection of a Nonmalignant Intraductal Papillary Mucinous Neoplasm

Intraductal papillary mucinous neoplasm (IPMN) is a pancreatic tumor that originates from the epithelium of the pancreatic duct. Although IPMN cysts can be complicated by infection, this has been reported to involve cysts that have ruptured, fistulized into surrounding organs, undergone malignant transformation, or were recently sampled. We present a 76-year-old man with a history of an IPMN who developed spontaneous cyst infection which was managed with fine-needle aspiration and antibiotics. To the best of our knowledge, this is the first reported case of spontaneous infection of a nonmalignant IPMN. Cyst infection should be considered as a very rare cause of unexplained fevers in patients with history of IPMN.

The Use of Intraoperative Frozen Sections in Guiding the Extent of Pancreatic Resections for Intraductal Papillary Mucinous Neoplasms: A Single Institution Experience and Review of the Literature

OBJECTIVES

The utility of frozen section evaluation of the pancreatic parenchymal resection margin(s) in the surgical management of intraductal papillary mucinous neoplasm (IPMN) remains controversial. We investigated the frequency of its use in IPMN resections and its impact on achievement of negative final parenchymal margin(s).

METHODS

Sixty-two IPMN resections (11 with invasive carcinoma) performed over a 12-year period were studied.

RESULTS

Frozen sections of the parenchymal margin(s) were performed on 44 of the 62 resections (71%), 30 (68%) of which had 10 positive and 22 indefinite margins on frozen section. Additional margin resections were performed in 14 of these 30 cases (47%), boosting the complete resection rate from 14% (2 of 14) on the initial margin(s) to 71% (10 of 14) on the final margin(s) (P = 0.002). Overall, negative final parenchymal margin(s) were achieved more frequently when evaluation of the initial margin(s) by frozen section was performed (35 of 44; 80%) than when it was not (11 of 18; 61%) (P = 0.13).

CONCLUSIONS

In the intraoperative management of IPMN, frozen sections are highly reliable for margin evaluation and are useful for guiding the extent of pancreatic resection.

Pancreatic intraductal papillary mucinous neoplasms: Current diagnosis and management

Intraductal papillary mucinous neoplasms (IPMNs) represent approximately 1% of all pancreatic neoplasms and 25% of cystic neoplasms. They are divided into three types: main duct-IPMN (MD-IPPMN), branch duct-IPMN (BD-IPMN), and mixed type-IPMN. In this review, diagnostics, including clinical presentation and radiological investigations, were described. Magnetic resonance imaging is the most useful for most IPMNs. Management depends on the type and radiological features of IPMNs. Surgery is recommended for MD-IPMN. For BD-IPMN, management involves surgery or surveillance depending on the tumor size, cyst growth rate, solid components, main duct dilatation, high-grade dysplasia in cytology, the presence of symptoms (jaundice, new-onset diabetes, pancreatitis), and CA 19.9 serum level. The patient’s age and comorbidities should also be taken into consideration. Currently, there are different guidelines regarding the diagnosis and management of IPMNs. In this review, the following guidelines were presented: Sendai International Association of Pancreatology guidelines (2006), American Gastroenterological Association guidelines, revised international consensus Fukuoka guidelines (2012), revised international consensus Fukuoka guidelines (2017), and European evidence-based guidelines according to the European Study Group on Cystic Tumours of the Pancreas (2018). The Verona Evidence-Based Meeting 2020 was also presented and discussed.

Bioinformatic Analysis and Integration of Transcriptome and Proteome Results Identify Key Coding and Noncoding Genes Predicting Malignancy in Intraductal Papillary Mucinous Neoplasms of the Pancreas

BACKGROUND

Intraductal papillary mucinous neoplasms (IPMNs) are precursor lesions of pancreatic ductal adenocarcinoma (PDAC). IPMNs are generally associated with high risk of developing malignancy and therefore need to be diagnosed and assessed accurately, once detected. Existing diagnostic methods are inadequate, and identification of efficient biomarker capable of detecting high-risk IPMNs is necessitated. Moreover, the mechanism of development of malignancy in IPMNs is also elusive.

METHODS

Gene expression meta-analysis conducted using 12 low-risk IPMN and 23 high-risk IPMN tissue samples. We have also listed all the altered miRNAs and long noncoding RNAs (lncRNAs), identified their target genes, and performed pathway analysis. We further enlisted cyst fluid proteins detected to be altered in high-risk or malignant IPMNs and compared them with fraction of differentially expressed genes secreted into cyst fluid.

RESULTS

Our meta-analysis identified 270 upregulated and 161 downregulated genes characteristically altered in high-risk IPMNs. We further identified 61 miRNAs and 14 lncRNAs and their target genes and key pathways contributing towards understanding of the gene regulation during the progression of the disease. Most importantly, we have detected 12 genes altered significantly both in cystic lesions and cyst fluid.

CONCLUSION

Our study reports, for the first time, a meta-analysis identifying key changes in gene expression between low-risk and high-risk IPMNs and also explains the regulatory aspect through construction of a miRNA-lncRNA-mRNA interaction network. The 12-gene-signature could function as potential biomarker in cyst fluid for detection of IPMN with a high risk of developing malignancy.

Cystic pancreatic lesions: MR imaging findings and management

Cystic pancreatic lesions (CPLs) are frequently casual findings in radiological examinations performed for other reasons in patients with unrelated symptoms. As they require different management according to their histological nature, differential diagnosis is essential. Radiologist plays a key role in the diagnosis and management of these lesions as imaging is able to correctly characterize most of them and thus address to a correct management. The first step for a correct characterization is to look for a communication between the CPLs and the main pancreatic duct, and then, it is essential to evaluate the morphology of the lesions. Age, sex and a history of previous pancreatic pathologies are important information to be used in the differential diagnosis. As some CPLs with different pathologic backgrounds can show the same morphological findings, differential diagnosis can be difficult, and thus, the final diagnosis can require other techniques, such as endoscopic ultrasound, endoscopic ultrasound-fine needle aspiration and endoscopic ultrasound-through the needle biopsy, and multidisciplinary management is important for a correct management.

Fatty Pancreas: An Underappreciated Intersection of the Metabolic Profile and Pancreatic Adenocarcinoma

Although the prevalence of pancreatic cancer is increasing, treatment strategies remain limited, and success is rare. A growing body of evidence links pancreatic cancer to pre-existing metabolic disorders, including, but not limited to, type 2 diabetes mellitus and obesity. An infrequently described finding, fatty pancreas, initially described in the context of obesity in the early 20th century, appears to be at the crossroads of type 2 diabetes and obesity on the one hand, and the development of pancreatic cancer on the other. Similarly, other conditions of the pancreas, such as intrapancreatic mucinous neoplasms, also seem to be related to diabetes while increasing the subsequent risk of pancreatic cancer. In this review, the author explores the diagnostic criteria for, and prevalence of, fatty pancreas and the potential link to other pancreatic conditions, including pancreatic cancer. Diagnostic limitations, and areas of controversy are also addressed, as are potential therapeutic approaches to fatty pancreas intended to reduce the subsequent risk of pancreatic cancer.

Hyperpolarized Magnetic Resonance and Artificial Intelligence: Frontiers of Imaging in Pancreatic Cancer

BACKGROUND

There is an unmet need for noninvasive imaging markers that can help identify the aggressive subtype(s) of pancreatic ductal adenocarcinoma (PDAC) at diagnosis and at an earlier time point, and evaluate the efficacy of therapy prior to tumor reduction. In the past few years, there have been two major developments with potential for a significant impact in establishing imaging biomarkers for PDAC and pancreatic cancer premalignancy: (1) hyperpolarized metabolic (HP)-magnetic resonance (MR), which increases the sensitivity of conventional MR by over 10,000-fold, enabling real-time metabolic measurements; and (2) applications of artificial intelligence (AI).

OBJECTIVE

Our objective of this review was to discuss these two exciting but independent developments (HP-MR and AI) in the realm of PDAC imaging and detection from the available literature to date.

METHODS

A systematic review following the PRISMA extension for Scoping Reviews (PRISMA-ScR) guidelines was performed. Studies addressing the utilization of HP-MR and/or AI for early detection, assessment of aggressiveness, and interrogating the early efficacy of therapy in patients with PDAC cited in recent clinical guidelines were extracted from the PubMed and Google Scholar databases. The studies were reviewed following predefined exclusion and inclusion criteria, and grouped based on the utilization of HP-MR and/or AI in PDAC diagnosis.

RESULTS

Part of the goal of this review was to highlight the knowledge gap of early detection in pancreatic cancer by any imaging modality, and to emphasize how AI and HP-MR can address this critical gap. We reviewed every paper published on HP-MR applications in PDAC, including six preclinical studies and one clinical trial. We also reviewed several HP-MR-related articles describing new probes with many functional applications in PDAC. On the AI side, we reviewed all existing papers that met our inclusion criteria on AI applications for evaluating computed tomography (CT) and MR images in PDAC. With the emergence of AI and its unique capability to learn across multimodal data, along with sensitive metabolic imaging using HP-MR, this knowledge gap in PDAC can be adequately addressed. CT is an accessible and widespread imaging modality worldwide as it is affordable; because of this reason alone, most of the data discussed are based on CT imaging datasets. Although there were relatively few MR-related papers included in this review, we believe that with rapid adoption of MR imaging and HP-MR, more clinical data on pancreatic cancer imaging will be available in the near future.

CONCLUSIONS

Integration of AI, HP-MR, and multimodal imaging information in pancreatic cancer may lead to the development of real-time biomarkers of early detection, assessing aggressiveness, and interrogating early efficacy of therapy in PDAC.

Burden of Pancreatic Cancer: From Epidemiology to Practice

Pancreatic cancer is the seventh leading cause of cancer-related deaths worldwide with 432,242 related deaths in 2018. Unlike other cancers, the incidence of pancreatic cancer continues to increase, with little improvement in survival rates. We review the epidemiologic features of pancreatic cancer, covering surveillance and early detection in high-risk persons. We summarize data on worldwide incidence and mortality and analyze the 1975-2016 data from 9 registries of the National Cancer Institute's Surveillance, Epidemiology, and End Results study, on the overall burden of pancreatic cancer as well as age-, sex-, and race-specific incidence, survival rates and trends. It is important to increase our knowledge of the worldwide and regional epidemiologic features of and risk factors for pancreatic cancer, to identify new approaches for prevention, surveillance, and treatment.

Role of stromal activin A in human pancreatic cancer and metastasis in mice

Pancreatic ductal adenocarcinoma (PDAC) has extensive stromal involvement and remains one of the cancers with the highest mortality rates. Activin A has been implicated in colon cancer and its stroma but its role in the stroma of PDAC has not been elucidated. Activin A expression in cancer and stroma was assessed in human PDAC tissue microarrays (TMA). Activin A expression in human TMA is significantly higher in cancer samples, with expression in stroma correlated with shorter survival. Cultured pancreatic stellate cells (PSC) were found to secrete high levels of activin A resulting in PDAC cell migration that is abolished by anti-activin A neutralizing antibody. KPC mice treated with anti-activin A neutralizing antibody were evaluated for tumors, lesions and metastases quantified by immunohistochemistry. KPC mice with increased tumor burden express high plasma activin A. Treating KPC mice with an activin A neutralizing antibody does not reduce primary tumor size but decreases tumor metastases. From these data we conclude that PDAC patients with high activin A expression in stroma have a worse prognosis. PSCs secrete activin A, promoting increased PDAC migration. Inhibition of activin A in mice decreased metastases. Hence, stroma-rich PDAC patients might benefit from activin A inhibition.

Abbreviated Magnetic Resonance Imaging With Breath-Hold Three-Dimensional Magnetic Resonance Cholangiopancreatography: Assessment of Malignant Risk of Pancreatic Intraductal Papillary Mucinous Neoplasm

BACKGROUND

For surveillance of pancreatic intraductal papillary mucinous neoplasms (IPMNs), magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatography (MRCP) is preferred over computed tomography, but the long acquisition time limits its use.

PURPOSE

To investigate the diagnostic performance of abbreviated MRI with breath-hold (BH) three-dimensional MRCP (abbreviated MRI-BH) for malignant risk assessment of pancreatic IPMN.

STUDY TYPE

Retrospective.

POPULATION

Two hundred and thirty-five patients with IPMNs (M:F = 115:120; mean age ± SD, 66 ± 9 years; typical imaging features with ≥2-year stability [N = 172] and histopathologically confirmed [N = 63]).

FIELD STRENGTH/SEQUENCE

3.0 T/ abbreviated MRI-BH (single-shot fast spin-echo, T1W fat-suppressed gradient-echo sequence, and BH-3D-MRCP).

ASSESSMENT

Abbreviated MRI-BH was reviewed by three reviewers, and its diagnostic performance was assessed using the predetermined scoring system. The diagnostic performance for the mural nodule detection was assessed. Additionally, diagnostic performance of abbreviated MRI was compared with that of full-sequence MRI.

STATISTICAL TESTS

Area under the receiver operating characteristic curve (AUC) with z-test, and linear-weighted kappa values.

RESULTS

Thirty-five patients had malignant IPMN. At a cut-off score ≥3, AUCs of abbreviated MRI-BH for detecting malignant IPMN were 0.959 for reviewer 1, 0.962 for reviewer 2, and 0.956 for reviewer 3. The sensitivity of reviewers 1, 2, and 3 was 97.1% for all, and the specificity was 85.5%, 86.0%, and 85.0%, respectively. Regarding mural nodule detection (N = 22), abbreviated MRI-BH demonstrated a sensitivity of 95.5% and a specificity of 88.3% for reviewer 1, a sensitivity of 86.4% and a specificity of 92.0% for reviewer 2, and a sensitivity of 86.4% and a specificity of 89.2% for reviewer 3. There were no significant differences between AUC of abbreviated MRI-BH and that of full-sequence MRI in the three reviewers (P > 0.05).

DATA CONCLUSION

Abbreviated MRI-BH showed good diagnostic performance for detecting malignant IPMNs by using a predetermined scoring system.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY STAGE: 2.

Comparison of Preoperative Evaluation with the Pathological Report in Intraductal Papillary Mucinous Neoplasms: A Single-Center Experience

The key to the successful management of pancreatic cystic neoplasm (PCN), among which intraductal papillary mucinous neoplasm (IPMN) is the one with the highest risk of advanced neoplasia in resected patients, is a careful combination of clinical, radiological, and histopathological findings. This study aims to perform the comparison of a preoperative evaluation with pathological reports in IPMN and further, to evaluate and compare the diagnostic performance of European evidence-based guidelines on pancreatic cystic neoplasms (EEBGPCN) and Fukuoka Consensus guidelines (FCG). We analyzed 106 consecutive patients diagnosed with different types of PCN, among whom 68 had IPMN diagnosis, at the Clinical Center of Serbia. All the patients diagnosed with IPMNs were stratified concerning the presence of the absolute and relative indications according to EEBGPCN and high-risk stigmata and worrisome features according to FCG. Final histopathology revealed that IPMNs patients were further divided into malignant (50 patients) and benign (18 patients) groups, according to the pathological findings. The preoperative prediction of malignancy according to EEBGPCN criteria was higher than 70% with high sensitivity of at least one absolute or relative indication for resection. The diagnostic performance of FCG was shown as comparable to EEBGPCN. Nevertheless, the value of false-positive rate for surgical resection showed that in some cases, overtreating patients or treating them too early cannot be prevented. A multidisciplinary approach is essential to adequately select patients for the resection considering at the same time both the risks of surgery and malignancy.

Mucin-filled CBD, difficult to manage cholangitis

Intraductal papillary mucinous neoplasms (IPMNs) are mucin-secreting cystic neoplasm of pancreas. They have a malignant potential. They are usually localised to the pancreas but occasionally can involve surrounding structures (1.9%-6.6%), like bile duct and duodenum, and are labelled as IPMN with invasion. Jaundice as a manifestation of IPMN is not common (4.5%). It can present as jaundice as a result of invasion of common bile duct (CBD) resulting in stricture formation or uncommonly as a result of fistulising to CBD with resultant obstruction of CBD by thick mucin secreted by this tumour. As only few cases (around 23) of mucin-filled CBD are reported in the literature. We are presenting our experience in dealing a rare case of obstructive jaundice caused by IPMN fistulising into CBD, highlighting the difficulties faced in managing such case, especially with regards to biliary drainage and what can be the optimum management in such cases.

Intestinal phenotype is maintained by Atoh1 in the cancer region of intraductal papillary mucinous neoplasm

Intraductal papillary mucinous neoplasm (IPMN) is a precancerous lesion of pancreatic cancer. Although there are 4 types of IPMN, among which intestinal-type IPMN is likely to progress into invasive cancer known as colloid carcinoma, no information regarding the involvement of the intestinal phenotype in the carcinogenesis of IPMN exists. The present study was conducted to explore how the intestinal differentiation system is maintained during the tumor progression of intestinal-type IPMN using surgical resection specimens. Results showed that Atoh1, a critical transcriptional factor for intestinal differentiation toward the secretory lineages of intestinal epithelial cells, was expressed in an invasive-grade IPMN. To determine the function of Atoh1 in pancreatic cancer, we generated a pancreatic ductal adenocarcinoma (PDAC) cell line overexpressing Atoh1. In a xenograft model, we successfully induced an IPMN phenotype in PDAC cells via Atoh1 induction. Finally, for the first time, we discovered that GPA33 is expressed in intestinal-type IPMN, thereby suggesting a novel target for cancer therapy. In conclusion, the intestinal differentiation system might be maintained during tumor progression of intestinal-type IPMN. Further analysis of the function of Atoh1 in IPMN might be useful for understanding the molecular mechanism underlying the malignant potential during the tumor progression of IPMN.

The diagnostic role of CT, MRI/MRCP, PET/CT, EUS and DWI in the differentiation of benign and malignant IPMN: A meta-analysis

PURPOSE

The objective of this study was to assess the diagnostic properties of computed tomography (CT), magnetic resonance imaging (MRI/MRCP) /Magnetic Resonance Cholangiopancreatography (MRCP), positron emission tomography/computed tomography (PET/CT), endoscopic ultrasound (EUS) and diffusion-weighted magnetic resonance imaging (DWI) in distinguishing benign and malignant intraductal papillary mucinous neoplasm (IPMN).

MATERIALS AND METHODS

Eligible databases were searched for eligible studies, published through July 2020 on the diagnostic accuracy of these modalities. Diagnostic accuracy parameters, including sensitivity, specificity, diagnostic odds ratio (DOR), and summary receiver operating characteristic curves (SROC) were calculated. Meta-regression was performed to identify the source of heterogeneity.

RESULTS

In total, 28 studies were included. Pooled sensitivities for CT, MRI/MRCP, PET/CT, EUS and DWI were 0.7, 0.76, 0.8, 0.6 and 0.72, respectively. Pooled specificities were 0.78, 0.83, 0.9, 0.8 and 0.97. The DORs were 8, 16, 35, 6 and 88. The areas under the curve (AUC) of SROC for CT, MRI/MRCP/MRCP, PET/CT, EUS and DW were 0.8, 0.87, 0.92, 0.79 and 0.82, respectively.

CONCLUSION

PET/CT showed the highest AUC and the overall diagnostic accuracy results support the use of MRI/MRCP, PET/CT interchangeably as a first-line examination in the diagnosis of malignant IPMN. With regard to DWI, EUS and CT, each techniques have their advantages and supportive to MRI/MRCP.

Intraductal papillary mucinous neoplasm complicated with intraductal bleeding in a young woman mimicked a cystic solid pseudo-papillary tumor: a case report

BACKGROUND

There are only 6 cases of intraductal papillary mucinous neoplasm (IPMN) complicated with intraductal hemorrhage have been reported in English literatures. All these 6 cases of IPMN occurred in the old people. The present rare case of IPMN complicated with intraductal hemorrhage occurred in a young woman, and mimicked a cystic solid pseudo-papillary neoplasm (SPN) on preoperative imaging findings.

CASE PRESENTATION

A 29-year-old young woman complained of a sustained mild right upper quadrant abdominal pain. CT and MRI showed a lobulated, partly ill-defined cystic lesion located in the pancreatic head. Spotted calcification within cystic wall was seen on CT. The lesion was demonstrated as predominantly homogeneous hyperattenuation on CT and homogeneous high signal without decreased signal on fat suppression sequence on T1WI. After contrast administration, the cystic wall and septa of lesion was showed gradually mild to moderate degree of enhancement over time both on CT and MRI. No communication between lesion and the main duct was found on MRCP and the main pancreatic duct and common bile duct were not dilated. Considering patient's age, gender and manifestations of lesion on CT and MRI (calcification, bleeding and gradually enhanced pattern), the present case mimicked as a cystic SPN. The lesion was pathologically confirmed a branch type IPMN after surgical resection.

CONCLUSION

We propose that IPMN may need to be taken into account in the differential diagnosis when pancreatic cystic lesions occur in young women with bleeding, calcification, progressive enhancement of cystic wall and no communication with the main pancreatic duct.

A mixed-type intraductal papillary mucinous neoplasm of the pancreas with a histologic combination of gastric and pancreatobiliary subtypes in a 70-year-old woman: a case report

Background

Intraductal papillary mucinous neoplasms are rare papillary pancreatic neoplasms arising from major pancreatic ducts, characterized by duct dilation and mucin secretion. They comprise approximately 1% of all exocrine neoplasms and are classified according to their anatomical sites into main duct-type, branch duct-type, and mixed-type intraductal papillary mucinous neoplasms. Histological examination plays a crucial role in distinguishing and classifying intraductal papillary mucinous neoplasms into gastric, intestinal, pancreatobiliary, and oncocytic subtypes.

Case presentation

We present the case of a 70-year-old Syrian woman who was admitted to our hospital due to an intermittent epigastric pain accompanied by diarrhea and weight loss with a recent diagnosis of diabetes mellitus. Following clinical, laboratory, and radiological examination, distal pancreatectomy involving the body and the tail of the pancreas was performed. Interestingly, histological examination of the resected specimens revealed the diagnosis of a mixed-type intraductal papillary mucinous neoplasm with a unique combination of gastric and pancreatobiliary subtypes.

Conclusion

To the best of our knowledge, the combination of multiple histological subtypes of intraductal papillary mucinous neoplasms has been recorded in a few studies with reference to the challenging histological detection. Herein, we report a rare case with a significant histological combination, highlighting the difficulties in differential diagnosis due to the absence of ancillary techniques, with a brief review on diagnostic methods, histological characteristics and surgical recommendations.

Exosomal glypican-1 for risk stratification of pancreatic cystic lesions: A case of pathological progression in the absence of any suspicious imaging finding

The clinical management of patients with pancreatic cystic lesions is of utmost importance to identify those at high risk for pathological progression. Current recommendations are guided by clinical presentation and radiologic criteria, but the results fall short for a disease that the only curative option is surgical resection. There is an urgent need for the introduction of biomarkers that can help in risk assessment of such lesions. We report a case of a pancreatic cystic lesion without imagiological findings suggestive of advanced disease, and high levels of a circulating biomarker, glypican-1 (GPC-1), which parallel those of patients with pancreatic cancer. One year after, the patient revealed malignant progression at follow-up. Our report is unprecedented in the literature. It describes a clinical case in which a biomarker was positive for a patient that only showed progression one year after its detection. This clinical information goes beyond the current knowledge in the field because it shows that the introduction of liquid biopsy and biomarkers is a highly promising clinical tool for the non-invasive assessment of pancreatic cancer precursor lesions, ultimately increasing the rate of patients eligible for surgical resection.

Pitfalls in the MDCT of pancreatic cancer: strategies for minimizing errors

Multidetector computed tomography (MDCT) is a widely used cross-sectional imaging modality for initial evaluation of patients with suspected pancreatic ductal adenocarcinoma (PDAC). However, diagnosis of PDAC can be challenging due to numerous pitfalls associated with image acquisition and interpretation, including technical factors, imaging features, and cognitive errors. Accurate diagnosis requires familiarity with these pitfalls, as these can be minimized using systematic strategies. Suboptimal acquisition protocols and other technical errors such as motion artifacts and incomplete anatomical coverage increase the risk of misdiagnosis. Interpretation of images can be challenging due to intrinsic tumor features (including small and isoenhancing masses, exophytic masses, subtle pancreatic duct irregularities, and diffuse tumor infiltration), presence of coexisting pathology (including chronic pancreatitis and intraductal papillary mucinous neoplasm), mimickers of PDAC (including focal fatty infiltration and focal pancreatitis), distracting findings, and satisfaction of search. Awareness of pitfalls associated with the diagnosis of PDAC along with the strategies to avoid them will help radiologists to minimize technical and interpretation errors. Cognizance and mitigation of these errors can lead to earlier PDAC diagnosis and ultimately improve patient prognosis.

Diagnostic and treatment of the intraductal papillary mucinous tumor of pancreas

OBJECTIVE

Adjustment of diagnostics and management of the surgical treatment of patients with intraductal papillary mucinous tumor of pancreas.

MATERIAL AND METHODS

From 2012 to 2018, 45 patients with intraductal papillary mucinous tumor were observed. During the observation the ultrasound examination, contrast-enhanced computed tomography and magnetic resonance tomography with contrast were used. In 29 cases radical surgery was performed, nonradical in 1 case; case follow-up is chosen for 15 patients.

RESULTS

Intraductal papillary mucinous tumor was diagnosed and the definition of the type of tumor was made on the base of 2 types of imaging methods. Intraductal papillary mucinous tumor type 1 was founded in 5 (11%), whereas intraductal papillary mucinous tumor type 2 was founded in 20 (44,5%) and intraductal papillary mucinous tumor type 3 was observed in 20 (44,5%) cases. Intraductal papillary mucinous tumor associated with carcinoma was observed in 16 cases. Pancreaticoduodenal resection was performed in 20, distal exsection of pancreas was performed in 4 cases (2 in open manner access, 2 in robot-assisted manner), pancreatic head resection was performed in 3 cases (1 in open manner access, 2 in laparoscopic access) and in 2 cases the duodenopancreatectomy was performed. Explorative laparotomy was performed in case of intraductal papillary mucinous tumor type 2 associated with mucilaginous carcinoma and miliary metastasis in the liver. Early postoperative complications were observed in 5 cases (16, 6%): biliary fistula (n=2), postoperative wound infection (n=2), arrosive hemorrhage type B in ISGPS (n=1, was treated in an X-ray endovascular manner). Case follow-up was chosen in 15 cases of intraductal papillary mucinous tumor over the course of 6 to 74 months and disease progression was not observed.

CONCLUSION

Intraductal papillary mucinous tumor is a condition associated with high risk of malignant change and demands early disease detection. The treatment should be provided in medical centers that specialize in the pancreas deceases, where a full patient examination as well as a clear-eyed understanding of diagnostic information with the execution of desirable type of surgical intervention with the guaranty of achievement R0 condition can be offered.

MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) VERSUS ENDOSONOGRAPHY-GUIDED FINE NEEDLE ASPIRATION (EUS-FNA) FOR DIAGNOSIS AND FOLLOW-UP OF PANCREATIC INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMS

Background:

Intraductal papillary mucinous tumor (IPMN) are being diagnosed with increasing frequency. Computerized tomography scanning is commonly used as the primary imaging modality before surgery nonetheless magnetic resonance cholangiopancreatography (MRCP) provides better characterization. Endosonography-guided fine needle aspiration (EUS-FNA) has emerged as a way to reach pathological diagnose.

Aim:

To compare results of both methods with surgical pathology findings for classification of IPMN.

Methods:

Thirty-six patients submitted to surgical resection with preoperative suspect of IPMN were submitted preoperatively to MRCP and EUS-FNA. Images obtained were analyzed according to a classification determined for each method. ROC curve was used for statistical analysis, that compared the images tests with the purpose of finding the best method for diagnosis and classification of IPMN.

Results:

Sixteen patients underwent pancreatoduodenectomy, 16 to subtotal pancreatectomy and only four laparotomy. Pathological diagnosis was IPMN (n=33) and pancreatic intraepithelial neoplasia type 2 (n=3). Twenty-nine revealed non-invasive neoplasia and invasive form in four patients. MRCP and EUS-FNA have correctly diagnosed and classified (type of IPMN), in 62.5% and 83.3% (p=0.811), the affected segment location in 69% and 92% (p=0.638) and identification of nodules and/or vegetation presence in 45% and 90% (p=0.5). Regarding to histopathological diagnosis by EUS-FNA the sensitivity was 83.3%; specificity was 100%; positive predictive value was 100%; negative predictive value was 33.3% and accuracy was 91.7%.

Conclusions:

There was no significant difference in the diagnosis of IPMN. However, EUS-FNA showed better absolute results than MRCP to identify nodule and/or vegetation.

Enrichment of oral microbiota in early cystic precursors to invasive pancreatic cancer

OBJECTIVES

Intraductal papillary mucinous neoplasms (IPMNs) are pancreatic cysts that can progress to invasive pancreatic cancer. Associations between oncogenesis and oral microbiome alterations have been reported. This study aims to investigate a potential intracystic pancreatic microbiome in a pancreatic cystic neoplasm (PCN) surgery patient cohort.

DESIGN

Paired cyst fluid and plasma were collected at pancreatic surgery from patients with suspected PCN (n=105). Quantitative and qualitative assessment of bacterial DNA by qPCR, PacBio sequencing (n=35), and interleukin (IL)-1β quantification was performed. The data were correlated to diagnosis, lesion severity and clinical and laboratory profile, including proton-pump inhibitor (PPI) usage and history of invasive endoscopy procedures.

RESULTS

Intracystic bacterial 16S DNA copy number and IL-1β protein quantity were significantly higher in IPMN with high-grade dysplasia and IPMN with cancer compared with non-IPMN PCNs. Despite high interpersonal variation of intracystic microbiota composition, bacterial network and linear discriminant analysis effect size analyses demonstrated co-occurrence and enrichment of oral bacterial taxa including Fusobacterium nucleatum and Granulicatella adiacens in cyst fluid from IPMN with high-grade dysplasia. The elevated intracystic bacterial DNA is associated with, but not limited to, prior exposure to invasive endoscopic procedures, and is independent from use of PPI and antibiotics.

CONCLUSIONS

Collectively, these findings warrant further investigation into the role of oral bacteria in cystic precursors to pancreatic cancer and have added values on the aetiopathology as well as the management of pancreatic cysts.