Predictive Value of Localized Stenosis of the Main Pancreatic Duct for Early Detection of Pancreatic Cancer

Repeated pancreatic juice cytology via endoscopic nasopancreatic drainage catheter combined with clinical findings improves diagnostic ability for malignant cases of suspected pancreatic cancer with non-identifiable tumors

BACKGROUND/OBJECTIVES

The detection of pancreatic cancer (PC) often depends on indirect indicators such as parenchyma atrophy (PPA), main pancreatic duct stenosis, and low echoic areas, particularly when no mass is evident on imaging. While pathological evaluation is the gold standard for differentiating malignant from benign conditions, endoscopic ultrasound-guided fine-needle aspiration/biopsy is not always feasible in such cases. Serial pancreatic juice aspiration cytologic examination (SPACE) via endoscopic nasopancreatic drainage (NPD) has emerged as an alternative diagnostic method, though its accuracy remains underevaluated. This study aimed to evaluate the diagnostic performance of SPACE and explore strategies to enhance its accuracy in diagnosing PC.

METHODS

This multicenter, retrospective study analyzed patients who underwent SPACE between January 2015 and September 2023. The inclusion criteria focused on cases lacking a clear pancreatic mass but exhibiting indirect signs suggestive of PC. Diagnostic accuracy was determined using surgical pathology or a minimum follow-up period of 12 months as the reference standard.

RESULTS

Among 164 patients, 85 (51.8 %) were diagnosed with malignancy. The sensitivity and specificity of SPACE were 74.1 % and 87.3 %, respectively, with a area under the receiver operating characteristic curve (ROC-AUC) of 0.807 (95%CI: 0.748-0.867). Incorporating patient age, CEA and PPA with SPACE results further improved diagnostic performance, yielding a ROC-AUC of 0.828 (95%CI: 0.76-0.897, p = 0.013).

CONCLUSIONS

Combining SPACE with clinical and imaging findings significantly enhances diagnostic accuracy in suspected PC cases where conventional imaging fails to detect tumors. This integrated approach has the potential to enhance clinical outcomes by facilitating more accurate patient management.

Diagnostic Ability and Safety of Repeated Pancreatic Juice Cytology Using an Endoscopic Nasopancreatic Drainage Catheter for Pancreatic Ductal Adenocarcinoma: A Multicenter Prospective Study

Pathological examination is essential for the diagnosis and treatment of pancreatic ductal adenocarcinoma (PDAC). Moreover, a reliable pathological diagnosis is extremely important for improving prognosis, especially in early-stage PDAC. This study prospectively evaluated the usefulness of repeated pancreatic juice cytology (PJC) using an endoscopic nasopancreatic drainage (ENPD) catheter for the diagnosis of PDAC. We enrolled 82 patients suspected of having resectable PDAC, based on imaging studies, and judged the necessity for cytology. The diagnostic yield of up to six repeated PJCs and the incidence of complications, such as pancreatitis, was evaluated. A total of 60 patients were diagnosed with PDAC. The overall sensitivity and specificity were 46.7% and 95.5%, respectively. The cumulative positivity rate increased with the number of sampling sessions, reaching 58.3% in the sixth session. The sensitivity was significantly higher in the pancreatic head than in the pancreatic tail (p = 0.043). Additionally, it was 100% in four patients with a tumor size ≤10 mm. Pancreatitis occurred in six patients (7.3%), all of whom were treated conservatively. In the diagnosis of PDAC, repeated PJC using an ENPD catheter revealed a cumulative effect of sensitivity up to six times and an excellent diagnostic yield for small PDAC.

Difference of risk of pancreatic cancer in new-onset diabetes and long-standing diabetes: population-based cohort study

CONTEXT

Considering the absence of methods to find pancreatic cancer early, surveillance of high-risk groups is needed for early diagnosis.

OBJECTIVE

The study aimed to investigate the effect in the incidence of pancreatic cancer and the differences between new-onset DM (NODM) and long-standing DM (LSDM) since NODM group is a representative high-risk group.

METHODS

The Korean National Health Insurance Service-National Sample Cohort between 2002 and 2013 data was used. Regarding 88,396 people with DM (case group), we conducted a 1:1 propensity score matching to select a matched non-DM population (control group). To investigate the interaction between DM and the time variable distinguishing NODM and LSDM, we performed a multi-variable time-dependent Cox regression analysis.

RESULTS

The incidence of pancreatic cancer was higher in the DM group compared to the non-DM group (0.52% vs. 0.16%, P < 0.001). The DM group had shown different risk of pancreatic cancer development according to the duration since the DM diagnosis (NODM hazard ratio (HR): 3.81, 95% confidence interval (CI): 2.97-4.88, P < 0.001; LSDM HR: 1.53, 95% CI: 1.11-2.11, P < 0.001). When the NODM and the LSDM groups were compared, the risk of pancreatic cancer was higher in the NODM group than LSDM group (HR: 1.55, P = 0.020). In subgroup analysis, NODM group showed that men (HR = 4.42 95% CI: 3.15-6.19, P < 0.001) and patients who were in their 50 s (HR = 7.54, 95% CI: 3.24-17.56, P < 0.001) were at a higher risk of developing pancreatic cancer than matched same sex or age control group (non-DM population), respectively.

CONCLUSION

The risk of pancreatic cancer was greater in people with DM than non-DM population. Among people with DM, NODM showed a higher risk of pancreatic cancer than long standing DM.

Current Screening Strategies for Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDAC) is a dreaded malignancy with a dismal 5-year survival rate despite maximal efforts on optimizing treatment strategies. Radical surgery is the only potential curative procedure. Unfortunately, the majority of patients are diagnosed with locally advanced or metastatic disease, which renders them ineligible for curative resection. Early detection of PDAC is thus considered to be the most effective way to improve survival. In this regard, pancreatic screening has been proposed to improve results by detecting asymptomatic stages of PDAC and its precursors. There is now evidence of benefits of systematic surveillance in high-risk individuals, and the current guidelines emphasize the potential of screening to affect overall survival in individuals with genetic susceptibility syndromes or familial occurrence of PDAC. Here we aim to summarize the current knowledge about screening strategies for PDAC, including the latest epidemiological data, risk factors, associated hereditary syndromes, available screening modalities, benefits, limitations, as well as management implications.

Endoscopic approach in the diagnosis of high-grade pancreatic intraepithelial neoplasia

Early diagnosis of pancreatic ductal adenocarcinoma (PDAC) is essential for improving prognosis; however, diagnosing PDAC at an early stage is challenging. In patients with localized high-grade pancreatic intraepithelial neoplasia (HG-PanIN), whose tumorous lesion is undetectable on cross-sectional images such as computed tomography or magnetic resonance image, long-term survival is expected. Pancreatic cystic lesions or main pancreatic duct (MPD) dilatation are important indirect findings for the initial diagnosis of HG-PanIN. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) should play important roles in detecting abnormal image findings, such as local irregular MPD stenosis, caliber MPD changes, small cystic lesions, or branch duct dilatation. Additionally, EUS could detect hypoechoic areas around the MPD stenosis in some patients with HG-PanIN. Subsequently, endoscopic retrograde cholangiopancreatography (ERCP) and its associated pancreatic juice cytology, including serial pancreatic juice aspiration cytologic examination (SPACE) after placement of an endoscopic nasopancreatic drainage (ENPD) tube, may have high diagnostic accuracy for confirming the malignancy in HG-PanIN. Although ERCP and its associated pancreatic cytology, including SPACE, may be associated with post-ERCP pancreatitis (PEP), a recent randomized trial suggested that a 4-Fr ENPD tube may reduce the incidence of PEP. In the future, further prospective multicenter studies are required to establish a standard method of SPACE. Additionally, further studies for novel biomarkers could help to establish evolutionary methods with duodenal fluid and pancreatic juice for the early and accurate diagnosis of early-stage PDAC.

Pre-Operative Imaging and Pathological Diagnosis of Localized High-Grade Pancreatic Intra-Epithelial Neoplasia without Invasive Carcinoma

Pancreatic ductal adenocarcinoma (PDAC) arises from precursor lesions, such as pancreatic intra-epithelial neoplasia (PanIN) and intraductal papillary mucinous neoplasm (IPMN). The prognosis of high-grade precancerous lesions, including high-grade PanIN and high-grade IPMN, without invasive carcinoma is good, despite the overall poor prognosis of PDAC. High-grade PanIN, as a lesion preceding invasive PDAC, is therefore a primary target for intervention. However, detection of localized high-grade PanIN is difficult when using standard radiological approaches. Therefore, most studies of high-grade PanIN have been conducted using specimens that harbor invasive PDAC. Recently, imaging characteristics of high-grade PanIN have been revealed. Obstruction of the pancreatic duct due to high-grade PanIN may induce a loss of acinar cells replaced by fibrosis and lobular parenchymal atrophy. These changes and additional inflammation around the branch pancreatic ducts (BPDs) result in main pancreatic duct (MPD) stenosis, dilation, retention cysts (BPD dilation), focal pancreatic parenchymal atrophy, and/or hypoechoic changes around the MPD. These indirect imaging findings have become important clues for localized, high-grade PanIN detection. To obtain pre-operative histopathological confirmation of suspected cases, serial pancreatic-juice aspiration cytologic examination is effective. In this review, we outline current knowledge on imaging characteristics of high-grade PanIN.

New-Onset or Exacerbation of Diabetes Mellitus Is a Clue to the Early Diagnosis of Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDAC), which accounts for majority of pancreatic cancers, is one of the most lethal human malignancies. Most patients are diagnosed at an advanced stage after symptom development. Early diagnosis of PDAC in asymptomatic subjects is important to improve prognosis. Diabetes mellitus (DM) is a risk factor for PDAC, and DM, especially new-onset DM, has attracted attentions as a diagnostic clue to PDAC. However, the impact of DM as a diagnostic opportunity on the prognosis of PDAC is unclear. We here retrospectively reviewed 489 PDAC patients and compared the clinical characteristics and prognosis according to the opportunities for PDAC diagnosis. PDAC was diagnosed upon presentation of symptoms, such as pain and jaundice, in 318 cases including 151 DM patients, upon new-onset or exacerbation of long-standing DM in 53 asymptomatic patients, and upon incidental detection by medical check-up or follow-up/work-up of other diseases in 118 asymptomatic patients. Asymptomatic patients including those with DM had smaller tumors, earlier disease stage, and higher resectability rates than symptomatic patients. Asymptomatic patients diagnosed in association with DM had better prognosis (median survival time, 771 days) than those diagnosed due to symptoms (343 days, P < 0.001), and similar to those diagnosed by incidental detection (869 days). The survival advantage was not evident in symptomatic patients with DM-associated signs. In conclusion, patients diagnosed in association with DM at asymptomatic stages had better prognosis than those diagnosed with symptoms. DM-associated signs might provide a clue to the early diagnosis of PDAC among asymptomatic subjects.