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Cuber A, Chopra S. Serous Cystadenoma of the Pancreas: An Easily Missed Cytological Diagnosis and Clues to Diagnosis. Diagn Cytopathol 2025; 53:139-145. [PMID: 39780323 DOI: 10.1002/dc.25437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Revised: 12/11/2024] [Accepted: 12/19/2024] [Indexed: 01/11/2025]
Abstract
Serous cystadenoma (SCA) of the pancreas is a benign nonmucinous cystic pancreatic neoplasm and the second most common type of pancreatic cystic neoplasm. Conservative management is advocated in asymptomatic cases as they have indolent clinical behavior and risk for postoperative morbidity, making an exact diagnosis essential. Morphologically, serous cystadenoma has a prominent subepithelial capillary meshwork causing the aspirate to be paucicellular and nondiagnostic. Therefore, cytologic diagnosis can be challenging, resulting in repeat aspirations or even unnecessary surgical resections. Since this is a diagnosis that is often overlooked, herein we offer a concise review of SCA along with characteristic radiology findings, diagnostic criteria including ancillary studies and possible differential considerations.
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Affiliation(s)
- Alicia Cuber
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Shefali Chopra
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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2
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Wang X, Zhang X, Hui P, Cai G. Improving diagnostic yield of pancreatic serous cystadenoma with cyst fluid ancillary testing, adjunct immunohistochemistry, and additional fine-needle biopsy sampling. Cancer Cytopathol 2024; 132:425-434. [PMID: 38450993 DOI: 10.1002/cncy.22808] [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: 12/13/2023] [Revised: 01/24/2024] [Accepted: 02/13/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Fine-needle aspiration (FNA) diagnosis of pancreatic serous cystadenoma (SCA) remains challenging. This retrospective study aimed to evaluate the roles of cyst fluid ancillary testing and combined fine-needle biopsy (FNB) in improving the diagnostic yield. METHODS The authors retrospectively reviewed cytology cases that were histologically confirmed SCAs. Clinical features and FNA cyst fluid biochemical and molecular analysis results along FNB findings were reviewed. RESULTS The study cohort included 31 cases from 13 male and 18 female patients with a mean age of 65. The original cytologic diagnoses were nondiagnostic (n = 6, 19%), negative for malignant cells/cyst contents (n = 7, 23%), atypical cells (n = 3, 10%), nonmucinous cyst (n = 11, 35%), and serous cystadenoma (n = 4, 13%). Cyst fluid carcinoembryonic antigen (CEA) analysis was performed in 17 cases, all of which showed a low CEA level (<192 ng/mL). All 14 cases with molecular testing showed a wild-type KRAS. Inhibin immunohistochemistry was retrospectively performed on the FNA cell blocks, inhibin was positive in six of seven cases tested. In 15 cases with concurrent FNA and FNB biopsies, the diagnosis of SCA was seen in only one FNA case (7%) but 13 FNB cases (87%). CONCLUSIONS This study suggests that FNA diagnosis of SCA remains challenging even with ancillary testing including cyst fluid CEA level and KRAS mutation analysis. Adjunct inhibin immunostaining may help improve the cytologic diagnosis of selective SCA cases. FNB appears superior to FNA for a definite diagnosis of SCA.
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Affiliation(s)
- Xi Wang
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Xuchen Zhang
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Pei Hui
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Guoping Cai
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Center, Yale University School of Medicine, New Haven, Connecticut, USA
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Ning K, Salamone A, Manos L, Lafaro KJ, Afghani E. Serous Cystadenoma: A Review on Diagnosis and Management. J Clin Med 2023; 12:7306. [PMID: 38068358 PMCID: PMC10707442 DOI: 10.3390/jcm12237306] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/11/2023] [Accepted: 11/18/2023] [Indexed: 05/02/2025] Open
Abstract
Incidental pancreatic cysts are highly prevalent, with management dependent on the risk of malignant progression. Serous cystadenomas (SCAs) are the most common benign pancreatic cysts seen on imaging. They have typical morphological patterns but may also show atypical features that mimic precancerous and cancerous cysts. If a confident diagnosis of SCA is made, no further follow-up is warranted. Therefore, a preoperative distinction between SCA and precancerous or cancerous lesions is critically essential. Distinguishing an SCA from other types of pancreatic cysts on imaging remains a challenge, thus leading to misdiagnosis and ramifications. This review summarizes the current evidence on diagnosing and managing SCA.
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Affiliation(s)
- Kylie Ning
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (K.N.)
| | - Ashley Salamone
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (K.N.)
| | - Lindsey Manos
- Division of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA (K.J.L.)
| | - Kelly J. Lafaro
- Division of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA (K.J.L.)
| | - Elham Afghani
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA; (K.N.)
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Wood LD, Adsay NV, Basturk O, Brosens LAA, Fukushima N, Hong SM, Kim SJ, Lee JW, Luchini C, Noë M, Pitman MB, Scarpa A, Singhi AD, Tanaka M, Furukawa T. Systematic review of challenging issues in pathology of intraductal papillary mucinous neoplasms. Pancreatology 2023; 23:878-891. [PMID: 37604731 DOI: 10.1016/j.pan.2023.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMNs) are a cystic precursor to pancreatic cancer. IPMNs deemed clinically to be at high-risk for malignant progression are frequently treated with surgical resection, and pathological examination of the pancreatectomy specimen is a key component of the clinical care of IPMN patients. METHODS Systematic literature reviews were conducted around eight topics of clinical relevance in the examination of pathological specimens in patients undergoing resection of IPMN. RESULTS This review provides updated perspectives on morphological subtyping of IPMNs, classification of intraductal oncocytic papillary neoplasms, nomenclature for high-grade dysplasia, assessment of T stage, distinction of carcinoma associated or concomitant with IPMN, role of molecular assessment of IPMN tissue, role of intraoperative assessment by frozen section, and preoperative evaluation of cyst fluid cytology. CONCLUSIONS This analysis provides the foundation for data-driven approaches to several challenging issues in the pathology of IPMNs.
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Affiliation(s)
- Laura D Wood
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - N Volkan Adsay
- Department of Pathology, Koç University Hospital and Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey
| | - Olca Basturk
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Noriyoshi Fukushima
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Joo Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae W Lee
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134, Verona, Italy; ARC-Net Research Center, University of Verona, 37134, Verona, Italy
| | - Michaël Noë
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134, Verona, Italy; ARC-Net Research Center, University of Verona, 37134, Verona, Italy
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mariko Tanaka
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toru Furukawa
- Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Mørch-Jessen T, Chatterjee SA. A case report: Serous cystadenoma in the pancreas turned malignant. Radiol Case Rep 2023; 18:2850-2853. [PMID: 37388257 PMCID: PMC10300473 DOI: 10.1016/j.radcr.2023.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 05/05/2023] [Accepted: 05/12/2023] [Indexed: 07/01/2023] Open
Abstract
Serous cystadenomas represent 16% of pancreatic serous neoplasms. It can be subdivided into 4 variants: polycystic, oligocystic, honeycomb and solid. Such tumors rarely turn malignant. Most are asymptomatic at the time of diagnosis, but symptomatic patients mainly suffer from abdominal pain and pancreaticobiliary symptoms. Due to the usually benign status, no follow-up or surgery is usually required. This case report concerns a histologically proven serous cystadenoma in an 84-year elderly woman. Due to benign status, no follow-up was required. Thirteen years later she was diagnosed with malignant transformation on computed tomography.
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Yang KS, O'Shea A, Zelga P, Liss AS, Del Castillo CF, Weissleder R. Extracellular vesicle analysis of plasma allows differential diagnosis of atypical pancreatic serous cystadenoma. Sci Rep 2023; 13:10969. [PMID: 37414831 PMCID: PMC10325992 DOI: 10.1038/s41598-023-37966-5] [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: 04/17/2023] [Accepted: 06/30/2023] [Indexed: 07/08/2023] Open
Abstract
Increased use of cross-sectional imaging has resulted in frequent detection of incidental cystic pancreatic lesions. Serous cystadenomas (SCAs) are benign cysts that do not require surgical intervention unless symptomatic. Unfortunately, up to half of SCAs do not have typical imaging findings ("atypical SCAs"), overlap with potentially malignant precursor lesions, and thus pose a diagnostic challenge. We tested whether the analysis of circulating extracellular vesicle (EV) biomarkers using a digital EV screening technology (DEST) could enhance the discrimination of cystic pancreatic lesions and avoid unnecessary surgical intervention in these atypical SCAs. Analysis of 25 different protein biomarkers in plasma EV from 68 patients identified a putative biomarker signature of Das-1, Vimentin, Chromogranin A, and CAIX with high discriminatory power (AUC of 0.99). Analysis of plasma EV for multiplexed markers may thus be helpful in clinical decision-making.
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Affiliation(s)
- Katherine S Yang
- Center for Systems Biology, Massachusetts General Hospital, 185 Cambridge St, CPZN 5206, Boston, MA, 02114, USA
- Department of Radiology, Massachusetts General Hospital, 32 Fruit St, Boston, MA, 02114, USA
| | - Aileen O'Shea
- Center for Systems Biology, Massachusetts General Hospital, 185 Cambridge St, CPZN 5206, Boston, MA, 02114, USA
- Department of Radiology, Massachusetts General Hospital, 32 Fruit St, Boston, MA, 02114, USA
| | - Piotr Zelga
- Department of Surgery, Massachusetts General Hospital, 32 Fruit St, Boston, MA, 02114, USA
| | - Andrew S Liss
- Department of Surgery, Massachusetts General Hospital, 32 Fruit St, Boston, MA, 02114, USA
| | | | - Ralph Weissleder
- Center for Systems Biology, Massachusetts General Hospital, 185 Cambridge St, CPZN 5206, Boston, MA, 02114, USA.
- Department of Radiology, Massachusetts General Hospital, 32 Fruit St, Boston, MA, 02114, USA.
- Department of Systems Biology, Harvard Medical School, 200 Longwood Ave, Boston, MA, 02115, USA.
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7
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Approach to FNA of Pancreatic Cysts. Adv Anat Pathol 2022; 29:349-357. [DOI: 10.1097/pap.0000000000000378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Comparative analysis of glucose and carcinoembryonic antigen in the diagnosis of pancreatic mucinous cysts: a systematic review and meta-analysis. Gastrointest Endosc 2021; 94:235-247. [PMID: 33852901 DOI: 10.1016/j.gie.2021.03.935] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 03/31/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Pancreatic cystic fluid (PCF) analysis is useful to distinguish between different cyst types and to guide management. The aim of our study was to compare the diagnostic accuracy of glucose level with carcinoembryonic antigen (CEA) in PCF for mucinous cyst diagnosis. METHODS We identified studies with PCF obtained by EUS before surgery, with cysts classified as mucinous and nonmucinous according to surgical specimens. A random-effects model was used for quantitative meta-analysis. Pooled sensitivities, specificities, and summary receiver operating characteristic (ROC) curve analysis were conducted. RESULTS For CEA, we included 31 studies with 5268 patients, of which 2083 were referred for surgery. For glucose, we included 4 studies with 345 patients, of which 275 were referred for surgery. Glucose performed better than CEA for mucinous cysts diagnosis (premalignant and malignant) with sensitivities of .90 (95% confidence interval [CI], .85-.94) and .67 (95% CI, .65-.70), specificities of .82 (95% CI, .72-.89) and .80 (95% CI, 0.76-0.83), and areas under the ROC curve of .96 and .79, respectively. Glucose had a higher sensitivity (90%), with uncommon false-negative results, making it an excellent biomarker to exclude a mucinous cyst. Sensitivity analysis demonstrated that the findings of the current meta-analysis are robust. CONCLUSION Glucose level in PCF is more accurate than CEA for preoperative diagnosis of mucinous cysts. It may become a useful first-line test, particularly in small cysts with a limited volume of PCF. Larger studies are awaited to confirm glucose as the single test for mucinous cyst diagnosis.
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Feng Y, Chang X, Zhao Y, Wu D, Meng Z, Wu X, Guo T, Jiang Q, Zhang S, Wang Q, Yang A. A new needle-based confocal laser endomicroscopy pattern of malignant pancreatic mucinous cystic lesions (with video). Endosc Ultrasound 2021; 10:200-206. [PMID: 32655084 PMCID: PMC8248307 DOI: 10.4103/eus.eus_35_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background and Objectives: The diagnosis of malignant pancreatic cystic lesions (PCLs) remains challenging. Needle-based confocal laser endomicroscopy (nCLE) is an emerging promising imaging technique capable of real-time in vivo microscopic imaging of the cyst wall. We aimed to develop and validate a new nCLE diagnostic criteria for malignant mucinous cystic lesions (MLs). Methods: Patients referred for EUS-FNA of indeterminate PCLs with at least one worrisome features according to Fukouka consensus were consecutively prospectively enrolled from July 2016 to July 2018. The final diagnosis was based on surgical histology, cytopathology, or committee consensus. Five investigators nonblindly reviewed nCLE features and identified potential diagnostic feature for malignant MLs, which was also reviewed in histology imaging accordingly. Furthermore, the nCLE diagnostic feature was evaluated with an independent nCLE dataset by two investigators in a double-blind manner. Results: A nCLE pattern of dark aggregates of neoplastic cells was identified as diagnostic for MLs, which was consistent with histological findings of irregular branching and budding in malignant MLs. An independent validation revealed that the accuracy, sensitivity, and specificity of this feature for the diagnosis of malignant MLs were 94%, 75%, and 100%, respectively. Conclusion: The new nCLE criterion is promising for diagnosis of malignant MLs which warrants further confirmation in large cohort.
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Affiliation(s)
- Yunlu Feng
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Xiaoyan Chang
- Department of Pathology, Peking Union Medical College Hospital, Beijing, China
| | - Yu Zhao
- Department of Pathology, Peking Union Medical College Hospital, Beijing, China
| | - Dong Wu
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Zhilan Meng
- Department of Pathology, Peking Union Medical College Hospital, Beijing, China
| | - Xi Wu
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Tao Guo
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Qingwei Jiang
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Shengyu Zhang
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Qiang Wang
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Aiming Yang
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
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10
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Gokozan HN, Michael CW. Nondiagnostic fine-needle aspirates of the pancreas: A root cause analysis. Cancer Cytopathol 2020; 128:704-714. [PMID: 32525623 DOI: 10.1002/cncy.22301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Fine-needle aspiration (FNA) of the pancreas is considered the primary and least invasive diagnostic method in the evaluation of pancreatic lesions. A nondiagnostic sample may trigger repeat FNA or a more invasive diagnostic procedure. The goal of this study was to identify the root causes of nondiagnostic samples. METHODS We performed a retrospective review of FNAs of the pancreas categorized as nondiagnostic at our institution between 2008 and 2019. Medical records and slides were reviewed to identify the features described by imaging, rapid on-site evaluation, fluid chemistry, final cytology diagnosis, and final histology. A root cause analysis was performed using the Ishikawa (or fishbone) diagram and the 5 Whys method. RESULTS A total of 30 cases were identified: 11 adenocarcinomas, 6 cases of pancreatitis, 4 intraductal papillary mucinous neoplasms, 3 serous cystadenomas, 3 neuroendocrine tumors, 1 mucinous cystic neoplasm, 1 retention cyst, and 1 case of Brunner gland hyperplasia. The root causes identified were: man in 8 cases, machine in 1 case, method in 17 cases, and material in 18 cases. In many cases, more than 1 root cause contributed to the problem. CONCLUSION Material related errors contributed to the majority of nondiagnostic results and were primarily related to fibrotic cancers, chronic pancreatitis, absence of diagnostic criteria of cystic lesions, and technically challenging cases. Only 1 major interpretation error was identified. Sampling and interpretive errors contributed equally to man-related causes. For mucinous cysts, neoplastic mucin was difficult to identify in liquid-based preparations. Pathologists tended to issue a nondiagnostic categorization when epithelial cells are lacking and particularly when the nature and radiological impression of the cyst was not communicated.
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Affiliation(s)
- Hamza N Gokozan
- Department of Pathology, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Claire W Michael
- Department of Pathology, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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11
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Westerveld DR, Ponniah SA, Draganov PV, Yang D. Diagnostic yield of EUS-guided through-the-needle microforceps biopsy versus EUS-FNA of pancreatic cystic lesions: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E656-E667. [PMID: 32355885 PMCID: PMC7164999 DOI: 10.1055/a-1119-6543] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/15/2020] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Accurate diagnosis and risk stratification of pancreatic cysts (PCs) is challenging. The aim of this study was to perform a systematic review and meta-analysis to assess the feasibility, safety, and diagnostic yield of endoscopic ultrasound-guided through-the-needle biopsy (TTNB) versus fine-needle aspiration (FNA) in PCs. Methods Comprehensive search of databases (PubMed, EMBASE, Cochrane, Web of Science) for relevant studies on TTNB of PCs (from inception to June 2019). The primary outcome was to compare the pooled diagnostic yield and concordance rate with surgical pathology of TTNB histology and FNA cytology of PCs. The secondary outcome was to estimate the safety profile of TTNB. Results: Eight studies (426 patients) were included. The diagnostic yield was significantly higher with TTNB over FNA for a specific cyst type (OR: 9.4; 95 % CI: [5.7-15.4]; I 2 = 48) or a mucinous cyst (MC) (OR: 3.9; 95 % CI: [2.0-7.4], I 2 = 72 %). The concordance rate with surgical pathology was significantly higher with TTNB over FNA for a specific cyst type (OR: 13.5; 95 % CI: [3.5-52.3]; I 2 = 48), for a MC (OR: 8.9; 95 % [CI: 1.9-40.8]; I 2 = 29), and for MC histologic severity (OR: 10.4; 95 % CI: [2.9-36.9]; I 2 = 0). The pooled sensitivity and specificity of TTNB for MCs were 90.1 % (95 % CI: [78.4-97.6]; I 2 = 36.5 %) and 94 % (95 % CI: [81.5-99.7]; I 2 = 0), respectively. The pooled adverse event rate was 7.0 % (95 % CI: [2.3-14.1]; I 2 = 82.9). Conclusions TTNB is safe, has a high sensitivity and specificity for MCs and may be superior to FNA cytology in risk-stratifying MCs and providing a specific cyst diagnosis.
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Affiliation(s)
- Donevan R. Westerveld
- Department of Internal Medicine, University of Florida, Gainesville, Florida, United States
| | - Sandeep A. Ponniah
- Department of Internal Medicine, University of Florida, Gainesville, Florida, United States
| | - Peter V. Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
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Sydney GI, Ioakim KJ, Michaelides C, Sepsa A, Sopaki-Valalaki A, Tsiotos GG, Theocharis S, Salla C, Nikas I. EUS-FNA diagnosis of pancreatic serous cystadenoma with the aid of cell blocks and α-inhibin immunochemistry: A case series. Diagn Cytopathol 2019; 48:239-243. [PMID: 31785091 DOI: 10.1002/dc.24348] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 10/24/2019] [Accepted: 11/12/2019] [Indexed: 12/18/2022]
Abstract
Serous cystadenoma (SCA) is an uncommon benign pancreatic neoplasm that is most often managed conservatively with follow-up rather than surgical excision. Therefore, to avoid the serious complications of pancreatic surgery, SCA should be diagnosed accurately at the preoperative level. Preoperative SCA diagnosis requires a multimodal diagnostic approach that includes imaging, cystic fluid biochemical analysis and/or endoscopic ultrasound fine-needle aspiration (EUS-FNA). In this brief report, we describe six EUS-FNA cases from five patients that were reported as "benign, consistent with serous cystadenoma". Samples were hypocellular, composed of loose clusters and single cuboidal, bland-looking cells among epithelial sheets representing gastrointestinal contamination. Cell blocks were prepared and all six FNA cases revealed cuboidal cells with a positive α-inhibin immunophenotype, consistent with a diagnosis of SCA. As EUS-FNAs of SCA commonly result in non-diagnostic interpretations, cell block preparations with subsequent immunochemistry can increase their diagnostic accuracy and guide patient management.
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Affiliation(s)
- Guy I Sydney
- School of Medicine, European University Cyprus, Nicosia, Cyprus
| | | | - Constantinos Michaelides
- School of Medicine, European University Cyprus, Nicosia, Cyprus.,First Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasia Sepsa
- First Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Stamatios Theocharis
- First Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Charitini Salla
- Department of Cytopathology, Hygeia & Mitera Hospital, Athens, Greece
| | - Ilias Nikas
- School of Medicine, European University Cyprus, Nicosia, Cyprus.,First Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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13
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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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14
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Jhala N, Srimunta P, Jhala D. Role of Ancillary Testing on Endoscopic US-Guided Fine Needle Aspiration Samples from Cystic Pancreatic Neoplasms. Acta Cytol 2019; 64:124-135. [PMID: 31509835 DOI: 10.1159/000502372] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 07/22/2019] [Indexed: 12/11/2022]
Abstract
Pancreatic cysts are increasingly detected on imaging studies. Accurate determination of the cyst type is important to provide appropriate care for the patients. It is also very clear that not one single modality can provide adequate diagnostic information. A multidisciplinary approach is the key to the diagnosis of pancreatic cysts. In this setting, the role of ancillary testing, which includes biochemical testing (carcinoembryonic antigen and amylase levels in the cyst), molecular testing (e.g., KRAS, GNAS, VHL, and CTNB1), and/or immunohistochemical tests are very important to obtain an accurate diagnosis. This review will discuss helpful ancillary tests in common pancreatic cyst neoplasms and how to approach the diagnosis of pancreatic cysts.
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Affiliation(s)
- Nirag Jhala
- Department of Pathology and Laboratory Medicine, Temple University Hospital, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA,
| | - Piyachat Srimunta
- Visiting Fellow, Department of Pathology and Laboratory Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Darshana Jhala
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Pathology and Laboratory Services, CMC Philadelphia VA Medical Center, Philadelphia, Pennsylvania, USA
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Multi-institutional Validation Study of Pancreatic Cyst Fluid Protein Analysis for Prediction of High-risk Intraductal Papillary Mucinous Neoplasms of the Pancreas. Ann Surg 2019; 268:340-347. [PMID: 28700444 DOI: 10.1097/sla.0000000000002421] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Preliminary work by our group suggested that proteins within the pancreatic cyst fluid (CF) may discriminate degree of IPMN dysplasia. We sought to externally validate these markers and determine whether their inclusion in a preoperative clinical nomogram could increase diagnostic accuracy. SUMMARY BACKGROUND DATA IPMN is the most common radiographically identifiable precursor to pancreatic cancer; however, the timing and frequency of its malignant progression are unknown, and there are currently no reliable preoperative tests that can determine the grade of dysplasia in IPMN. METHODS Clinical and radiographic data, as well as CF samples, were obtained from 149 patients who underwent resection for IPMN at 1 of 3 institutions. High-risk disease was defined as the presence of high-grade dysplasia or invasive carcinoma. Multianalyte bead array analysis (Luminex) of CF was performed for 4 protein markers that were previously associated with high-risk disease. Logistic regression models were fit on training data, with and without adjustment for a previously developed clinical nomogram and validated with an external testing set. The models incorporating clinical risk score were presented graphically as nomograms. RESULTS Within the group of 149 resected patients, 89 (60%) had low-risk disease, and 60 (40%) had high-risk disease. All 4 CF markers (MMP9, CA72-4, sFASL, and IL-4) were overexpressed in patients with high-risk IPMN (P < 0.05). Two predictive models based on preselected combinations of CF markers had concordance indices of 0.76 (Model-1) and 0.80 (Model-2). Integration of each CF marker model into a previously described clinical nomogram leads to increased discrimination compared with either the CF models or nomogram alone (c-indices of 0.84 and 0.83, respectively). CONCLUSIONS This multi-institutional study validated 2 CF protein marker models for preoperative identification of high-risk IPMN. When combined with a clinical nomogram, the ability to predict high-grade dysplasia was even stronger.
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Impact of needle-based confocal laser endomicroscopy on the therapeutic management of single pancreatic cystic lesions. Surg Endosc 2019; 34:2532-2540. [PMID: 31410626 PMCID: PMC7214514 DOI: 10.1007/s00464-019-07062-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 08/05/2019] [Indexed: 12/14/2022]
Abstract
Background and aim The diagnosis and therapeutic management of large single pancreatic cystic lesions (PCLs) represent major issues for clinicians and essentially rely on endoscopic ultrasound fine-needle aspiration (EUS-FNA) findings. Needle-based confocal laser endomicroscopy (nCLE) has high diagnostic performance for PCLs. This study aimed to evaluate the impact of nCLE on the therapeutic management of patients with single PCLs. Methods Retrospective and comparative study. Five independent pancreatic disease experts from tertiary hospitals independently reviewed data from a prospective database of 206 patients with single PCL, larger than 2 cm and who underwent EUS-FNA and nCLE. Two evaluations were performed. The first one included the sequential review of clinical information, EUS report and FNA results. The second one included the same data + nCLE report. Participants had to propose a therapeutic management for each case. Results The addition of nCLE to EUS-FNA led to significant changes in therapeutic management for 28% of the patients (p < 0.001). nCLE significantly increased the interobserver agreement of 0.28 (p < 0.0001), from 0.36 (CI 95% 0.33–0.49) to 0.64 (CI 95% 0.61–0.67). nCLE improved the rates of full agreement among the five experts of 24% (p < 0.0001), from 30 to 54%. With nCLE, the surveillance rate of benign SCAs fell by 35%, from 40 (28/70) to 5% (4/76). Conclusion The addition of nCLE to EUS-FNA significantly improves reliability of PCL diagnosis and could impact the therapeutic management of patients with single PCLs. ClinicalTrials.gov number, NCT01563133. Electronic supplementary material The online version of this article (10.1007/s00464-019-07062-9) contains supplementary material, which is available to authorized users.
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Charville GW, Kao CS. Serous Neoplasms of the Pancreas: A Comprehensive Review. Arch Pathol Lab Med 2019; 142:1134-1140. [PMID: 30141993 DOI: 10.5858/arpa.2017-0195-rs] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Serous neoplasms are uncommon, usually cystic tumors that account for less than 1% of all primary pancreatic lesions. They consist predominantly of a monomorphic epithelial cell population with a glycogen-rich, clear cytoplasm, reminiscent of clear cell renal cell carcinoma, with which serous neoplasms share an association with underlying VHL loss-of-function mutations. Serous neoplasms have no metastatic potential. Accurate recognition of this entity, including its various architectural subtypes, is critical to appropriate prognostication and treatment. Immunohistochemical detection of inhibin and calponin expression, along with the absence of both estrogen and progesterone receptors and nuclear β-catenin, can help to distinguish serous neoplasms from mimics. With the advent of minimally invasive and molecularly driven diagnostic techniques, the pathologist's role in the assessment and management of serous neoplasms has become increasingly complex and important. We provide an update on the histologic, immunohistochemical, and molecular features of pancreatic serous neoplasms for the practicing pathologist.
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Affiliation(s)
| | - Chia-Sui Kao
- From the Department of Pathology, Stanford University School of Medicine, Stanford, California
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Keegan MJ, Paranandi B. Diagnosis and management of pancreatic cystic neoplasms. Frontline Gastroenterol 2019; 10:300-308. [PMID: 31288258 PMCID: PMC6583589 DOI: 10.1136/flgastro-2018-101122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/18/2019] [Accepted: 01/19/2019] [Indexed: 02/04/2023] Open
Abstract
This review outlines the current classification of pancreatic cystic lesions, with a particular emphasis on pancreatic cystic neoplasms (PCNs). It will describe the diagnostic approach to PCNs, with reference to clinicopathological features, cross-sectional radiology and endoscopic ultrasound. This review will conclude with an evidence-based discussion of the management of PCNs focused on recent clinical guidelines.
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Affiliation(s)
- Mathew James Keegan
- Gastroenterology, Northern Beaches Hospital, Sydney, New South Wales, Australia,Department of Gastroenterology, Peninsula Gastroenterology, Sydney, New South Wales, Australia
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Pointer L, Rothermel LD, Strosberg C, Anaya D, Hodul P. Giant symptomatic serous cystadenoma mimicking carcinoma: A case report and literature review. Int J Surg Case Rep 2019; 60:106-110. [PMID: 31212091 PMCID: PMC6581980 DOI: 10.1016/j.ijscr.2019.05.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/19/2019] [Accepted: 05/23/2019] [Indexed: 02/07/2023] Open
Abstract
The diagnosis of serous cystadenoma is challenging. Surgery may be indicated for select serous cystadenoma. Serous cystadenocarcinoma is a rare entity and histologically indistinguishable from its benign counterpart. Introduction Advanced imaging has led to an increase in the incidental diagnosis of pancreatic cysts. Serous cystadenomas (SCAs) account for nearly 30% of cases. These are typically considered benign lesions but up to 16% of cases are resected for aggressive behavior and symptoms. Presentation of case A 64 year old female presented with a large incidental cyst in the pancreatic body. Pre-operative imaging conferred a diagnosis of SCA. After 2 years the cyst grew resulting in abdominal pain. Enlargement was associated with splenic vein occlusion and varices of the short gastric vessels. This change in behavior was concerning for malignant transformation. The cyst was resected by distal pancreatectomy and splenectomy. The patient recovered with minimal morbidity. Final pathology revealed a 15.5 × 10.3 × 8.5 cm SCA with negative margins. Discussion In this case a patient presents with aggressive radiographic features and new symptoms suggesting malignant transformation of a previously diagnosed SCA on imaging. Although malignant variants can be diagnosed by findings of metastatic deposits at the time of surgery or as recurrence years later, histologic findings cannot discriminate benign from malignant potential. Preoperative imaging is challenging with erroneous characterization in nearly 60% of cases. Conclusion Based on the low risk of malignancy, selective surgical resection for SCA appears warranted. Accepted indications for surgery include development of symptoms or concern for correct diagnosis in a medically fit individual. Routine resection for cysts >4 cm has been suggested however, prospective studies are needed to determine benefit over risk rationale.
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Affiliation(s)
- Lauren Pointer
- University of South Florida, Gastroenterology, 12901 Bruce B. Downs Blvd., MDC 82, Tampa, FL, 33612, United States.
| | - Luke D Rothermel
- Moffitt Cancer Center, Department of Gastrointestinal Oncology, 12902 Magnolia Drive, Tampa, FL, 33612, United States.
| | - Carolina Strosberg
- Moffitt Cancer Center, Department of Anatomic Pathology, 12902 Magnolia Drive, Tampa, FL, 33612, United States.
| | - Daniel Anaya
- Moffitt Cancer Center, Department of Gastrointestinal Oncology, 12902 Magnolia Drive, Tampa, FL, 33612, United States.
| | - Pamela Hodul
- Moffitt Cancer Center, Department of Gastrointestinal Oncology, 12902 Magnolia Drive, Tampa, FL, 33612, United States.
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Diagnostic ability of artificial intelligence using deep learning analysis of cyst fluid in differentiating malignant from benign pancreatic cystic lesions. Sci Rep 2019; 9:6893. [PMID: 31053726 PMCID: PMC6499768 DOI: 10.1038/s41598-019-43314-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 04/03/2019] [Indexed: 12/15/2022] Open
Abstract
The diagnosis of pancreatic cystic lesions remains challenging. This study aimed to investigate the diagnostic ability of carcinoembryonic antigen (CEA), cytology, and artificial intelligence (AI) by deep learning using cyst fluid in differentiating malignant from benign cystic lesions. We retrospectively reviewed 85 patients who underwent pancreatic cyst fluid analysis of surgical specimens or endoscopic ultrasound-guided fine-needle aspiration specimens. AI using deep learning was used to construct a diagnostic algorithm. CEA, carbohydrate antigen 19-9, carbohydrate antigen 125, amylase in the cyst fluid, sex, cyst location, connection of the pancreatic duct and cyst, type of cyst, and cytology were keyed into the AI algorithm, and the malignant predictive value of the output was calculated. Area under receiver-operating characteristics curves for the diagnostic ability of malignant cystic lesions were 0.719 (CEA), 0.739 (cytology), and 0.966 (AI). In the diagnostic ability of malignant cystic lesions, sensitivity, specificity, and accuracy of AI were 95.7%, 91.9%, and 92.9%, respectively. AI sensitivity was higher than that of CEA (60.9%, p = 0.021) and cytology (47.8%, p = 0.001). AI accuracy was also higher than CEA (71.8%, p < 0.001) and cytology (85.9%, p = 0.210). AI may improve the diagnostic ability in differentiating malignant from benign pancreatic cystic lesions.
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21
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Legrand M, Delalande F, Blechet C, Kerdraon R, Saint-Marc O, Michenet P. [Microcystic serous cystadenoma: An uncommon neoplasm of pancreas. Report of two cases]. Ann Pathol 2019; 39:292-296. [PMID: 30711334 DOI: 10.1016/j.annpat.2018.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/18/2018] [Accepted: 12/19/2018] [Indexed: 10/27/2022]
Abstract
Microcystic variant of serous cystadenoma of the pancreas is a rare neoplasm; essentially located in the body or tail of the pancreas and associated with the von Hippel-Lindau. Often, patients are asymptomatic and the neoplasm is incidentally discovered. Usually radiographic manifestations are characteristic. Histopathological examination revealed uniform clear cuboidal cells; they can be confused with other clear cell neoplasms like renal cell carcinomas, well-differentiated neuroendocrine tumors and solid pseudopapillary tumors of the pancreas. Immunohistochemistry can be help to establish the diagnosis and to remove differential diagnosis. Serous cystadenoma is a benign neoplasm whose prognosis is excellent. We herein report two cases of microcystic serous cystadenomas of the pancreas diagnosed in two asymptomatic women and review analysis in the literature to remind the main features of this lesion and the main differential diagnosis.
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Affiliation(s)
- Mélanie Legrand
- Service d'anatomie et cytologie pathologiques, hôpital de la Source, BP 86709, 45067 Orléans cedex 2, France.
| | - Flore Delalande
- Service d'anatomie et cytologie pathologiques, hôpital de la Source, BP 86709, 45067 Orléans cedex 2, France
| | - Claire Blechet
- Service d'anatomie et cytologie pathologiques, hôpital de la Source, BP 86709, 45067 Orléans cedex 2, France
| | - Rémy Kerdraon
- Service d'anatomie et cytologie pathologiques, hôpital de la Source, BP 86709, 45067 Orléans cedex 2, France
| | - Olivier Saint-Marc
- Service de chirurgie digestive, hôpital de la Source, BP 86709, 45067 Orléans cedex 2, France
| | - Patrick Michenet
- Service d'anatomie et cytologie pathologiques, hôpital de la Source, BP 86709, 45067 Orléans cedex 2, France
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Hwang H, Yu JS, Cho ES, Kim JH, Chung JJ. Serous Cystic Neoplasms of the Pancreas: Endoscopic Ultrasonographic Versus Computed Tomography and Magnetic Resonance Imaging Features of Surgically Removed Masses. Ultrasound Q 2019; 34:122-127. [PMID: 29509575 DOI: 10.1097/ruq.0000000000000346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Our purpose was to assess the endoscopic ultrasonography (EUS) features of serous cystic neoplasms (SCNs) of the pancreas in determining the surgical removal compared with computed tomography (CT) and magnetic resonance imaging (MRI) features. For 33 consecutive patients with 34 surgically confirmed SCNs over the past 11 years, preoperative EUS features were compared with those of CT and MRI (CT&MRI). Besides the lesion size and location, a retrospective analysis of the various imaging features was performed by 2 observers to understand the characteristics that determine the need for surgical intervention in terms of multiplicity of locules, calcification, mural thickening, mural nodules, ductal communication, and main pancreatic duct dilatation in addition to the gross morphologic type: microcystic, macrocystic (>1 cm), mixed, or solid. The most common gross morphologic type was mixed lesions, which consisted of microcystic and macrocystic components (15/34; 44%), followed by microcystic (38%), macrocystic (15%), and solid (3%) lesions. A minority (5/34; 18%) of the lesions showed main pancreatic duct dilatation (upstream, n = 3; downstream, n = 0; diffuse, n = 2). Mural nodules or solid components were more frequently noted in EUS (67%) than in CT&MRI (25%; P = 0.001), whereas other findings showed no remarkable difference between EUS and CT&MRI (P > 0.05). In determining the surgical treatment of multiloculated cystic lesions, interpretation of EUS features for the presence of solid component or mural nodules should be more carefully determined, especially in the patients with suggestive features of SCN on CT or MRI to avoid unnecessary surgery.
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Affiliation(s)
- Hyeonseung Hwang
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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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: 0.7] [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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Manfrin E, Perini C, Di Stefano S, Bernardoni L, Parisi A, Frulloni L, Sina S, Remo A, Gabbrielli A, Crinò SF. Pseudo solid-appearing pancreatic serous microcystic adenomas: Histologic diagnosis with the EUS core biopsy fork-tip needle. Endosc Ultrasound 2019; 8:334-341. [PMID: 30924447 PMCID: PMC6791108 DOI: 10.4103/eus.eus_11_19] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background and Objectives: Despite rarely, serous cystic adenoma (SCA) can assume a pseudo-solid aspect mimicking other pancreatic neoplasm as neuroendocrine tumor. EUS-FNA cytology has low diagnostic accuracy due to the scant cellularity of the collected samples. Histological diagnosis is usually made after resection. Recently, end-cutting needles for EUS-fine-needle biopsy (EUS-FNB), which obtain tissue cores by penetrating the lesions, have been developed. We aimed to assess the capability of EUS-FNB with SharkCore™ needles in the preoperative diagnosis of serous cystic adenoma pseudo-solid-appearing on imaging (Sa-SCA). Materials and Methods: Between January 2016 and January 2018, data from consecutive adult patients, who were referred for EUS-FNB of a solid pancreatic lesion and were diagnosed with having SCA, were retrieved from a single-center institutional database. Results: Two patients were excluded because of microcystic aspect at EUS. Histological diagnosis of SCA was made by EUS-FNB in the remaining 7 patients (5 females; mean age of 62.5 years). Lesions (mean size of 19.8 mm) were hypervascular on cross-sectional imaging, slightly hyperdense magnetic resonance imaging with T2-weighted images can, and negative at 68Ga-somatostatin receptor positron emission tomography and 18fluoro-deoxyglucose positron emission tomography. EUS-FNB samples were judged adequate for a definitive diagnosis in all cases, achieving specimens suitable for histological evaluation and several ancillary stains. Histochemical positivity for periodic acid-Schiff (PAS) and PAS with diastase digestion was observed in 7/7 cases. Immunohistochemical positivity for α-inhibin (7/7), GLUT1 (6/6), MUC6 (5/5), and negativity for synaptophysin (7/7) and chromogranin A (2/2) favored SCA diagnosis. Conclusions: In the case of preoperative workup suspected for Sa-SCA, a “forward acquiring” needle could improve the rate of preoperative histological diagnosis.
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Affiliation(s)
- Erminia Manfrin
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Claudia Perini
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Serena Di Stefano
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Laura Bernardoni
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Alice Parisi
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Luca Frulloni
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Sokol Sina
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Andrea Remo
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
| | - Armando Gabbrielli
- Unit of Digestive Endoscopy, The Pancreas Institute, University of Verona, Verona, Italy
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Tariq MU, Ahmad Z, Abdul-Ghafar J, Din NU. Serous cystadenoma of pancreas: A clinicopathologic experience of 23 cases from a major tertiary care center. Rare Tumors 2018; 10:2036361318809183. [PMID: 30542522 PMCID: PMC6236590 DOI: 10.1177/2036361318809183] [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: 07/15/2018] [Accepted: 10/04/2018] [Indexed: 12/25/2022] Open
Abstract
Background: Serous cystadenomas of pancreas are rare benign epithelial neoplasms, which
predominantly occur in the pancreatic body and tail of elderly females.
Majority of these tumors have microcystic appearance. Macrocystic and solid
variants have also been described. A number of more aggressive cystic
pancreatic lesions are included in the differential diagnosis. Distinction
from such lesions is important for optimal management. Objective: Our aim was to study the clinical and histological features of serous
cystadenomas which would be helpful in making their correct diagnosis and
understanding their behavior. Methods: We reviewed 23 cases of serous cystadenomas diagnosed in our institution
between January 2001 and June 2018. Results: Mean age at presentation was 53.43 years. Female to male ratio was 4.75:1.
Over half (56.5%) of the cases were diagnosed incidentally. Abdominal pain
was the most common symptom. Body and tail (either alone or in combination)
were the most common locations. Tumor size ranged from 2 to 16 cm. Central
scar was seen in 43.4% cases. Two cases were unilocular (macrocystic).
Microscopically, all cases showed simple cuboidal to flattened epithelium
with round, uniform nuclei, and glycogen-rich clear cytoplasm. Focal
micropapillae formation was seen in eight cases (34.7%). Surgical resection
was performed in 82.6% cases. Recurrence occurred in only one single
case. Conclusion: Pancreatic serous cystadenomas are benign neoplasms with excellent prognosis.
The tumors showed typical morphological features in all cases. Surgical
resection was performed in the majority of cases in our study owing to lack
of optimal and complete radiological workup pre-operatively and the concern
for not missing and adequately treating pancreatic mucinous cystic
neoplasms.
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Affiliation(s)
- Muhammad Usman Tariq
- Section of Histopathology, Department of
Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi,
Pakistan
- Muhammad Usman Tariq, Section of
Histopathology, Department of Pathology and Laboratory Medicine, Aga Khan
University Hospital, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan.
| | - Zubair Ahmad
- Section of Histopathology, Department of
Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi,
Pakistan
| | - Jamshid Abdul-Ghafar
- Department of Pathology and Clinical
Laboratory, French Medical Institute for Mothers and Children, Kabul,
Afghanistan
| | - Nasir Ud Din
- Section of Histopathology, Department of
Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi,
Pakistan
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Chen HY, Zhao J, Lu YF, Lv SY, Chen JY, Pan Y, Shi D, Xu XF, Yu RS. The "extracapsular cystic" sign in pancreatic serous cystic neoplasms: A clinicopathologic study of 177 patients with cystic pancreatic lesions. Eur J Radiol 2018; 106:167-172. [PMID: 30150040 DOI: 10.1016/j.ejrad.2018.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 07/30/2018] [Accepted: 08/02/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess a new imaging feature that we have named the extracapsular cystic sign which can make a constructive contribution towards differentiating serous cystic neoplasms (SCNs) from other pancreatic cystic lesions. MATERIAL AND METHODS We retrospectively reviewed 177 CTs/MRIs of patients who underwent pancreatic resection of cystic lesions at two institutions from January 2011/2013, to September 2017. For each patient, demographic information, clinical presentation, especially imaging features were carefully investigated by two experienced abdominal radiologists, retrospectively. All statistical analyses were performed using SPSS V.23.0. RESULTS Twenty-one lesions had extracapsular cystic signs which were newly discovered, 17 (28.3%) of 60 SCNs and 4 (3.4%) (mucinous cystic neoplasm = 1, walled-off necrosis = 2, retention cyst = 1) of 117 Non-SCNs were included, from which indicating that the extracapsular cystic sign was more often detected on SCNs. As for 21 lesions, 86% (n = 18) were females, and mean age at diagnosis was 51.2 years. 71% (n = 15) located in the pancreatic body and tail. Average size was 27.2 mm (23.7-53.4), mean (SD) ratio of biggest daughter cyst to mother cyst was 0.51[0.14] (p = 0.99), average (SD) angle between two of them was 105.5° [14.9] (p = 0.84). The average time interval between last imaging examination and surgery was 8.4 days. CONCLUSIONS The new sign named the extracapsular cystic sign in SCNs may help differentiate SCNs from other pancreatic cystic lesions. Furthermore, this study supports an original diagnosis for SCNs when the sign of extracapsular cyst appears.
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Affiliation(s)
- Hai-Yan Chen
- Department of Radiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jin Zhao
- Department of Radiology, Zhejiang Hospital, Hangzhou, China
| | - Yuan-Fei Lu
- Department of Radiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Sang-Ying Lv
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jie-Yu Chen
- Department of Radiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yao Pan
- Department of Radiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Dan Shi
- Department of Radiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiu-Fang Xu
- Department of Radiology, Hangzhou Medical College, Hangzhou, China.
| | - Ri-Sheng Yu
- Department of Radiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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Incidence and reasons of pancreatic resection in patients with asymptomatic serous cystadenoma. Pancreatology 2018; 18:577-584. [PMID: 29903633 DOI: 10.1016/j.pan.2018.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 05/23/2018] [Accepted: 06/07/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Despite diagnostic refinements, pancreatic resection (PR) is eventually performed in some patients with asymptomatic serous cystadenoma (A-SCA). The aim of this study was to define incidence and reasons of PR in A-SCA. METHODS A retrospective analysis of a prospectively maintained database was performed for all the patients referred for pancreatic cystic lesions (PCL) between January 2005 and March 2016. RESULTS Overall, there were 1488 patients with PCL, including 1271 (85.4%) with incidental PCL (I-PCL). During the study period referral of I-PCL increased 8.5-fold. Surgery was immediately advised in 94 I-PCL (7.3%) and became necessary later on in 11 additional patients (0.9%), because of the development of symptoms. Overall, PR was performed in 105/1271 patients presenting with I-PCL (8.2%), including 27 with A-SCA (2.1%). All patients with A-SCA underwent ultrasonography and contrast-enhanced computed tomography. Magnetic resonance imaging was performed in 21 patients (77.8%), 18 F-FDG positron emission tomography in 8 (29.6%), endoscopic ultrasonography (EUS) in 2 (7.4%), and EUS-guided fine needle aspiration (EUS-FNA) in 1 (3.7%). These studies demonstrated a combination of atypical features such as solid tumor (3; 11.1%), oligo-/macrocystic tumor (24; 88.8%), mural nodules (14; 51.8%), enhancing cyst walls (17; 62.9%), dilation of the main pancreatic duct (3; 11.1%), and upstream pancreatic atrophy (1; 3.7%). Additionally, 14/27 patients (51.8%) were females with oligo-/macrocystic tumors located in the body-tail of the pancreas. CONCLUSIONS Management of patients with A-SCA entails a small risk of PR especially when these tumors demonstrate atypical radiologic features associated with confounding anatomic and demographic characteristics.
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Basar O, Yuksel O, Yang DJ, Samarasena J, Forcione D, DiMaio CJ, Wagh MS, Chang K, Casey B, Fernandez-Del Castillo C, Pitman MB, Brugge WR. Feasibility and safety of microforceps biopsy in the diagnosis of pancreatic cysts. Gastrointest Endosc 2018; 88:79-86. [PMID: 29510146 DOI: 10.1016/j.gie.2018.02.039] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 02/20/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The tissue acquisition and diagnostic yield of cyst fluid cytology is low-to-moderate and rarely provides a specific diagnosis. The aim of this study was to compare the tissue acquisition and diagnostic tissue yield of microforceps biopsy (MFB) with cyst fluid cytology. METHODS In this multicenter study, data of 42 patients who had cysts both aspirated by EUS-guided FNA (EUS-FNA) and biopsy specimens were then obtained with an MFB device, were collected. Cytology analysis of cyst fluid and histologic analysis of biopsy specimens were done. Acquisition yield was defined as percentage of patients with tissue present in the aspirate or biopsy. Diagnostic tissue yield was evaluated at 3 levels: the ability of differentiation between mucinous and/or nonmucinous cysts, detection of high risk for malignancy, and specific cyst type diagnosis. RESULTS The mean patient age was 69 years. Sixteen pancreatic cysts (38.1%) were located in the head, 17 (40.5%) in the body, and 9 (21.4%) in the tail. The mean cyst size was 28.2 mm (12-60 mm); 25 of 42 (60%) were septated. The EUS-FNA tissue (fluid) acquisition yield was 88.1% (37/42). The MFB tissue acquisition yield was 90.4% (38/42). The diagnostic cytology yield to differentiate between mucinous and/or nonmucinous cysts was 47.6% (20/42), and the MFB histologic yield to differentiate between mucinous and/or nonmucinous cysts was 61.9% (26/42) (P = .188). The percentage of cysts at high risk for malignancy by cytology was 54.7% (23/42), and MFB was 71.5% (30/42) (P = .113). However, the ability of MFB to provide a specific cyst type diagnosis was 35.7% (15/42), and that for cytology was 4.8% (2/42) (P = .001). Surgical histology was concordant with that of MFB in 6 of 7 patients (85%), and with that of cytology in 1 of 7 patients (15%). CONCLUSION The cyst tissue acquisition yield for MFBs was 90%. Although cytology of cyst fluid and MFB were comparable in distinguishing mucinous and nonmucinous cysts and detecting cysts at high risk for malignancy, MFB was far superior to cytology for providing a specific cyst diagnosis.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Biopsy/instrumentation
- Biopsy/methods
- Carcinoembryonic Antigen/metabolism
- Carcinoma, Pancreatic Ductal/diagnosis
- Carcinoma, Pancreatic Ductal/metabolism
- Carcinoma, Pancreatic Ductal/pathology
- Cyst Fluid/cytology
- Cyst Fluid/metabolism
- Cystadenoma/diagnosis
- Cystadenoma/metabolism
- Cystadenoma/pathology
- Cystadenoma, Serous/diagnosis
- Cystadenoma, Serous/metabolism
- Cystadenoma, Serous/pathology
- Endoscopic Ultrasound-Guided Fine Needle Aspiration/methods
- Feasibility Studies
- Female
- Humans
- Male
- Middle Aged
- Neoplasms, Cystic, Mucinous, and Serous/diagnosis
- Neoplasms, Cystic, Mucinous, and Serous/metabolism
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neuroendocrine Tumors/diagnosis
- Neuroendocrine Tumors/metabolism
- Neuroendocrine Tumors/pathology
- Pancreatic Cyst/diagnosis
- Pancreatic Cyst/metabolism
- Pancreatic Cyst/pathology
- Pancreatic Neoplasms/diagnosis
- Pancreatic Neoplasms/metabolism
- Pancreatic Neoplasms/pathology
- Surgical Instruments
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Affiliation(s)
- Omer Basar
- Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Osman Yuksel
- Department of Gastroenterology, Eryaman Private Hospital, Ankara, Turkey
| | - Dennis J Yang
- Division of Gastroenterology, University of Florida Health, Gainesville, Florida
| | - Jason Samarasena
- Division of Gastroenterology and Hepatology, University of California, Aurora, California
| | - David Forcione
- Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Mihir S Wagh
- Division of Gastroenterology and Hepatology, University of Colorado, Denver, Colorado, USA
| | - Kenneth Chang
- Division of Gastroenterology and Hepatology, University of California, Aurora, California
| | - Brenna Casey
- Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William R Brugge
- Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
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Zhang ML, Arpin RN, Brugge WR, Forcione DG, Basar O, Pitman MB. Moray micro forceps biopsy improves the diagnosis of specific pancreatic cysts. Cancer Cytopathol 2018; 126:414-420. [PMID: 29660844 DOI: 10.1002/cncy.21988] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 02/23/2018] [Accepted: 02/23/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Making a specific diagnosis of pancreatic cysts preoperatively is difficult. The new disposable Moray micro forceps biopsy (MFB) device allows tissue sampling from the pancreatic cyst wall/septum and aims to improve diagnosis. This study compares the diagnostic performance of the MFB with the current conventional analysis of pancreatic cyst fluid (PCF). METHODS A total of 48 patients sampled with MFB were identified. Cysts were classified as mucinous on PCF based on extracellular mucin/mucinous epithelium, carcinoembryonic antigen (CEA) levels ≥192 ng/mL, or KRAS/GNAS mutation. A diagnosis of intraductal papillary mucinous neoplasm was supported by GNAS mutation; a diagnosis of serous cystadenoma was supported by Von Hippel-Lindau tumor suppressor (VHL) mutation. A diagnosis of mucinous cystic neoplasm required the presence of subepithelial ovarian-type stroma. A high-risk cyst was defined as a mucinous cyst with high-grade dysplasia or an adenocarcinoma. Comparisons in diagnostic performance between PCF and MFB were made. RESULTS The mean age of the patients was 69.6 years (range, 27-90 years); 25 of 48 patients (52.1%) were female. Cysts were in the pancreatic head (13 patients), neck (2 patients), body (20 patients), and tail (13 patients), averaging 3.1 cm (range, 1.2-6.0 cm). There was concordance with mucinous versus nonmucinous classification (60.4% for PCF vs 58.3% for MFB; P = .949). Three high-risk cysts were detected by PCF and 2 were detected by MFB (P = .670). However, MFB diagnosed significantly more specific cysts compared with PCF (50.0% for MFB vs 18.8% for PCF; P<.001). CONCLUSIONS PCF analysis and MFB have comparable performance in distinguishing between mucinous and nonmucinous cysts and for detecting high-risk cysts. However, MFB was found to be superior for diagnosing specific cyst subtypes, thus adding significant value to preoperative patient management. Cancer Cytopathol 2018;126:414-20. © 2018 American Cancer Society.
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Affiliation(s)
- M Lisa Zhang
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ronald N Arpin
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - William R Brugge
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - David G Forcione
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Omer Basar
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
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Okumura Y, Noda T, Eguchi H, Iwagami Y, Yamada D, Asaoka T, Kawamoto K, Gotoh K, Kobayashi S, Umeshita K, Hashimoto Y, Takeda Y, Tanemura M, Shigekawa M, Morii E, Takehara T, Mori M, Doki Y. Middle segment pancreatectomy for a solid serous cystadenoma diagnosed by MRCP and review of the literature: A case report. Mol Clin Oncol 2018; 8:675-682. [PMID: 29725534 PMCID: PMC5920357 DOI: 10.3892/mco.2018.1598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 03/20/2018] [Indexed: 01/02/2023] Open
Abstract
Solid serous cystadenoma of the pancreas is the rarest subtype of serous cystadenoma. Cystic structures are difficult to recognize by imaging studies. In the clinical setting, it is crucial to discriminate a solid serious cystadenoma from other solid pancreatic tumors. The present study reported a case of solid serous cystadenoma in which the magnetic resonance cholangiopancreatography (MRCP) findings were useful for diagnosis and decision-making regarding the surgical strategy, with a review of the previous reports of solid serous cystadenoma. A 50-year-old woman was referred to our hospital for investigation of a pancreatic body mass. A 2-cm hypervascular solid tumor was revealed by computed tomography. No typical radiological imaging findings of small cysts were detected, such as a honeycomb structure, and an adequate specimen could not be gained by biopsy under endoscopic ultrasonography. However, the tumor showed high intensity on MRCP, suggesting its cystic nature. A solid serous cystadenoma was suspected based on these radiological findings, and middle segment pancreatectomy was performed as a function-preserving surgery. The histological findings were compatible with a solid serous cystadenoma. In conclusion, MRCP imaging may be helpful for diagnosis and decision-making regarding the most appropriate surgical method for solid serous cystadenomas.
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Affiliation(s)
- Yuichiro Okumura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Takehiro Noda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Yoshifumi Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Daisaku Yamada
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Tadafumi Asaoka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Koichi Kawamoto
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Kunihito Gotoh
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Shogo Kobayashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Koji Umeshita
- Division of Health Science, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Yasuji Hashimoto
- Department of Surgery, Yao Municipal Hospital, Osaka 581-0069, Japan
| | - Yutaka Takeda
- Department of Surgery, Kansai Rosai Hospital, Hyogo 660-8511, Japan
| | | | - Minoru Shigekawa
- Departments of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Eiichi Morii
- Department of Pathology, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Tetsuo Takehara
- Departments of Gastroenterology and Hepatology, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka 565-0871, Japan
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32
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Abstract
The pancreas is a complex organ that may give rise to large number of neoplasms and non-neoplastic lesions. This article focuses on benign neoplasms, such as serous neoplasms, and tumorlike (pseudotumoral) lesions that may be mistaken for neoplasm not only by clinicians and radiologists, but also by pathologists. The family of pancreatic pseudotumors, by a loosely defined conception of that term, includes a variety of lesions including heterotopia, hamartoma, and lipomatous pseudohypertrophy. Autoimmune pancreatitis and paraduodenal ("groove") pancreatitis may also lead to pseudotumor formation. Knowledge of these entities will help in making an accurate diagnosis.
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Affiliation(s)
- Olca Basturk
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Gokce Askan
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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33
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Wright PK, Shelton DA, Holbrook MR, Thiryayi SA, Narine N, Slater D, Rana DN. Outcomes of endoscopic ultrasound-guided pancreatic FNAC diagnosis for solid and cystic lesions at Manchester Royal Infirmary based upon the Papanicolaou Society of Cytopathology pancreaticobiliary terminology classification scheme. Cytopathology 2017; 29:71-79. [DOI: 10.1111/cyt.12502] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 12/12/2022]
Affiliation(s)
- P. K. Wright
- Manchester Cytology Centre; Manchester Royal Infirmary; Manchester University NHS Foundation Trust; Manchester UK
| | - D. A. Shelton
- Manchester Cytology Centre; Manchester Royal Infirmary; Manchester University NHS Foundation Trust; Manchester UK
| | - M. R. Holbrook
- Manchester Cytology Centre; Manchester Royal Infirmary; Manchester University NHS Foundation Trust; Manchester UK
| | - S. A. Thiryayi
- Manchester Cytology Centre; Manchester Royal Infirmary; Manchester University NHS Foundation Trust; Manchester UK
| | - N. Narine
- Manchester Cytology Centre; Manchester Royal Infirmary; Manchester University NHS Foundation Trust; Manchester UK
| | - D. Slater
- Manchester Cytology Centre; Manchester Royal Infirmary; Manchester University NHS Foundation Trust; Manchester UK
| | - D. N. Rana
- Manchester Cytology Centre; Manchester Royal Infirmary; Manchester University NHS Foundation Trust; Manchester UK
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34
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Basar O, Brugge WR. My Treatment Approach: Pancreatic Cysts. Mayo Clin Proc 2017; 92:1519-1531. [PMID: 28890216 DOI: 10.1016/j.mayocp.2017.06.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/21/2017] [Accepted: 06/06/2017] [Indexed: 12/12/2022]
Abstract
Our treatment approach for either symptomatic or incidentally found pancreatic cysts continues to improve. The true incidence of pancreatic cysts is not known, and pancreatic cystic neoplasms, especially intraductal papillary mucinous neoplasms, are currently most commonly diagnosed and resected. This is a result of increasing awareness, widespread availability of imaging, and better understanding of the nature of pancreatic cysts as well. Recent studies on molecular analysis and devices such as microbiopsy forceps help us better define and select the treatment approach to alleviate symptoms and to prevent malignant tumors while avoiding unnecessary surgery.
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Affiliation(s)
- Omer Basar
- Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA.
| | - William R Brugge
- Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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35
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Le Pen C, Palazzo L, Napoléon B. A health economic evaluation of needle-based confocal laser endomicroscopy for the diagnosis of pancreatic cysts. Endosc Int Open 2017; 5:E987-E995. [PMID: 29159273 PMCID: PMC5633408 DOI: 10.1055/s-0043-117947] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/04/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND AND STUDY AIMS The low sensitivity of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), especially for the diagnosis of serous cystadenomas (SCAs), can be associated with diagnostic uncertainty that can regularly lead to unnecessary surgical procedures. Needle-based confocal laser endomicroscopy (nCLE) used with EUS-FNA improves diagnostic accuracy, helping to reduce unnecessary surgery and patient follow-up. This study was conducted to evaluate the economic benefit of EUS-FNA + nCLE. PATIENTS AND METHODS Probabilities used were derived from two studies representative of the two diagnostic strategies: a retrospective analysis of patients diagnosed by EUS-FNA alone and a prospective study of patients diagnosed by EUS-FNA + nCLE. Costs were based on French healthcare system rates; both private and public sector rates were included. A decision tree structure model used these probabilities and costs for two hypothetical cohorts of 1000 patients. RESULTS EUS-FNA + nCLE resulted in a reduction of 23 % in the total rate of surgical intervention, which translated to a reduction in clinical costs of 13 % (public sector) and 14 % (private sector). Additionally, the reduced rate of surgery would save the lives of 4 in 1000 patients. A stochastic sensitivity analysis using 100 simulations showed that in all cases the number of interventions was less for EUS-FNA + nCLE than for EUS-FNA. There was also a reduction in the incidence of false negatives using EUS-FNA + nCLE. CONCLUSIONS EUS-FNA + nCLE results in significant economic benefits by reducing the incidence of misdiagnosis through improved diagnostic accuracy.
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Affiliation(s)
- Claude Le Pen
- Université Paris-Dauphine, Paris, France,Corresponding author Claude Le Pen Laboratoire d’Économie et de Gestion des Organisations de Santé (LEGOS)Université Paris-DauphinePlace du Maréchal de Lattre de Tassigny75016 ParisFrance+33-1-44054949
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36
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Dietrich CF, Dong Y, Jenssen C, Ciaravino V, Hocke M, Wang WP, Burmester E, Moeller K, Atkinson NSS, Capelli P, D’Onofrio M. Serous pancreatic neoplasia, data and review. World J Gastroenterol 2017; 23:5567-5578. [PMID: 28852316 PMCID: PMC5558120 DOI: 10.3748/wjg.v23.i30.5567] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 06/08/2017] [Accepted: 07/22/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To describe the imaging features of serous neoplasms of the pancreas using ultrasound, endoscopic ultrasound, computed tomography and magnetic resonance imaging. METHODS This multicenter international collaboration enhances a literature review to date, reporting features of 287 histologically confirmed cases of serous pancreatic cystic neoplasms (SPNs). RESULTS Female predominance is seen with most SPNs presenting asymptomatically in the 5th through 7th decade. Mean lesion size was 38.7 mm, 98% were single, 44.2% cystic, 46% mixed cystic and solid, and 94% hypoechoic on B-mode ultrasound. Vascular patterns and contrast-enhancement profiles are described as hypervascular and hyperenhancing. CONCLUSION The described ultrasound features can aid differentiation of SPN from other neoplastic lesions under most circumstances.
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Tanaka M, Fernández-Del Castillo C, Kamisawa T, Jang JY, Levy P, Ohtsuka T, Salvia R, Shimizu Y, Tada M, Wolfgang CL. Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology 2017; 17:738-753. [PMID: 28735806 DOI: 10.1016/j.pan.2017.07.007] [Citation(s) in RCA: 1130] [Impact Index Per Article: 141.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 07/12/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023]
Abstract
The management of intraductal papillary mucinous neoplasm (IPMN) continues to evolve. In particular, the indications for resection of branch duct IPMN have changed from early resection to more deliberate observation as proposed by the international consensus guidelines of 2006 and 2012. Another guideline proposed by the American Gastroenterological Association in 2015 restricted indications for surgery more stringently and recommended physicians to stop surveillance if no significant change had occurred in a pancreatic cyst after five years of surveillance, or if a patient underwent resection and a non-malignant IPMN was found. Whether or not it is safe to do so, as well as the method and interval of surveillance, has generated substantial debate. Based on a consensus symposium held during the meeting of the International Association of Pancreatology in Sendai, Japan, in 2016, the working group has revised the guidelines regarding prediction of invasive carcinoma and high-grade dysplasia, surveillance, and postoperative follow-up of IPMN. As the working group did not recognize the need for major revisions of the guidelines, we made only minor revisions and added most recent articles where appropriate. The present guidelines include updated information and recommendations based on our current understanding, and highlight issues that remain controversial or where further research is required.
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Affiliation(s)
- Masao Tanaka
- Department of Surgery, Shimonoseki City Hospital, Shimonoseki, Japan.
| | | | - Terumi Kamisawa
- Department of Gastroenterology, Komagome Metropolitan Hospital, Tokyo, Japan
| | - Jin Young Jang
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Philippe Levy
- Pôle des Maladies de l'Appareil Digestif, Service de Gastroentérologie-Pancréatologie, Hopital Beaujon, Clichy Cedex, France
| | - Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Yasuhiro Shimizu
- Dept. of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Christopher L Wolfgang
- Cameron Division of Surgical Oncology and The Sol Goldman Pancreatic Cancer Research Center, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
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38
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Carr RA, Yip-Schneider MT, Dolejs S, Hancock BA, Wu H, Radovich M, Schmidt CM. Pancreatic Cyst Fluid Vascular Endothelial Growth Factor A and Carcinoembryonic Antigen: A Highly Accurate Test for the Diagnosis of Serous Cystic Neoplasm. J Am Coll Surg 2017; 225:93-100. [PMID: 28633941 PMCID: PMC6037560 DOI: 10.1016/j.jamcollsurg.2017.05.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 04/03/2017] [Accepted: 05/05/2017] [Indexed: 12/18/2022]
Abstract
Accurate differentiation of pancreatic cystic lesions is important for early detection and prevention of pancreatic cancer, as well as avoidance of unnecessary surgical intervention. Serous cystic neoplasms (SCNs) have no malignant potential, but can mimic the following premalignant mucinous cystic lesions: mucinous cystic neoplasm and intraductal papillary mucinous neoplasm (IPMN). We recently identified vascular endothelial growth factor (VEGF)-A as a novel pancreatic fluid biomarker for SCN. We hypothesize that combining cyst fluid CEA with VEGF-A will improve the diagnostic accuracy of VEGF-A. Pancreatic cyst/duct fluid was collected from consenting patients undergoing surgical cyst resection with corresponding pathologic diagnoses. Pancreatic fluid VEGF-A and CEA levels were detected by ELISA. One hundred and forty-nine patients with pancreatic cystic lesions met inclusion criteria. Pathologic diagnoses included pseudocyst (n = 14), SCN (n = 26), mucinous cystic neoplasm (n = 40), low-/moderate-grade IPMN (n = 34), high-grade IPMN (n = 20), invasive IPMN (n = 10), and solid pseudopapillary neoplasm (n = 5). Vascular endothelial growth factor A was significantly elevated in SCN cyst fluid compared with all other diagnoses (p < 0.001). With a threshold of >5,000 pg/mL, VEGF-A alone has 100% sensitivity and 83.7% specificity to distinguish SCNs from other cystic lesions. With a threshold of ≤10 ng/mL, CEA alone identifies SCN with 95.5% sensitivity and 81.5% specificity. Sensitivity and specificity of the VEGF-A/CEA combination are 95.5% and 100%, respectively. The c-statistic increased from 0.98 to 0.99 in the receiver operating characteristic analysis when CEA was added to VEGF-A alone. Although VEGF-A alone is a highly accurate test for SCN, the combination of VEGF-A with CEA approaches the gold standard for pathologic diagnosis, importantly avoiding false positives. Patients with a positive test indicating benign SCN can be spared a high-risk surgical pancreatic resection.
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Affiliation(s)
- Rosalie A. Carr
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
- Department of Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN
| | - Michele T. Yip-Schneider
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
- Department of Walther Oncology Center, Indianapolis, IN
- Department of Indiana University Cancer Center, Indianapolis, IN
- Department of Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN
| | - Scott Dolejs
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Bradley A. Hancock
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Huangbing Wu
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
- Department of Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN
| | - Milan Radovich
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
- Department of Walther Oncology Center, Indianapolis, IN
- Department of Indiana University Cancer Center, Indianapolis, IN
| | - C. Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
- Department of Biochemistry/Molecular Biology, Indiana University School of Medicine, Indianapolis, IN
- Department of Walther Oncology Center, Indianapolis, IN
- Department of Indiana University Cancer Center, Indianapolis, IN
- Department of Indiana University Health Pancreatic Cyst and Cancer Early Detection Center, Indianapolis, IN
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39
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Abstract
Pancreatic cytopathology, particularly through the use of endoscopic ultrasound-guided fine-needle aspiration (FNA), has excellent specificity and sensitivity for the diagnosis of pancreatic lesions. Such diagnoses can help guide preoperative management of patients, provide prognostic information, and confirm diagnoses in patients who are not surgical candidates. Furthermore, FNA can be used to obtain cyst fluid for ancillary tests that can improve the diagnosis of cystic lesions. In this article, we describe the cytomorphological features and differential diagnoses of the most commonly encountered pancreatic lesions on FNA.
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Affiliation(s)
- Jennifer A Collins
- Department of Pathology, The Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Syed Z Ali
- Department of Pathology, The Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Christopher J VandenBussche
- Department of Pathology, The Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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Wangermez M. Endoscopic ultrasound of pancreatic tumors. Diagn Interv Imaging 2016; 97:1287-1295. [PMID: 27866871 DOI: 10.1016/j.diii.2016.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 10/20/2016] [Indexed: 12/18/2022]
Abstract
Computed tomography (CT) and endoscopic ultrasound (EUS) are the two most effective techniques for the assessment of pancreatic cancers. CT has revolutionized the field of tumor imaging in pancreatic cancer and is now a well-established imaging technique for diagnosis and staging. However, EUS still plays an important role in several situations, especially when the diagnosis is uncertain or when histopathological confirmation of the lesion is needed. Similarly, regarding cystic lesions, magnetic resonance imaging and CT have very good performances but are often inadequate because the diagnosis can be difficult to establish, while the consequences for the patient are major. New biopsy needles, the use of elastography and ultrasonographic contrast agents, and confocal laser endomicroscopy can also provide additional and essential information to improve diagnosis confidence of pancreatic lesions with EUS.
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Affiliation(s)
- M Wangermez
- Digestive Endoscopy, Department of Hepato-Gastroenterology, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France.
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Pitman MB. Cancer Cytopathology: 20 years of advancing the field of pancreaticobiliary cytopathology. Cancer Cytopathol 2016; 124:690-694. [PMID: 27740727 DOI: 10.1002/cncy.21773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 08/16/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Martha Bishop Pitman
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Shirley LA, Walker J, Krishna S, El-Dika S, Muscarella P, Ellison EC, Schmidt CR, Bloomston M. Routine Cyst Fluid Cytology Is Not Indicated in the Evaluation of Pancreatic Cystic Lesions. J Gastrointest Surg 2016; 20:1581-1585. [PMID: 27230996 DOI: 10.1007/s11605-016-3175-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 05/18/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND The work-up of cystic lesions of the pancreas often involves endoscopic ultrasound (EUS) with fine needle aspiration (FNA). In addition to CEA and amylase measurement, fluid is routinely sent for cytologic examination. We evaluated the utility of cytologic findings in clinical decision-making. MATERIALS AND METHODS Records of patients who underwent EUS-guided pancreatic cyst aspiration were reviewed. Findings from axial imaging and EUS were compared to cyst fluid cytology as well as fluid amylase and CEA. All results were then compared to final diagnosis, determined by clinical analysis for those patients not resected, and surgical pathology report for those who underwent resection. RESULTS A total of 167 patients were reviewed. Of 48 patients with suspicious findings on imaging, cytology yielded diagnostic information in 89.6 % of cases (43 patients). However, in the 119 patients where no suspicious components were revealed on imaging, fluid cytology yielded no significant diagnostic results in any case. In all cases where mucin was noted on cytologic review, thick fluid was also seen at the time of aspiration. DISCUSSION In our cohort of patients with cystic pancreatic lesions, cytologic analysis of pancreatic cyst fluid yielded no diagnostic benefit over radiologic findings alone. In such cases where fluid is to be aspirated, specimens that would otherwise be sent for cytologic evaluation would be better served for other purposes, such as molecular analysis or banking for future research.
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Affiliation(s)
- Lawrence A Shirley
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 410 W. 10th Ave, N924 Doan Hall, Columbus, OH, 43210, USA.
| | - Jon Walker
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Somashekar Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Samer El-Dika
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Peter Muscarella
- Department of Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - E Christopher Ellison
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Carl R Schmidt
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, 410 W. 10th Ave, N924 Doan Hall, Columbus, OH, 43210, USA
| | - Mark Bloomston
- Division of Surgical Oncology, 21st Century Oncology, Ft. Myers, FL, USA
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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: 11] [Impact Index Per Article: 1.2] [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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Abstract
The incidence of pancreatic cystic neoplasms is rising, in part from detection through the increasing use of high-resolution cross-sectional imaging techniques. Initial diagnosis is generally based on imaging characteristics identified on computed tomography and/or MRI. Endoscopic ultrasound provides further imaging characterization and also enables fluid aspiration and analysis to additionally aid differentiation. The general approach to these lesions includes surgical intervention and/or surveillance imaging. Taking into account diverse presentations, varying malignant potential, and the uncertain natural history of some of these lesions, an evidence-based approach is limited. This article discusses recent updates in the diagnosis and management of cystic neoplasms of the pancreas.
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Affiliation(s)
| | - Koenraad J Mortele
- Division of Abdominal Imaging, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Martin AK, Zhou Z. Endoscopic ultrasound-guided fine-needle aspiration for the diagnosis of pancreatic cysts by combined cytopathology and cystic content analysis. World J Gastrointest Endosc 2015; 7:1157-1169. [PMID: 26504505 PMCID: PMC4613805 DOI: 10.4253/wjge.v7.i15.1157] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 08/03/2015] [Accepted: 09/08/2015] [Indexed: 02/05/2023] Open
Abstract
Recent advances in imaging technology have resulted in an increase in incidental discoveries of pancreatic cystic lesions. Pancreatic cysts comprise a wide variety of lesions and include non-neoplastic cysts and neoplastic cysts. Because some pancreatic cysts have more of a malignant potential than others, it is absolutely essential that an accurate diagnosis is rendered so that effective care can be given to each patient. In many centers, endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) has emerged as the modality of choice that enables one to distinguish between mucinous and non-mucinous lesion, diagnose malignancy and collect cyst fluid for further diagnostic studies, such as pancreatic enzyme levels, molecular analysis and other tumor biomarkers. The current review will focus on EUS-guided FNA and the cytological diagnosis for pancreatic cysts.
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In vivo characterization of pancreatic cystic lesions by needle-based confocal laser endomicroscopy (nCLE): proposition of a comprehensive nCLE classification confirmed by an external retrospective evaluation. Surg Endosc 2015; 30:2603-12. [PMID: 26428198 DOI: 10.1007/s00464-015-4510-5] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 08/05/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS The differential diagnosis of solitary pancreatic cystic lesions is sometimes difficult. Needle-based confocal laser endomicroscopy (nCLE) performed during endoscopic ultrasound-fine-needle aspiration (EUS-FNA) enables real-time imaging of the internal structure of such cysts. Criteria have already been described for serous cystadenoma and intraductal papillary mucinous neoplasm (IPMN). The aims of the study were to determine new nCLE criteria for the diagnosis of pancreatic cystic lesions, to propose a comprehensive nCLE classification for the characterization of those lesions, and to carry out a first external retrospective validation . METHODS Thirty-three patients with a lone pancreatic cystic lesion were included (CONTACT 1 study). EUS-FNA was combined with nCLE. Diagnosis was based on either pathology result (Group 1, n = 20) or an adjudication committee consensus (Group 2, n = 13). Six investigators, unblinded, studied cases from Group 1 and identified nCLE criteria for mucinous cystic neoplasm (MCN), pseudocyst (PC), and cystic neuroendocrine neoplasm (NEN). Four external reviewers assessed, blinded, the yield and interobserver agreement for the newly identified (MCN, PC) and previously described (IPMN, SC) criteria in a subset of 31 cases. RESULTS New nCLE criteria were described for MCN (thick gray line), PC (field of bright particles), and cystic NEN (black neoplastic cells clusters with white fibrous areas). These criteria correlated with the histological features of the corresponding lesions. In the retrospective validation, a conclusive nCLE result was obtained for 74 % of the cases (87 % "true" and 13 % "false" with respect to the final diagnosis). On this limited case series, the nCLE criteria showed a trend for high diagnostic specificity (>90 % for mucinous cysts, 100 % for non-mucinous cysts). CONCLUSIONS Based on this newly completed atlas of interpretation criteria, nCLE could facilitate the diagnosis of pancreatic cystic lesion types.
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O'Connor K, Cheriyan DG, Li-Chang HH, Kalloger SE, Garrett J, Byrne MF, Weiss AA, Donnellan F, Schaeffer DF. Gastrointestinal Endoscopic Ultrasound-Guided Fine-Needle Aspiration Biopsy Specimens: Adequate Diagnostic Yield and Accuracy Can Be Achieved without On-Site Evaluation. Acta Cytol 2015; 59:305-10. [PMID: 26339900 DOI: 10.1159/000439398] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 08/04/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) is the preferred method for biopsying the gastrointestinal tract, and rapid on-site cytological evaluation is considered standard practice. Our institution does not perform on-site evaluation; this study analyzes our overall diagnostic yield, accuracy, and incidence of nondiagnostic cases to determine the validity of this strategy. DESIGN Data encompassing clinical information, procedural records, and cytological assessment were analyzed for gastrointestinal EUS-FNA procedures (n = 85) performed at Vancouver General Hospital from January 2012 to January 2013. We compared our results with those of studies that had on-site evaluation and studies that did not have on-site evaluation. RESULTS Eighty-five biopsies were performed in 78 patients, from sites that included the pancreas, the stomach, the duodenum, lymph nodes, and retroperitoneal masses. Malignancies were diagnosed in 45 (53%) biopsies, while 24 (29%) encompassed benign entities. Suspicious and atypical results were recorded in 8 (9%) and 6 (7%) cases, respectively. Only 2 (2%) cases received a cytological diagnosis of 'nondiagnostic'. Our overall accuracy was 72%, our diagnostic yield was 98%, and our nondiagnostic rate was 2%. Our results did not significantly differ from those of studies that did have on-site evaluation. CONCLUSION Our study highlights that adequate diagnostic accuracy can be achieved without on-site evaluation.
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Affiliation(s)
- Kate O'Connor
- Division of Anatomic Pathology, Vancouver General Hospital, Vancouver, B.C., Canada
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Hypervascular solid-appearing serous cystic neoplasms of the pancreas: Differential diagnosis with neuroendocrine tumours. Eur Radiol 2015; 26:1348-58. [DOI: 10.1007/s00330-015-3961-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 07/14/2015] [Accepted: 08/03/2015] [Indexed: 12/11/2022]
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Brugge WR. Diagnosis and management of cystic lesions of the pancreas. J Gastrointest Oncol 2015; 6:375-88. [PMID: 26261724 DOI: 10.3978/j.issn.2078-6891.2015.057] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 04/23/2015] [Indexed: 12/13/2022] Open
Abstract
Pancreatic cystic lesions (PCLs) are being increasingly identified in recent years. They show a wide spectrum of imaging and clinical features. The diagnosis and discrimination of these lesions are very important because of the risk for concurrent or later development of malignancy. PCLs are usually first diagnosed and characterized by conventional imaging modalities such as trans-abdominal ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI). However, their ability to differentiate the benign and malignant lesions remains limited. Endoscopic US may be more helpful for the diagnosis and differentiation of PCLs because of its high resolution and better imaging characteristics than cross-sectional imaging modalities. It also allows for fine-needle aspiration (FNA) of cystic lesions for biochemical, cytological and DNA analysis that might be further helpful for diagnosis and differentiation. The management options of PCLs are to observe, endoscopic treatment or surgical resection. However, the decision for management is sometimes hampered by limitations in current diagnostic and tissue sampling techniques. As further diagnostic and non-invasive management options become available, clinical decision-making will become much easier for these lesions.
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Wu RI, Sluss PM, Mino-Kenudson M, Brugge WR, Pitman MB. Analysis of VEGF/PlGF heterodimer level in pancreatic cyst fluid as a biomarker for serous cystadenoma. J Am Soc Cytopathol 2015; 4:79-83. [PMID: 31051713 DOI: 10.1016/j.jasc.2014.09.205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/05/2014] [Accepted: 09/05/2014] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Pancreatic cyst fluid (PCF) analysis provides valuable information in the preoperative evaluation of pancreatic cysts. Vascular endothelial growth factors (VEGF) and other proangiogenesis factors such a placental growth factor (PlGF) are promising biomarkers for identifying serous cystadenoma (SCA). VEGF-A has recently been reported as a SCA marker. We sought to assess the value of the VEGF-A/PlGF heterodimer as a potential biomarker of SCA in PCF. MATERIALS AND METHODS PCF was analyzed for VEGF/PlGF and 7 additional proangiogenic markers including VEGF-A, VEGF-C, VEGF-D, TEK tyrosine kinase, endothelial (TIE-2), soluble fms-like tyrosine kinase-1 (sFlt-1), PlGF, and basic fibroblast growth factor (bFGF). True-positive or false-negative results were determined by histological confirmation of SCA and false-positive or true-negative results with confirmation of a non-SCA cyst by either cytology or histology, elevated carcinoembryonic antigen ≥192 ng/mL, elevated amylase ≥5000 U/L, or detected KRAS/GNAS mutations. RESULTS Forty-eight PCFs were analyzed; 1 was technically inadequate. Of the remaining 47, 3 (6%) contained measurable (>60 pg/mL) concentrations of VEGF/PlGF heterodimer: 1 pseudocyst, 1 cystic adenocarcinoma, and 1 SCA. Of 6 histologically confirmed SCAs, there was only 1 (17%) true positive. Six PCFs were not classifiable due to insufficient data, leaving 41 PCFs for performance calculations (33 true negative, 5 false negative, 1 true positive, and 2 false positive) yielding a sensitivity of 17% and specificity of 94%. CONCLUSIONS VEGF/PlGF heterodimer is present in low concentrations in PCF and is an insensitive biomarker for SCA. Additional study is required to determine clinical utility of heterodimeric VEGF/PlGF in combination with other proangiogenic markers.
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Affiliation(s)
- Roseann I Wu
- Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Warren 219, Boston, Massachusetts
| | - Patrick M Sluss
- Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Warren 219, Boston, Massachusetts
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Warren 219, Boston, Massachusetts
| | - William R Brugge
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Warren 219, Boston, Massachusetts.
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