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Desolneux G, Castanet F. [Precancerous lesions of the pancreas, prophylactic surgery]. Bull Cancer 2025; 112:263-269. [PMID: 40049795 DOI: 10.1016/j.bulcan.2024.06.003] [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: 05/20/2024] [Revised: 05/28/2024] [Accepted: 06/04/2024] [Indexed: 03/15/2025]
Abstract
Pancreatic cancer is a serious pathology whose incidence is increasing. Advances in imaging have made it possible to fortuitously highlight more and more cystic pancreatic lesions, some of which have a malignant potential, leading to the consideration of prophylactic excision. The various known precancerous lesions of the pancreas as well as current management recommendations are here reviewed.
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Affiliation(s)
- Gregoire Desolneux
- Chirurgie digestive oncologique, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France.
| | - Fanny Castanet
- Chirurgie digestive oncologique, institut Bergonié, 229, cours de l'Argonne, 33076 Bordeaux cedex, France
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2
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De Stefano F, Pellegrini R, Marchegiani G, Crippa S. Reducing the burden of pancreatic cancer by surveilling mucinous cystic neoplasms: are we there yet? Best Pract Res Clin Gastroenterol 2025; 74:101998. [PMID: 40210333 DOI: 10.1016/j.bpg.2025.101998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2024] [Revised: 02/27/2025] [Accepted: 03/10/2025] [Indexed: 04/12/2025]
Abstract
Pancreatic cystic neoplasms are a common condition, with intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs) being of particular concern due to their potential for malignant transformation. Resection of these lesions before progression to invasive cancer represents a crucial opportunity to reduce the burden of pancreatic cancer. However, the benefit of early-resection must be weighed against the risk of overtreatment. Applying current guidelines, nearly half of the patients who undergo resection for IPMN might not have required surgery, while malignancy is detected in only 16 % of resected MCNs. This raises concerns, particularly given the increasing detection of small cysts with the widespread use of radiological imaging and the significant postoperative risks, including exocrine and endocrine insufficiency. Emerging evidence suggests that surveillance strategies could be more broadly applied, reducing unnecessary surgeries. This review aims to reassess the current evidence regarding both surgical resection and surveillance of IPMNs and MCNs.
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Affiliation(s)
- Federico De Stefano
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Riccardo Pellegrini
- Department of Surgical Oncological and Gastroenterological Sciences, Padua University Hospital, Padua, Italy
| | - Giovanni Marchegiani
- Department of Surgical Oncological and Gastroenterological Sciences, Padua University Hospital, Padua, Italy.
| | - Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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3
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Kim H, Kim JH, An J, Choi JS. Comparison with surgically resected mucinous cystic neoplasm of pancreas and branch-duct type intraductal papillary mucinous neoplasm considering clinico-radiological high-risk features: a reassessment of current guidelines. Abdom Radiol (NY) 2024; 49:2746-2755. [PMID: 38744705 DOI: 10.1007/s00261-024-04364-y] [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: 03/17/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024]
Abstract
PURPOSE To perform a comparative analysis of surgically resected mucinous cystic neoplasm (MCN) of pancreas and branch-duct type intraductal papillary mucinous neoplasms (BD-IPMN) considering clinico-radiological high-risk predictors for malignant tumors using the current management guidelines. MATERIALS AND METHODS 224 patients who underwent surgical resection and had histopathologically confirmed MCNs (benign 73; malignant 17) or BD-IPMNs (benign 110; malignant 24) and had pre-operative CT or MRI were retrospectively reviewed. Tumors classified as either high-grade dysplasia or invasive carcinoma were considered malignant, whereas those with low-grade dysplasia were considered benign. Imaging features were analyzed by two radiologists based on selected high-risk stigmata or worrisome features proposed by prevalent guidelines except tumors with main pancreatic duct dilatation (> 5 mm) were excluded. RESULTS MCNs and BD-IPMNs showed significant differences in aspects like tumor size, location, the presence and size of enhancing mural nodules, the presence of wall or septal thickening, and multiplicity. Multivariate analyses revealed tumor size (OR, 1.336; 95% CI, 1.124-1.660, p = 0.002) and the presence of enhancing mural nodules (OR, 67.383; 95% CI, 4.490-1011.299, p = 0.002) as significant predictors of malignant MCNs. The optimal tumor size differentiating benign from malignant tumor was 8.95 cm, with a 70.6% sensitivity, 89% specificity, PPV of 27.6%, and NPV of 96.9%, demonstrating superior specificity than the guideline-suggested threshold of 4.0 cm. For malignant BD-IPMNs, the presence of enhancing mural nodules (OR, 15.804; 95% CI, 4.439-56.274, p < 0.001) and CA 19 - 9 elevation (OR, 19.089; 95%CI, 2.868-127.068, p = 0.002) as malignant predictors, with a size of enhancing mural nodule threshold of 5.5 mm providing the best malignancy differentiation. CONCLUSION While current guidelines may be appropriate for managing BD-IPMNs, our results showed a notably larger optimal threshold size for malignant MCNs than that suggested by current guidelines. This warrants reconsidering existing guideline thresholds for initial risk stratification and management of MCNs.
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Affiliation(s)
- HeeSoo Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jung Hoon Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Department of Radiology, Seoul National University College of Medicine, 28, Yongon-dong, Chongno-gu, Seoul, 110-744, Republic of Korea.
| | - Jihae An
- Department of Radiology, Sun Medical Center, 93, Bugyuseong-daero, Yuseong-gu, Daejeon, South Korea
| | - Jin Sol Choi
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
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4
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Hozaka Y, Ohtsuka T, Nakamura M, Hijioka S, Unno M, Shimizu Y, Tanabe M, Nagakawa Y, Hatano E, Kawai M, Sano T, Koshita S, Katanuma A, Kita E, Hanada K, Nakai Y, Aoki T, Serikawa M, Okamoto K, Takeyama Y. Feasibility of Surveillance for Mucinous Cystic Neoplasm of the Pancreas: A Multi-Institutional Retrospective Study of 328 Patients by the Japanese Pancreatic Society. Pancreas 2023; 52:e288-e292. [PMID: 37922344 DOI: 10.1097/mpa.0000000000002254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2023]
Abstract
OBJECTIVE We aimed to elucidate the feasibility of surveillance of patients with mucinous cystic neoplasm (MCN). METHODS We performed a retrospective, multi-institutional study of 328 patients who underwent surgery for MCN at 18 Japanese institutions. Patients with MCN were divided into an immediate surgery group and a surveillance group, which underwent surgery after surveillance. RESULTS The median surveillance period until surgery in the surveillance group was 27 months (range, 7-165 months). Compared with the immediate surgery group, the surveillance group showed smaller tumor diameter (46 vs 50 mm, P = 0.01), more frequent laparoscopic approach (58% vs 37%, P < 0.01), and less frequent malignancy (7% vs 15%, P = 0.03). The new appearance of mural nodules and elevation of serum tumor markers were associated with malignancy in the surveillance group. Two patients in the surveillance group experienced postoperative recurrence, although there was no significant difference in recurrence or disease-free survival between the two groups. In the surveillance group, the 1-, 5-, and 10-year cumulative incidence rates of malignant MCN were 0.8%, 5.6%, and 36.5%, respectively. CONCLUSION As the risk of progression to malignant MCNs increases over the long term, MCNs should be resected rather than subjected to unnecessary surveillance.
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Affiliation(s)
- Yuto Hozaka
- From the Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Takao Ohtsuka
- From the Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Aichi, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Etsuro Hatano
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Manabu Kawai
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - Tsuyoshi Sano
- Division of Gastroenterological Surgery, Department of Surgery, Aichi Medical University, Aichi, Japan
| | - Shinsuke Koshita
- Department of Gastroenterology, Sendai City Medical Center, Miyagi, Japan
| | - Akio Katanuma
- Center for Gastroenterology, Teine Keijinkai Hospital, Hokkaido, Japan
| | - Emiri Kita
- Department of Gastroenterology, Chiba Cancer Center, Chiba, Japan
| | - Keiji Hanada
- Department of Gastroenterology, Onomichi General Hospital, Onomichi, Japan
| | | | - Takeshi Aoki
- Department of Gastroenterological and General Surgery, School of Medicine, Showa University, Tokyo, Japan
| | - Masahiro Serikawa
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kojun Okamoto
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kinki University Faculty of Medicine, Osaka, Japan
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5
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Oyama K, Iwagami Y, Kobayashi S, Sasaki K, Yamada D, Tomimaru Y, Akita H, Noda T, Asaoka T, Nakahira S, Gotoh K, Takahashi H, Tanemura M, Doki Y, Eguchi H. A Ruptured Mucinous Cystadenocarcinoma of the Pancreas Extensively Evaluated Before and After the Rupture: A Case Report. Pancreas 2023; 52:e163-e167. [PMID: 37523608 DOI: 10.1097/mpa.0000000000002198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
ABSTRACT Pancreatic mucinous cystic neoplasm (MCN) rarely ruptures because of their surrounding fibrotic capsules and has never been reported with detailed information regarding prerupture and postrupture states. We report a case of MCN rupture where performed emergency surgery was performed while waiting for elective surgery. A 54-year-old woman was referred to our department for a pancreatic cystic tumor with slight abdominal pain. A cystic tumor with a nodular lesion was found, with a contrast effect measuring 78 mm in diameter. On day 21, the patient visited our hospital complaining of increased abdominal pain, but few signs of peritonitis were observed. Tests conducted revealed moderate ascites, marginal shrinkage of the cyst diameter, and a slight elevation of inflammatory markers. We suspected an MCN rupture and immediately performed distal pancreatectomy. Brown turbid ascites and rupture of the anterior wall of the cyst were observed. In the ascites, amylase levels were not elevated, and bacterial cultures were negative. The histopathological diagnosis was noninvasive mucinous cystadenocarcinoma. At 9 months after surgery, she started chemotherapy because of a recurrence of the peritoneal dissemination. This case provided valuable insight into the rupture of MCNs using thorough imaging techniques, laboratory, and physical findings before and after rupturing.
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Affiliation(s)
- Keisuke Oyama
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University
| | - Yoshifumi Iwagami
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University
| | - Shogo Kobayashi
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University
| | - Kazuki Sasaki
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University
| | - Daisaku Yamada
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University
| | - Yoshito Tomimaru
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University
| | - Hirofumi Akita
- Department of Gastroenterological Surgery, Osaka International Cancer Institute
| | - Takehiro Noda
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University
| | | | - Shin Nakahira
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University
| | - Kunihito Gotoh
- Department of Gastroenterological Surgery, National Hospital Organization Osaka National Hospital
| | - Hidenori Takahashi
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University
| | | | - Yuichiro Doki
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University
| | - Hidetoshi Eguchi
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University
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6
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Ramia JM, del Rio Martín J, Blanco-Fernández G, Cantalejo-Diaz M, Pardo F, Muñoz-Forner E, Carabias A, Manuel-Vazquez A, Hernández-Rivera PJ, Jaén-Torrejimeno I, Kälviäinen-Mejia HK, Rotellar-Sastre F, Garcés-Albir M, Latorre R, Longoria-Dubocq T, De Armas-Conde N, Serrablo-Requejo A, Esteban Gordillo S, Sabater L, Serradilla-Martín M. Pancreatic mucinous cystic neoplasms located in the distal pancreas: a multicenter study. Gland Surg 2022; 11:795-804. [PMID: 35694091 PMCID: PMC9177270 DOI: 10.21037/gs-21-703] [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: 10/17/2021] [Accepted: 03/29/2022] [Indexed: 01/11/2025]
Abstract
BACKGROUND Mucinous cysts of the pancreas (MCN) are infrequent, usually unilocular tumors which occur in postmenopausal women and are located in the pancreatic body/tail. The risk of malignancy is low. The objective is to define preoperative risk factors of malignancy in pancreatic MCN and to assess the feasibility of the laparoscopic approach. METHODS Retrospective multicenter observational study of prospectively recorded data regarding distal pancreatectomies was carried out at seven hepatopancreatobiliary (HPB) Units between 01/01/08 and 31/12/18 (the ERPANDIS Project). RESULTS Four hundred and forty-four distal pancreatectomies were recorded including 47 MCN (10.6%). Thirty-five were non-invasive tumors (74.5%). In all, 93% of patients were female, and 60% were ASA (American Society of Anaesthesiology) II. The mean preoperative size was 46 mm. Patients with invasive tumors were older (54 vs. 63 years). Invasive tumors were larger (6 vs. 4 cm), although the difference was not significant (P=0.287). Sixty percent was operated via laparoscopic approach, which was used in 74.6% of non-invasive tumors and in 16.7% of the invasive ones. The spleen was not preserved in 93.6% of the patients. R0 resection was obtained in all patients. Two patients with invasive tumors died. CONCLUSIONS In our surgical series of MCN, patients with malignancy were older and presented larger tumors, although the difference was not statistically significant. Laparoscopy is a safe and feasible approach for MCN. Prospective studies are now needed to define risk factors that can guide the decision whether to administer conservative treatment or to operate.
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Affiliation(s)
- Jose M. Ramia
- Department of Surgery, Hospital General Universitario de Alicante, ISABIAL: Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain
- Universidad Miguel Hernandez Alicante, Alicante, Spain
| | | | | | | | - Fernando Pardo
- Department of Surgery, Clínica Universitaria de Navarra, Pamplona, Spain
| | - Elena Muñoz-Forner
- Department of Surgery, Hospital Clínico, University of Valencia, Biomedical Research Institute, Valencia, Spain
| | | | - Alba Manuel-Vazquez
- Hospital Universitario de Getafe, Getafe, Spain
- Hospital Universitario de Guadalajara, Guadalajara, Spain
| | | | | | | | | | - Marina Garcés-Albir
- Department of Surgery, Hospital Clínico, University of Valencia, Biomedical Research Institute, Valencia, Spain
| | - Raquel Latorre
- Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Texell Longoria-Dubocq
- Department of Surgery, University of Puerto Rico School of Medicine, San Juan, Puerto Rico, USA
| | | | | | | | - Luis Sabater
- Department of Surgery, Hospital Clínico, University of Valencia, Biomedical Research Institute, Valencia, Spain
| | - Mario Serradilla-Martín
- Department of Surgery, Instituto de Investigación Sanitaria Aragón, Hospital Universitario Miguel Servet, Zaragoza, Spain
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7
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Marchegiani G, Andrianello S, Crippa S, Pollini T, Belfiori G, Gozzini L, Cassalia F, Caravati A, Luchini C, Doglioni C, Bassi C, Falconi M, Salvia R. Actual malignancy risk of either operated or non-operated presumed mucinous cystic neoplasms of the pancreas under surveillance. Br J Surg 2021; 108:1097-1104. [PMID: 34059873 DOI: 10.1093/bjs/znab131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 03/25/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite the low malignant potential of pancreatic mucinous cystic neoplasms (MCNs), surgery is still performed. The aim of this pragmatic study was to assess the outcome of surgery and surveillance for patients presenting with a presumed MCN at the first evaluation. METHODS Data for patients with a presumed MCN observed from 2000 to 2016 at the Verona Pancreas Institute and San Raffaele Hospital were extracted from prospective databases. The endpoints were risk of malignancy at pathology and rate of misdiagnosis for the surgical series, expressed as an odds ratio (OR) with 95 per cent confidence interval, and disease-specific survival (DSS) for the surveillance cohort investigated by the Kaplan-Meier method. RESULTS A total of 424 patients were identified. In the surgical series (229 patients), the rate of misdiagnosis was 19.2 per cent. The rate of malignant MCNs was 10.9 per cent (25 patients). The overall rate of malignancy, including misdiagnoses, was 11.3 per cent (26 patients). Predictors of malignancy were mural nodules (OR 27.75, 95 per cent c.i. 4.44-173.61; P < 0.001), size at least 50 mm (OR 13.39, 2.01 to 89.47; P = 0.007), and carbohydrate antigen 19.9 level (OR 3.98, 1.19 to 13.30; P = 0.025). In the absence of mural nodules and enhancing walls, none of the resected presumed MCNs smaller than 50 mm were malignant. Only patients with high-risk stigmata undergoing surgery experienced a significantly reduced 5-year DSS compared with all other patients (88 versus 100 per cent; P = 0.031). CONCLUSION Presumed MCNs with mural nodules, enhancing walls or cysts of 50 mm or larger should be considered for upfront surgical resection owing to the high risk of malignancy. In the absence of these features, the incidence of malignancy is negligible, favouring surveillance in selected patients given the low risk of malignancy and the high rate of misdiagnosis. LAY SUMMARY Malignant degeneration of presumed pancreatic mucinous cystic neoplasms takes several years, if it occurs at all. Mural nodules, enhancing walls or cysts of 50 mm or larger call for surgical resection owing to an increased risk of malignancy; otherwise, surveillance seems a good option.
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Affiliation(s)
- G Marchegiani
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - S Andrianello
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - S Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy
| | - T Pollini
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - G Belfiori
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy
| | - L Gozzini
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy
| | - F Cassalia
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - A Caravati
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - C Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona Hospital Trust, Verona, Italy
| | - C Doglioni
- Department of Pathology, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy
| | - C Bassi
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - M Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy
| | - R Salvia
- General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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8
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Vullierme MP, Gregory J, Rebours V, Cros J, Abelhady-Attia Y, Vilgrain V, Aguilera-Munoz L, Laurent L, Levy P, Sauvanet A, Ronot M. MRI is useful to suggest and exclude malignancy in mucinous cystic neoplasms of the pancreas. Eur Radiol 2021; 32:1297-1307. [PMID: 34374801 DOI: 10.1007/s00330-021-08091-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/21/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To evaluate the value of MRI in differentiating benign (b-MCN) and malignant (m-MCN) MCN. European guidelines suggest that certain mucinous cystic neoplasms (MCN) of the pancreas can be conservatively managed. METHODS A retrospective single-center study of consecutive patients with resected MCN. MRIs were independently reviewed by two readers blinded to the pathological results. The authors compared b-MCN (i.e., mucinous-cystadenoma comprising high-grade dysplasia (HGD)) and m-MCN (i.e., cystadenocarcinoma). RESULTS Sixty-three patients (62 women [98%]) with 63 MCN (6 m-MCN, 2 HGD) were included. m-MCN tumors had a tendency to be larger than b-MCN (median 86 [25-103] vs. 45 [17-130] mm, p = .055). The combination of signal heterogeneity on T2-weighted imaging, wall thickness ≥ 5 mm, the presence of mural nodules ≥ 9 mm, and enhancing septa had an area under the ROC curve of 0.97 (95% CI 0.91-1.00) for the diagnosis of m-MCN. A total of 24 (37%), 20 (32%), 10 (16%), 5 (8%), and 4 (6%) out of 63 MCNs showed 0, 1, 2, 3, and 4 of these features, respectively. The corresponding rate of m-MCN was 0%, 0%, 10%, 20%, and 100%, respectively, with a good-to-excellent inter-reader agreement. Patterns with a high NPV for m-MCN included an absence of enhancing septa or walls (NPV 97% and 100%, respectively), wall thickness < 3 mm (NPV 100%), and no mural nodules (NPV 100%). CONCLUSIONS A combination of 4 imaging features suggests malignant MCN on MRI. On the other hand, visualization of a thin non-enhancing wall with no mural nodules suggests benign MCN. KEY POINTS • A heterogenous signal on T2-weighted MRI, a ≥ 5-mm-thick wall, mural nodules ≥ 9 mm, and/or enhancing septa suggest malignant MCNs. • A thin non-enhancing wall with no mural nodules suggests benign MCNs. • MRI should be performed in the pre-therapeutic evaluation of MCN to help determine the therapeutic strategy in these patients.
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Affiliation(s)
- Marie-Pierre Vullierme
- Assistance Publique-Hôpitaux de Paris, APHP.Nord, Department of Radiology, Beaujon University Hospital, 100 bd general Leclerc, 92110, Clichy, France. .,Université Paris Diderot-Paris 7, Université de Paris, F-75018, Paris, France.
| | - Jules Gregory
- Assistance Publique-Hôpitaux de Paris, APHP.Nord, Department of Radiology, Beaujon University Hospital, 100 bd general Leclerc, 92110, Clichy, France
| | - Vinciane Rebours
- Université Paris Diderot-Paris 7, Université de Paris, F-75018, Paris, France.,Assistance Publique-Hôpitaux de Paris, APHP.Nord, Department of Pancreatology, Beaujon Hospital, 100 bd general Leclerc, 92110, Clichy, France
| | - Jerome Cros
- Université Paris Diderot-Paris 7, Université de Paris, F-75018, Paris, France.,Assistance Publique-Hôpitaux de Paris, APHP.Nord, Department of Pathology, Beaujon University Hospital, 100 bd general Leclerc, 92110, Clichy, France
| | - Yasser Abelhady-Attia
- Department of Radiology, Benha University Hospital, Fareed Nada Street, Benha, Qalubiya Governorate, 13511, Egypt
| | - Valerie Vilgrain
- Assistance Publique-Hôpitaux de Paris, APHP.Nord, Department of Radiology, Beaujon University Hospital, 100 bd general Leclerc, 92110, Clichy, France.,Centre de Recherche de l'Inflammation (CRI), INSERM U1149, Université de Paris, F-75018, Paris, France
| | - Lina Aguilera-Munoz
- Assistance Publique-Hôpitaux de Paris, APHP.Nord, Department of Pancreatology, Beaujon Hospital, 100 bd general Leclerc, 92110, Clichy, France
| | - Lucie Laurent
- Assistance Publique-Hôpitaux de Paris, APHP.Nord, Department of Pancreatology, Beaujon Hospital, 100 bd general Leclerc, 92110, Clichy, France
| | - Philippe Levy
- Université Paris Diderot-Paris 7, Université de Paris, F-75018, Paris, France.,Assistance Publique-Hôpitaux de Paris, APHP.Nord, Department of Pancreatology, Beaujon Hospital, 100 bd general Leclerc, 92110, Clichy, France
| | - Alain Sauvanet
- Université Paris Diderot-Paris 7, Université de Paris, F-75018, Paris, France.,Assistance Publique-Hôpitaux de Paris, APHP.Nord, Department of Hepato Pancreato Biliary Surgery, Beaujon University Hospital, 100 bd general Leclerc, 92110, Clichy, France
| | - Maxime Ronot
- Assistance Publique-Hôpitaux de Paris, APHP.Nord, Department of Radiology, Beaujon University Hospital, 100 bd general Leclerc, 92110, Clichy, France.,Université Paris Diderot-Paris 7, Université de Paris, F-75018, Paris, France
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9
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Deng S, Fan Z, Gong Y, Cheng H, Jin K, Qian Y, Xiao Z, Liu Y, Wang R, Zheng Y, Ni Q, Yu X, Liu C, Luo G. Clinical implication of serum CA125 for the prediction of malignancy in mucinous cystic neoplasms of the pancreas. Exp Ther Med 2020; 20:158. [PMID: 33093896 PMCID: PMC7571373 DOI: 10.3892/etm.2020.9287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/06/2020] [Indexed: 02/06/2023] Open
Abstract
Mucinous cystic neoplasms (MCNs) of the pancreas have malignant potential. Carbohydrate antigen 125 (CA125) is a common widely used biomarker for cancers. However, the role of CA125 in predicting the malignant change of MCNs is currently unidentified. Patients with resected and pathologically confirmed MCN were identified from a prospectively maintained database. The predictive role of serum CA125 in assessing malignant change of MCNs was analyzed and compared with serum carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA). This study included 164 patients with MCN (low/moderate grade, 153 cases; high grade and invasive, 11 cases). The serum levels of CA125 in the high grade and invasive group (45.1±42.1 U/ml) was significantly higher than those in the low/moderate grade group (21.0±46.2 U/ml, P=0.006). The area under the receiver operating characteristic (ROC) curve of CA125 (0.75) for predicting malignancy of MCNs was higher than that of CA19-9 (0.68) or CEA (0.72). The prediction value of CA125 was improved when combined with CEA (CA125 alone, sensitivity 36.4%, specificity 90.6%, accuracy 86.6%; combined with CEA, sensitivity 45.5%, specificity 88.2%, accuracy 85.0%). It was concluded that serum CA125 shows value in predicting the malignant change of MCNs, especially when combined with serum CEA.
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Affiliation(s)
- Shengming Deng
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Zhiyao Fan
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Yitao Gong
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - He Cheng
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Kaizhou Jin
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Yunzhen Qian
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Zhiwen Xiao
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Yu Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Ruijie Wang
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Yuwei Zheng
- Department of Pathology, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China
| | - Quanxing Ni
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Xianjun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Chen Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
| | - Guopei Luo
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, P.R. China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, P.R. China.,Pancreatic Cancer Institute, Fudan University, Shanghai Pancreatic Cancer Institute, Shanghai 200032, P.R. China
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10
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Revoredo F, de Vinatea J, Reaño G, Villanueva L, Kometter F, Arenas J, Polanco PM. Mucinous cystic neoplasms of the pancreas associated with pregnancy: Two case reports. Medicine (Baltimore) 2020; 99:e21471. [PMID: 32756169 PMCID: PMC7402798 DOI: 10.1097/md.0000000000021471] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
RATIONALE Although rare, pancreatic neoplasms can occur during pregnancy, both in benign and malignant forms. Mucinous cystic neoplasms (MCNs) of the pancreas, a type of these neoplasms, are precursor lesions to invasive pancreatic cancer. The presence of the ovarian-type stroma is a defining feature. PATIENT CONCERNS The first case was a 38-year-old woman in her 18th week of pregnancy with abdominal pain that worsens a few weeks later. The second case was a 30-year-old woman in her 17th week of pregnancy with abdominal pain in the left hypochondrium. DIAGNOSIS The patients were under clinical examination and laboratory test including carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA). Both patients had magnetic resonance imaging (MRI). The diagnosis of a MCNs of the pancreas was done preoperatively in the 2 cases. INTERVENTIONS Both patients underwent distal pancreatectomy during pregnancy. One of them was an emergency laparotomy because of a ruptured MCN. OUTCOMES Both patients were completely recovered from distal pancreatectomy and continued to full term, delivering a healthy baby by Caesarean section. After 6 years of follow-up, the first patient underwent a total gastrectomy, because of a gastric cancer with carcinomatosis. Currently the 2 patients are still alive after 8 years and 5 years of follow-up, respectively. LESSONS Surgical resection of MCNs during pregnancy should be considered during the second trimester given common distal pancreas location, rapid growth, risk of spontaneous rupture, and malignant potential.
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Affiliation(s)
| | | | | | | | | | - José Arenas
- Department of Pathology, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Perú
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11
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Prediction of the Probability of Malignancy in Mucinous Cystic Neoplasm of the Pancreas With Ovarian-Type Stroma: A Nationwide Multicenter Study in Japan. Pancreas 2020; 49:181-186. [PMID: 32011526 DOI: 10.1097/mpa.0000000000001475] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of the study was to develop a formula for predicting the probability of malignancy of mucinous cystic neoplasm (MCN) of the pancreas with ovarian-type stroma. METHODS A total of 364 patients were enrolled. A total score was calculated as the sum of the approximate integers of the odds ratios of the predictive factors identified by multivariate analysis. The relationship between the total score and pathological results was assessed. RESULTS A total of 321 patients had benign MCN and 43 had malignant MCN. Five possible predictive factors were analyzed: 56 years or older, high serum carcinoembryonic antigen level, high carbohydrate antigen 19-9 level, tumor size of 51 mm or greater, and the presence of mural nodules. The total score was significantly higher in patients with malignant MCN (median, 24; range, 0-37) compared with benign MCN (median, 5; range, 0-33; P < 0.001). Receiver operating characteristic curve analysis demonstrated that the area under the curve was 0.86, and the sensitivity and specificity of the total score for discriminating malignant MCNs were 72% and 83%, respectively, using a cut-off value of 22. CONCLUSIONS The current simple formula can predict the malignancy of MCN and may thus contribute to the adequate management of patients with MCN.
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12
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Yang J, Guo X, Zhang H, Zhang W, Song J, Xu H, Ma X. Differential diagnosis of pancreatic serous cystadenoma and mucinous cystadenoma: utility of textural features in combination with morphological characteristics. BMC Cancer 2019; 19:1223. [PMID: 31842793 PMCID: PMC6915993 DOI: 10.1186/s12885-019-6421-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/02/2019] [Indexed: 02/05/2023] Open
Abstract
Background Texture analysis of medical images has been reported to be a reliable method for differential diagnosis of neoplasms. This study was to investigate the performance of textural features and the combined performance of textural features and morphological characteristics in the differential diagnosis of pancreatic serous and mucinous cystadenomas. Methods We retrospectively reviewed 59 patients with pancreatic serous cystadenoma and 32 patients with pancreatic mucinous cystadenoma at our hospital. A three-dimensional region of interest (ROI) around the margin of the lesion was drawn manually in the CT images of each patient, and textural parameters were retrieved from the ROI. Textural features were extracted using the LifeX software. The least absolute shrinkage and selection operator (LASSO) method was applied to select the textural features. The differential diagnostic capabilities of morphological features, textural features, and their combination were evaluated using receiver operating characteristic (ROC) analysis, and the area under the receiver operating characteristic curve (AUC) was used as the main indicator. The diagnostic accuracy based on the AUC value is defined as follows: 0.9–1.0, excellent; 0.8–0.9, good; 0.7–0.8, moderate; 0.6–0.7, fair; 0.5–0.6, poor. Results In the differential diagnosis of pancreatic serous and mucinous cystadenomas, the combination of morphological characteristics and textural features (AUC 0.893, 95% CI 0.816–0.970) is better than morphological characteristics (AUC 0.783, 95% CI 0.665–0.900) or textural features (AUC 0.777, 95% CI 0.673–0.880) alone. Conclusions In conclusion, our preliminary results highlighted the potential of CT texture analysis in discriminating pancreatic serous cystadenoma from mucinous cystadenoma. Furthermore, the combination of morphological characteristics and textural features can significantly improve the diagnostic performance, which may provide a reliable method for selecting patients with surgical intervention indications in consideration of the different treatment principles of the two diseases.
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Affiliation(s)
- Jing Yang
- Department of Biotherapy, Cancer Center, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, People's Republic of China
| | - Xinli Guo
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Hao Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Weiwei Zhang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jinen Song
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Hui Xu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xuelei Ma
- Department of Biotherapy, Cancer Center, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No. 37 GuoXue Alley, Chengdu, 610041, People's Republic of China.
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13
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Carmicheal J, Patel A, Dalal V, Atri P, Dhaliwal AS, Wittel UA, Malafa MP, Talmon G, Swanson BJ, Singh S, Jain M, Kaur S, Batra SK. Elevating pancreatic cystic lesion stratification: Current and future pancreatic cancer biomarker(s). Biochim Biophys Acta Rev Cancer 2019; 1873:188318. [PMID: 31676330 DOI: 10.1016/j.bbcan.2019.188318] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/25/2019] [Accepted: 10/25/2019] [Indexed: 02/06/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an incredibly deadly disease with a 5-year survival rate of 9%. The presence of pancreatic cystic lesions (PCLs) confers an increased likelihood of future pancreatic cancer in patients placing them in a high-risk category. Discerning concurrent malignancy and risk of future PCL progression to cancer must be carefully and accurately determined to improve survival outcomes and avoid unnecessary morbidity of pancreatic resection. Unfortunately, current image-based guidelines are inadequate to distinguish benign from malignant lesions. There continues to be a need for accurate molecular and imaging biomarker(s) capable of identifying malignant PCLs and predicting the malignant potential of PCLs to enable risk stratification and effective intervention management. This review provides an update on the current status of biomarkers from pancreatic cystic fluid, pancreatic juice, and seromic molecular analyses and discusses the potential of radiomics for differentiating PCLs harboring cancer from those that do not.
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Affiliation(s)
- Joseph Carmicheal
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Asish Patel
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Vipin Dalal
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Pranita Atri
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Amaninder S Dhaliwal
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Uwe A Wittel
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Mokenge P Malafa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Geoffrey Talmon
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Benjamin J Swanson
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Shailender Singh
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Maneesh Jain
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sukhwinder Kaur
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Surinder K Batra
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA; Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA; Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA.
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14
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Fan X, Wang W, Li C, Tang T, Han Y, An K. An osteoclast-like giant cell tumor embedded in the mural nodule of a pancreatic mucinous cystic neoplasm: A case report and literature review. Medicine (Baltimore) 2019; 98:e15246. [PMID: 31008959 PMCID: PMC6494236 DOI: 10.1097/md.0000000000015246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
RATIONALE Mucinous cystic neoplasms (MCNs) are relatively rare lesions, accounting for 2%-5% of all exocrine pancreatic neoplasms. MCNs mainly occur in women (female:male ratio = 20:1), with a peak incidence in the 5th decade of life. Osteoclast-like giant cell tumors (OGCTs) are rare and relatively aggressive neoplasms, comprising <1% of all pancreatic carcinomas. Herein, we present a rare "combination tumor" case and discuss the impact of mural nodules in pancreatic MCNs considering malignant transformation. PATIENT CONCERNS A 54-year-old Mongolian man, without vomiting, nausea or jaundice, presented with abdominal distention since 3 months. He had a 7-year history of diabetes. Physical examinations indicated slight middle abdominal tenderness without rebound tenderness or rigidity. Laboratory results revealed that the level of carcinoembryonic antigen (CEA) was 1.16 ng/ml (normal: <5 ng/ml); CA-199: 30.02 U/ml (normal: <27 U/ml); hemoglobin: 143 g/L; fasting glucose: 7.71 mmol/L; and albumin: 43 g/L. Abdominal enhanced computed tomography revealed a 7 × 6 cm solid neoplasm in the pancreatic body with partial enhancement and heterogeneity. Endoscopic ultrasound revealed a solid-cystic space-occupying lesion in the pancreatic body. DIAGNOSIS The preoperative preliminary diagnosis was pancreatic solid-cystic tumor, possibly a solid pseudopapillary tumor. Postoperative pathological findings revealed a pancreatic borderline MCN with an OGCT embedded in a mural nodule of the capsule. Immunohistochemical results indicated a simultaneous dual origin from the epithelium and stroma. INTERVENTIONS The patient underwent open distal pancreatectomy and splenectomy. Postoperative blood glucose levels were closely monitored and regulated. We intravenously administered single-agent gemcitabine (1400 mg on day 1) as the first-time chemotherapy, 1 month after surgery. After the first chemotherapy, the patient refused to receive further treatment owing to personal reasons. OUTCOMES The patient showed uneventful recovery and was discharged 13 days after the initial surgery. Follow-up was performed 1, 3 and 6 months after surgery. At 6 months, abdominal computed tomography scan showed no signs of recurrence, regional lymphadenopathy, or other abnormalities. And laboratory tests showed a platelet count of 301 × 10/L, postprandial blood glucose of 12.9 mmol/L and CA-199 level of 20 U/ml. The patient had no obvious discomfort. LESSONS Although pancreatic MCNs are widely accepted as borderline tumors, malignant transformations may occur due to various risk factors (cyst size, mural nodules, septations, and tumor location). The combination tumor in this case was more likely to increase the possibility of malignant biological behavior, thereby worsening overall prognosis. Therefore, long-term follow-up must be maintained with strict monitoring.
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Affiliation(s)
- XiaoYu Fan
- Peking University China-Japan Friendship School of Clinical Medicine
| | - WenYue Wang
- Peking University China-Japan Friendship School of Clinical Medicine
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - ChaoFeng Li
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Tao Tang
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - YongXin Han
- Peking University China-Japan Friendship School of Clinical Medicine
| | - Ke An
- Peking University China-Japan Friendship School of Clinical Medicine
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15
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Bowman AW, Bolan CW. MRI evaluation of pancreatic ductal adenocarcinoma: diagnosis, mimics, and staging. Abdom Radiol (NY) 2019; 44:936-949. [PMID: 29967986 DOI: 10.1007/s00261-018-1686-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The radiologist's role in the evaluation of pancreatic ductal adenocarcinoma remains critical in the management of this deadly disease. Imaging plays a vital role in the diagnosis and staging of pancreatic cancer. Although CT is more commonly used for staging pancreatic cancer, MR is increasingly playing an important role in this regard. In our institution, all pancreatic malignancies undergo staging with MRI. In this pictoral essay, we illustrate the MR imaging features of pancreatic ductal adenocarcinoma and its mimics, and we also discuss pearls and pitfalls in MR staging of pancreatic carcinoma.
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Affiliation(s)
- Andrew W Bowman
- Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
| | - Candice W Bolan
- Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
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16
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Salom F, Prat F. Current indications and yield of endoscopic ultrasound and ancillary techniques in pancreatic cystic neoplasms. Clin J Gastroenterol 2018; 12:93-101. [PMID: 30565189 DOI: 10.1007/s12328-018-00930-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 12/12/2018] [Indexed: 12/11/2022]
Abstract
An increase in the diagnosis of pancreatic cystic neoplasm has been described lately. Surgical treatment or surveillance is advised depending on the type of lesion diagnosed. The most accurate diagnostic approach is needed to make the best therapeutic decision. Endoscopic ultrasound is a very valuable tool in the evaluation of pancreatic cystic neoplasm. It generates high-quality images and allows the possibility of sampling the cystic fluid for cytology, microbiological and molecular evaluation. Even with this evaluation, the sensitivity of this approach is not always adequate. New technological resources have been developed to try to improve the diagnostic accuracy of pancreatic cystic neoplasms. The two most promising techniques are needle-based confocal laser endomicroscopy and contrast-enhanced harmonic endoscopic ultrasound. Needle-based confocal laser endomicroscopy allows a microscopic evaluation of mucosal glands and vascular pattern, to differentiate mucinous from non-mucinous lesions. Contrast-enhanced harmonic endoscopic ultrasound is used for the vascular evaluation of the microcirculation of the cyst wall and mural nodule, mainly to make the difference between malignant nodules and mucus plugs. A combination of these different diagnostic techniques can improve the diagnostic accuracy of pancreatic cystic neoplasms to offer the adequate therapeutic decision.
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Affiliation(s)
- Federico Salom
- Departamento de Gastroenterología, Hospital México, San José, 1641-2050, Costa Rica.
| | - Frédéric Prat
- Service de Gastroenterologie, d'endoscopie et de Cancerologie Digestive, APHP-Hopital Cochin, 75014, Paris, France
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17
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Keane MG, Shamali A, Nilsson LN, Antila A, Millastre Bocos J, Marijinissen Van Zanten M, Verdejo Gil C, Maisonneuve P, Vaalavuo Y, Hoskins T, Robinson S, Ceyhan GO, Abu Hilal M, Pereira SP, Laukkarinen J, Del Chiaro M. Risk of malignancy in resected pancreatic mucinous cystic neoplasms. Br J Surg 2018; 105:439-446. [PMID: 29488646 DOI: 10.1002/bjs.10787] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/12/2017] [Accepted: 11/16/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Pancreatic mucinous cystic neoplasms (MCNs) are rare mucin-producing cystic tumours defined by the presence of ovarian-type stroma. MCNs have a malignant potential and thus surgery is frequently performed. The aim of this cohort study was to define better the criteria for surgical resection in patients with MCN. METHODS This multicentre retrospective study included all resected MCNs between 2003 and 2015 in participating centres. Lesions without ovarian-type stroma were excluded. Patient characteristics, preoperative findings, histopathology findings and follow-up data were recorded. RESULTS The study included 211 patients; their median age was 53 (range 18-82) years, and 202 (95·7 per cent) were women. Median preoperative tumour size was 55 (range 12-230) mm. Thirty-four of the 211 (16·1 per cent) were malignant, and high-grade dysplasia (HGD) was found in a further 13 (6·2 per cent). One-third of MCNs in men were associated with invasive cancer, compared with 15·3 per cent in women. Five cases of malignant transformation occurred in MCNs smaller than 4 cm. All cases of malignancy or HGD were associated with symptoms or features of concern on preoperative cross-sectional imaging. In multivariable analysis, raised carbohydrate antigen 19-9 (odds ratio (OR) 10·54, 95 per cent c.i. 2·85 to 218·23; P < 0·001), tumour size (OR 4·23, 3·02 to 11·03; P = 0·001), mural nodules (OR 3·55, 1·31 to 20·55; P = 0·002) and weight loss (OR 3·40, 2·34 to 12·34; P = 0·034) were independent factors predictive of malignant transformation. CONCLUSIONS Small indeterminate MCNs with no symptoms or features of concern may safely be observed as they have a low risk of malignant transformation.
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Affiliation(s)
- M G Keane
- Institute for Liver and Digestive Health, University College London, London
| | - A Shamali
- Department of Surgery, Southampton University Hospital, Southampton, UK
| | - L N Nilsson
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - A Antila
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - J Millastre Bocos
- Department of Gastroenterology, Miguel Servet University Hospital, Zaragoza, Spain
| | | | - C Verdejo Gil
- Department of Gastroenterology, Ciudad Real University Hospital, Ciudad Real, Spain
| | | | - Y Vaalavuo
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - T Hoskins
- Department of Hepato-Pancreato-Biliary Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - S Robinson
- Department of Hepato-Pancreato-Biliary Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - G O Ceyhan
- Surgical Clinic, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - M Abu Hilal
- Department of Surgery, Southampton University Hospital, Southampton, UK
| | - S P Pereira
- Institute for Liver and Digestive Health, University College London, London
| | - J Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - M Del Chiaro
- Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
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18
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Ridtitid W, Al-Haddad MA. Endoscopic Ultrasound Imaging for Diagnosing and Treating Pancreatic Cysts. Gastrointest Endosc Clin N Am 2017; 27:615-642. [PMID: 28918802 DOI: 10.1016/j.giec.2017.06.004] [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] [Indexed: 02/04/2023]
Abstract
Cystic pancreatic lesions are increasingly diagnosed owing to the abundant use of cross-sectional imaging. Given their malignant potential, true pancreatic cysts should be considered for resection or periodic follow-up. Cystic lesions of the pancreas (CLPs) require further evaluation and management. Therefore, it is important to establish a solid diagnosis at the time of detection. Endoscopic ultrasound examination is the imaging modality of choice. Fine needle aspiration provides fluid for cytologic, biochemical, and molecular assays to classify lesions and predict biological behavior. This review provides an overview of the diagnosis and management of various types of commonly encountered true CLPs.
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Affiliation(s)
- Wiriyaporn Ridtitid
- Division of Gastroenterology and Hepatology, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok 10330, Thailand
| | - Mohammad A Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100, Indianapolis, IN 46202, USA.
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19
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Abstract
Mortality due to pancreatic ductal adenocarcinoma (PDAC) will increase in the near future. The only curative treatment for PDAC is radical resection; however, even small carcinomas exhibit micrometastases leading to early relapse. Accordingly, detection of premalignant precursor lesions is important. In essence, PDAC develops from three precursor lesions: pancreatic intraepithelial lesions (PanIN), intraductal papillary-mucinous neoplasia (IPMN) and mucinous-cystic neoplasia (MCN). Together with serous cystic neoplasia (SCN) and solid pseudopapillary neoplasia (SPN), these cystic lesions constitute the most common cystic neoplasms in the pancreas. In the case of IPMN, main and branch duct IPMN have to be differentiated because of a markedly different malignancy potential. While main duct IPMN and MCN have a high malignancy transformation rate, branch duct IPMNs are more variable with respect to malignant transformation. This shows that differential diagnosis of cystic lesions is important; however, this is often very difficult to accomplish using conventional imaging. Novel biomarkers and diagnostic tools based on the molecular differences of cystic pancreatic lesions could be helpful to differentiate these lesions and facilitate early diagnosis. The aim is to distinguish the premalignant cysts from strictly benign cystic lesions and a timely detection of malignant transformation. This article provides an overview on the molecular characteristics of cystic pancreatic lesions as a basis for improved diagnostics and the development of new biomarkers.
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Affiliation(s)
- A W Berger
- Klinik für Innere Medizin 1, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland
| | - T Seufferlein
- Klinik für Innere Medizin 1, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland.
| | - A Kleger
- Klinik für Innere Medizin 1, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland.
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20
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Abstract
Pancreatic cysts, especially incidental asymptomatic ones seen on noninvasive imaging such as CT or MR imaging, remain a clinical challenge. The etiology of such cysts may range from benign cysts without any malignant potential such as pancreatic pseudocysts and serous cystadenomas to premalignant or frankly malignant cysts such as mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, cystic degeneration associated with solid tumors such as pancreatic ductal adenocarcinoma or pancreatic endocrine neoplasms, and solid pseudopapillary neoplasms. The clinical challenge in 2017 is to accurately preoperatively diagnose them and their malignant potential before deciding about surgery, surveillance or doing nothing. This review will focus on the currently available clinical guidelines for doing so.
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Affiliation(s)
- James J Farrell
- Yale Center for Pancreatic Diseases, Interventional Endoscopy, Yale School of Medicine, New Haven, CT, USA. .,Section of Digestive Diseases, Yale University School of Medicine, LMP 1080, 15 York Street, New Haven, CT, 06510-3221, USA.
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21
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Postlewait LM, Ethun CG, McInnis MR, Merchant N, Parikh A, Idrees K, Isom CA, Hawkins W, Fields RC, Strand M, Weber SM, Cho CS, Salem A, Martin RCG, Scoggins C, Bentrem D, Kim HJ, Carr J, Ahmad S, Abbott DE, Wilson GC, Kooby DA, Maithel SK. Association of Preoperative Risk Factors With Malignancy in Pancreatic Mucinous Cystic Neoplasms: A Multicenter Study. JAMA Surg 2017; 152:19-25. [PMID: 27760255 DOI: 10.1001/jamasurg.2016.3598] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance Pancreatic mucinous cystic neoplasms (MCNs) harbor malignant potential, and current guidelines recommend resection. However, data are limited on preoperative risk factors for malignancy (adenocarcinoma or high-grade dysplasia) occurring in the setting of an MCN. Objectives To examine the preoperative risk factors for malignancy in resected MCNs and to assess outcomes of MCN-associated adenocarcinoma. Design, Setting, and Participants Patients who underwent pancreatic resection of MCNs at the 8 academic centers of the Central Pancreas Consortium from January 1, 2000, through December 31, 2014, were retrospectively identified. Preoperative factors of patients with and without malignant tumors were compared. Survival analyses were conducted for patients with adenocarcinoma. Main Outcomes and Measures Binary logistic regression models were used to determine the association of preoperative factors with the presence of MCN-associated malignancy. Results A total of 1667 patients underwent resection of pancreatic cystic lesions, and 349 (20.9%) had an MCN (310 women [88.8%]; mean (SD) age, 53.3 [14.7] years). Male sex (odds ratio [OR], 3.72; 95% CI, 1.21-11.44; P = .02), pancreatic head and neck location (OR, 3.93; 95% CI, 1.43-10.81; P = .01), increased radiographic size of the MCN (OR, 1.17; 95% CI, 1.08-1.27; P < .001), presence of a solid component or mural nodule (OR, 4.54; 95% CI, 1.95-10.57; P < .001), and duct dilation (OR, 4.17; 95% CI, 1.63-10.64; P = .003) were independently associated with malignancy. Malignancy was not associated with presence of radiographic septations or preoperative cyst fluid analysis (carcinoembryonic antigen, amylase, or mucin presence). The median serum CA19-9 level for patients with malignant neoplasms was 210 vs 15 U/mL for those without (P = .001). In the 44 patients with adenocarcinoma, 41 (93.2%) had lymph nodes harvested, with nodal metastases in only 14 (34.1%). Median follow-up for patients with adenocarcinoma was 27 months. Adenocarcinoma recurred in 11 patients (25%), with a 64% recurrence-free survival and 59% overall survival at 3 years. Conclusions and Relevance Adenocarcinoma or high-grade dysplasia is present in 14.9% of resected pancreatic MCNs for which risks include male sex, pancreatic head and neck location, larger MCN, solid component or mural nodule, and duct dilation. Mucinous cystic neoplasm-associated adenocarcinoma appears to have decreased nodal involvement at the time of resection and increased survival compared with typical pancreatic ductal adenocarcinoma. Indications for resection of MCNs should be revisited.
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Affiliation(s)
- Lauren M Postlewait
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia
| | - Cecilia G Ethun
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia
| | - Mia R McInnis
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia
| | - Nipun Merchant
- Division of Surgical Oncology, Department of Surgery, University of Miami, Miami, Florida
| | - Alexander Parikh
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chelsea A Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William Hawkins
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Matthew Strand
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Clifford S Cho
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Charles Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - David Bentrem
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hong J Kim
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill
| | - Jacquelyn Carr
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill
| | - Syed Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati Cancer Institute, Cincinnati, Ohio
| | - Daniel E Abbott
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati Cancer Institute, Cincinnati, Ohio
| | - Gregory C Wilson
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati Cancer Institute, Cincinnati, Ohio
| | - David A Kooby
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia
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22
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Lekkerkerker SJ, Besselink MG, Busch OR, Verheij J, Engelbrecht MR, Rauws EA, Fockens P, van Hooft JE. Comparing 3 guidelines on the management of surgically removed pancreatic cysts with regard to pathological outcome. Gastrointest Endosc 2017; 85:1025-1031. [PMID: 27693645 DOI: 10.1016/j.gie.2016.09.027] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 09/19/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Currently, 3 guidelines are available for the management of pancreatic cysts. These guidelines vary in their indication for resection of high-risk cysts. We retrospectively compared the final pathologic outcome of surgically removed pancreatic cysts with the indications for resection according to 3 different guidelines. METHODS Patients who underwent pancreatic resection were extracted from our prospective pancreatic cyst database (2006-present). The final histopathologic diagnosis was compared with the initial indication for surgery stated by the guidelines of the International Association of Pancreatology (IAP), European Study Group on Cystic tumors of the Pancreas and American Gastroenterological Association (AGA). We considered surgery in retrospect justified for malignancy, high-grade dysplasia, solid pseudopapillary neoplasms, neuroendocrine tumors or symptom improvement. Furthermore, we evaluated the patients with suspected intraductal papillary mucinous neoplasm (IPMN) separately. RESULTS Overall, 115 patients underwent pancreatic resection. The preoperative diagnosis was correct in 83 of 115 patients (72%) and differentiation between benign and premalignant in 99 of 115 patients (86%). In retrospect, surgery was justified according to the aforementioned criteria in 52 of 115 patients (45%). For patients with suspected IPMN (n = 75) resection was justified in 36 of 67 (54%), 36 of 68 (53%), and 32 of 54 (59%) of patients who would have had surgery based on the IAP, European, or AGA guidelines, respectively. The AGA guideline would have avoided resection in 21 of 75 (28%) patients, versus 8 of 75 (11%) and 7 of 75 (9%) when the IAP or European guideline would have been applied strictly. Nevertheless, 4 of 33 patients (12%) with high-grade dysplasia or malignancy would have been missed with the AGA guidelines, compared with none with the IAP or European guidelines. CONCLUSION Although fewer patients undergo unnecessary surgery based on the AGA guidelines, the risk of missing malignancy or high-grade dysplasia with this guideline seems considerably high.
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Affiliation(s)
- Selma J Lekkerkerker
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Joanne Verheij
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marc R Engelbrecht
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Erik A Rauws
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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23
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Best LMJ, Rawji V, Pereira SP, Davidson BR, Gurusamy KS. Imaging modalities for characterising focal pancreatic lesions. Cochrane Database Syst Rev 2017; 4:CD010213. [PMID: 28415140 PMCID: PMC6478242 DOI: 10.1002/14651858.cd010213.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Increasing numbers of incidental pancreatic lesions are being detected each year. Accurate characterisation of pancreatic lesions into benign, precancerous, and cancer masses is crucial in deciding whether to use treatment or surveillance. Distinguishing benign lesions from precancerous and cancerous lesions can prevent patients from undergoing unnecessary major surgery. Despite the importance of accurately classifying pancreatic lesions, there is no clear algorithm for management of focal pancreatic lesions. OBJECTIVES To determine and compare the diagnostic accuracy of various imaging modalities in detecting cancerous and precancerous lesions in people with focal pancreatic lesions. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase, and Science Citation Index until 19 July 2016. We searched the references of included studies to identify further studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. SELECTION CRITERIA We planned to include studies reporting cross-sectional information on the index test (CT (computed tomography), MRI (magnetic resonance imaging), PET (positron emission tomography), EUS (endoscopic ultrasound), EUS elastography, and EUS-guided biopsy or FNA (fine-needle aspiration)) and reference standard (confirmation of the nature of the lesion was obtained by histopathological examination of the entire lesion by surgical excision, or histopathological examination for confirmation of precancer or cancer by biopsy and clinical follow-up of at least six months in people with negative index tests) in people with pancreatic lesions irrespective of language or publication status or whether the data were collected prospectively or retrospectively. DATA COLLECTION AND ANALYSIS Two review authors independently searched the references to identify relevant studies and extracted the data. We planned to use the bivariate analysis to calculate the summary sensitivity and specificity with their 95% confidence intervals and the hierarchical summary receiver operating characteristic (HSROC) to compare the tests and assess heterogeneity, but used simpler models (such as univariate random-effects model and univariate fixed-effect model) for combining studies when appropriate because of the sparse data. We were unable to compare the diagnostic performance of the tests using formal statistical methods because of sparse data. MAIN RESULTS We included 54 studies involving a total of 3,196 participants evaluating the diagnostic accuracy of various index tests. In these 54 studies, eight different target conditions were identified with different final diagnoses constituting benign, precancerous, and cancerous lesions. None of the studies was of high methodological quality. None of the comparisons in which single studies were included was of sufficiently high methodological quality to warrant highlighting of the results. For differentiation of cancerous lesions from benign or precancerous lesions, we identified only one study per index test. The second analysis, of studies differentiating cancerous versus benign lesions, provided three tests in which meta-analysis could be performed. The sensitivities and specificities for diagnosing cancer were: EUS-FNA: sensitivity 0.79 (95% confidence interval (CI) 0.07 to 1.00), specificity 1.00 (95% CI 0.91 to 1.00); EUS: sensitivity 0.95 (95% CI 0.84 to 0.99), specificity 0.53 (95% CI 0.31 to 0.74); PET: sensitivity 0.92 (95% CI 0.80 to 0.97), specificity 0.65 (95% CI 0.39 to 0.84). The third analysis, of studies differentiating precancerous or cancerous lesions from benign lesions, only provided one test (EUS-FNA) in which meta-analysis was performed. EUS-FNA had moderate sensitivity for diagnosing precancerous or cancerous lesions (sensitivity 0.73 (95% CI 0.01 to 1.00) and high specificity 0.94 (95% CI 0.15 to 1.00), the extremely wide confidence intervals reflecting the heterogeneity between the studies). The fourth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (dysplasia) provided three tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing invasive carcinoma were: CT: sensitivity 0.72 (95% CI 0.50 to 0.87), specificity 0.92 (95% CI 0.81 to 0.97); EUS: sensitivity 0.78 (95% CI 0.44 to 0.94), specificity 0.91 (95% CI 0.61 to 0.98); EUS-FNA: sensitivity 0.66 (95% CI 0.03 to 0.99), specificity 0.92 (95% CI 0.73 to 0.98). The fifth analysis, of studies differentiating cancerous (high-grade dysplasia or invasive carcinoma) versus precancerous (low- or intermediate-grade dysplasia) provided six tests in which meta-analysis was performed. The sensitivities and specificities for diagnosing cancer (high-grade dysplasia or invasive carcinoma) were: CT: sensitivity 0.87 (95% CI 0.00 to 1.00), specificity 0.96 (95% CI 0.00 to 1.00); EUS: sensitivity 0.86 (95% CI 0.74 to 0.92), specificity 0.91 (95% CI 0.83 to 0.96); EUS-FNA: sensitivity 0.47 (95% CI 0.24 to 0.70), specificity 0.91 (95% CI 0.32 to 1.00); EUS-FNA carcinoembryonic antigen 200 ng/mL: sensitivity 0.58 (95% CI 0.28 to 0.83), specificity 0.51 (95% CI 0.19 to 0.81); MRI: sensitivity 0.69 (95% CI 0.44 to 0.86), specificity 0.93 (95% CI 0.43 to 1.00); PET: sensitivity 0.90 (95% CI 0.79 to 0.96), specificity 0.94 (95% CI 0.81 to 0.99). The sixth analysis, of studies differentiating cancerous (invasive carcinoma) from precancerous (low-grade dysplasia) provided no tests in which meta-analysis was performed. The seventh analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) provided two tests in which meta-analysis was performed. The sensitivity and specificity for diagnosing cancer were: CT: sensitivity 0.83 (95% CI 0.68 to 0.92), specificity 0.83 (95% CI 0.64 to 0.93) and MRI: sensitivity 0.80 (95% CI 0.58 to 0.92), specificity 0.81 (95% CI 0.53 to 0.95), respectively. The eighth analysis, of studies differentiating precancerous or cancerous (intermediate- or high-grade dysplasia or invasive carcinoma) from precancerous (low-grade dysplasia) or benign lesions provided no test in which meta-analysis was performed.There were no major alterations in the subgroup analysis of cystic pancreatic focal lesions (42 studies; 2086 participants). None of the included studies evaluated EUS elastography or sequential testing. AUTHORS' CONCLUSIONS We were unable to arrive at any firm conclusions because of the differences in the way that study authors classified focal pancreatic lesions into cancerous, precancerous, and benign lesions; the inclusion of few studies with wide confidence intervals for each comparison; poor methodological quality in the studies; and heterogeneity in the estimates within comparisons.
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Affiliation(s)
- Lawrence MJ Best
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRowland Hill StreetLondonUKNW32PF
| | - Vishal Rawji
- University College London Medical SchoolLondonUK
| | - Stephen P Pereira
- Royal Free Hospital CampusUCL Institute for Liver and Digestive HealthUpper 3rd FloorLondonUKNW3 2PF
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRowland Hill StreetLondonUKNW32PF
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24
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Greer JB, Ferrone CR. Spectrum and Classification of Cystic Neoplasms of the Pancreas. Surg Oncol Clin N Am 2016; 25:339-50. [PMID: 27013368 DOI: 10.1016/j.soc.2015.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
As patients are living longer and axial imaging is more widespread, increasing numbers of cystic neoplasms of the pancreas are found. Intraductal papillary mucinous neoplasms and mucinous cystic neoplasms are the most common. The revised Sendai guidelines provide a safe algorithm for expectant management of certain cystic neoplasms; however, studies are ongoing to identify further subgroups that can be treated nonoperatively. For those patients with high-risk clinical features or symptoms, surgical resection can be performed safely at high-volume pancreatic centers. Accurate diagnosis is critical for accurate decision making.
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Affiliation(s)
- Jonathan B Greer
- General Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRB-425, Boston, MA 02114, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA 02114, USA.
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25
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Scourtas A, Dudley JC, Brugge WR, Kadayifci A, Mino-Kenudson M, Pitman MB. Preoperative characteristics and cytological features of 136 histologically confirmed pancreatic mucinous cystic neoplasms. Cancer Cytopathol 2016; 125:169-177. [PMID: 27926784 DOI: 10.1002/cncy.21806] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/11/2016] [Accepted: 11/10/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Mucinous cystic neoplasms (MCNs) of the pancreas present a management conundrum. The majority are benign but all are resected due to their malignant potential. Recent studies have recommended nonsurgical management. In the current study, the authors analyzed the preoperative imaging, cytology, and cyst fluid characteristics of 136 histologically confirmed MCNs to assess predictors of a high-risk (HR) cyst for surgical triage. METHODS MCNs resected at the Massachusetts General Hospital between 1990 and 2014 formed the study cohort. Patient demographics, cyst size, and mural nodules (MNs) by endoscopic ultrasound, cytology, and cyst fluid carcinoembryonic antigen and amylase levels were correlated with histological grade. A HR cyst was defined as high-grade dysplasia or invasive carcinoma on histology. Performance characteristics were assessed for each parameter, with a cyst size ≥3 cm or a MN on imaging and malignant cytology considered to be "true-positive" results for predicting malignancy. RESULTS Only 15 of the 136 cysts had HR histology (11%). On average, patients with HR cysts were older than those with low-risk cysts (55 years vs 49 years, respectively). High-grade cytology was the most accurate predictor of malignancy (95%) followed by MN and cyst size together (88%) and MN alone (83%). The average carcinoembryonic antigen level (in ng/mL) increased with the grade of dysplasia but the ranges overlapped between low risk and HR cysts. CONCLUSIONS To the authors' knowledge, the current study is the largest series to date analyzing the cytological features of histologically confirmed MCN. Cytology is insensitive but very specific for detecting a HR MCN and outperformed imaging for the detection of HR MCN. Endoscopic ultrasound-guided fine-needle aspiration and cytology should be performed on any clinically suspected MCN that is being considered for conservative management. Cancer Cytopathol 2017;125:169-177. © 2016 American Cancer Society.
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Affiliation(s)
- Aristana Scourtas
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan C Dudley
- Department of Pathology, Stanford University Medical Center, Palo Alto, California
| | - William R Brugge
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Abdurrahman Kadayifci
- Division of Gastroenterology, Gaziantep University School of Medicine, Gaziantep, Turkey
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
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26
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Vullierme MP, Lagadec M. Predisposing factors for pancreatic adenocarcinoma: What is the role of imaging? Diagn Interv Imaging 2016; 97:1233-1240. [DOI: 10.1016/j.diii.2016.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 08/25/2016] [Indexed: 02/07/2023]
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27
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You L, Xiao J, Cao Z, Zhang W, Liao Q, Dai M, Zhang T, Zhao Y. Analysis of clinical characteristics and treatment of pancreatic cystic tumors. Chin J Cancer Res 2016; 28:519-527. [PMID: 27877011 PMCID: PMC5101226 DOI: 10.21147/j.issn.1000-9604.2016.05.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective To summarize experience in the diagnosis and treatment of pancreatic cystic neoplasms. Methods This is a retrospective study of 207 patients who were diagnosed with pancreatic cystic tumors at Peking Union Medical College Hospital between Jan 2009 and Mar 2014. Clinical data, such as clinical manifestations, radiological and pathological images and surgical recordings, were collected. Results Of the 207 included patients, females accounted for 76.81%, and the mean patient age was 52.04 years. Malignancy was more common in older patients who presented with marasmus and jaundice. Other risk factors included solid components in the tumor, a large tumor size, and elevated levels of tumor markers. Surgical treatment was required when a malignant tumor was suspected. The operation approach was selected based on the location, size and characteristics of the tumor. The position of the tumor relative to the pancreatic duct also played a significant role. Conclusions No specific symptoms were observed for the patients with pancreatic cystic tumors. Imaging played an important role in making a differential diagnosis. Furthermore, surgical treatment should be proposed for patients with significant symptoms and potentially malignant tumors. The tumor resection rate is high, suggestive of good prognosis.
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Affiliation(s)
- Lei You
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Jianchun Xiao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Zhe Cao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wanying Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Quan Liao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
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28
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Arshad HMS, Bharmal S, Duman DG, Liangpunsakul S, Turner BG. Advanced endoscopic ultrasound management techniques for preneoplastic pancreatic cystic lesions. J Investig Med 2016; 65:7-14. [PMID: 27574295 PMCID: PMC5284342 DOI: 10.1136/jim-2016-000167] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2016] [Indexed: 12/13/2022]
Abstract
Pancreatic cystic lesions can be benign, premalignant or malignant. The recent increase in detection and tremendous clinical variability of pancreatic cysts has presented a significant therapeutic challenge to physicians. Mucinous cystic neoplasms are of particular interest given their known malignant potential. This review article provides a brief but comprehensive review of premalignant pancreatic cystic lesions with advanced endoscopic ultrasound (EUS) management approaches. A comprehensive literature search was performed using PubMed, Cochrane, OVID and EMBASE databases. Preneoplastic pancreatic cystic lesions include mucinous cystadenoma and intraductal papillary mucinous neoplasm. The 2012 International Sendai Guidelines guide physicians in their management of pancreatic cystic lesions. Some of the advanced EUS management techniques include ethanol ablation, chemotherapeutic (paclitaxel) ablation, radiofrequency ablation and cryotherapy. In future, EUS-guided injections of drug-eluting beads and neodymium:yttrium aluminum agent laser ablation is predicted to be an integral part of EUS-guided management techniques. In summary, International Sendai Consensus Guidelines should be used to make a decision regarding management of pancreatic cystic lesions. Advanced EUS techniques are proving extremely beneficial in management, especially in those patients who are at high surgical risk.
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Affiliation(s)
- Hafiz Muhammad Sharjeel Arshad
- Department of Internal Medicine, University of Illinois at Chicago/Advocate Christ Medical Center, Oak Lawn, Illinois, USA
| | - Sheila Bharmal
- Department of Gastroenterology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Deniz Guney Duman
- Department of Gastroenterology, Marmara University, Istanbul, Turkey
| | - Suthat Liangpunsakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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29
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Farrell JJ. Prevalence, Diagnosis and Management of Pancreatic Cystic Neoplasms: Current Status and Future Directions. Gut Liver 2016; 9:571-89. [PMID: 26343068 PMCID: PMC4562774 DOI: 10.5009/gnl15063] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cystic neoplasms of the pancreas are found with increasing prevalence, especially in elderly asymptomatic individuals. Although the overall risk of malignancy is very low, the presence of these pancreatic cysts is associated with a large degree of anxiety and further medical investigation due to concerns about malignancy. This review discusses the different cystic neoplasms of the pancreas and reports diagnostic strategies based on clinical features and imaging data. Surgical and nonsurgical management of the most common cystic neoplasms, based on the recently revised Sendai guidelines, is also discussed, with special reference to intraductal papillary mucinous neoplasm (IPMN; particularly the branch duct variant), which is the lesion most frequently identified incidentally. IPMN pathology, its risk for development into pancreatic ductal adenocarcinoma, the pros and cons of current guidelines for management, and the potential role of endoscopic ultrasound in determining cancer risk are discussed. Finally, surgical treatment, strategies for surveillance of pancreatic cysts, and possible future directions are discussed.
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Affiliation(s)
- James J Farrell
- Yale Center for Pancreatic Diseases, Interventional Endoscopy, Yale School of Medicine, New Haven, CT, USA
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30
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Wang G, Ji L, Qu FZ, Li L, Cao CL, Li ZB, Zhu H, Sun B. Acinar cell cystadenoma of the pancreas: A retrospective analysis of ten-year experience from a single academic institution. Pancreatology 2016; 16:625-31. [PMID: 27086062 DOI: 10.1016/j.pan.2016.03.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/02/2016] [Accepted: 03/29/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVE Acinar cell cystadenoma (ACA), also referred to as "acinar cystic transformation", is a rare and newly recognized cystic lesion of the pancreas displaying apparent acinar cell differentiation with benign outcomes. We summarized our experience with the diagnosis, clinicopathologic feature, treatment and prognosis of ACA to provide a reference for the disposal of this uncommon condition. METHODS We retrospectively analyzed the clinical data from eight patients with ACA treated in our hospital between March, 2005 and January, 2015. RESULTS Among eight patients, five of whom were female and the age at diagnosis ranged from 33 to 67 years (mean, 49.8 y). The most commonly clinical symptom was abdominal pain. Eight lesions were unifocal and either unilocular (n = 5) or multilocular (n = 3) with average size of 10.5 cm (range, 5.1-19.7 cm). All the patients were treated surgically and a definite diagnosis of ACA was obtained by the histopathological, histochemical and immunohistochemical tests. The length of stay range was from 11 to 17 days and there were no perioperative deaths. At a median follow-up of 57.3 months, all the patients were alive and there was no evidence of recurrence, distant metastasis or malignant transformation. CONCLUSIONS Appropriately preoperative differential diagnosis of ACA remains challenging and the final result is usually gained by the histopathology and immunohistochemistry. Although the origin of ACA is still contradictory, surgery is actively advocated as the most effective method for relieving the symptoms and preventing the tumor from local extension or malignant transformation so as to obtain an optimal long-term survival.
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Affiliation(s)
- Gang Wang
- From the Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Liang Ji
- From the Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Feng-Zhi Qu
- From the Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Le Li
- From the Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Cheng-Liang Cao
- From the Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Zong-Bei Li
- From the Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China
| | - Hong Zhu
- From the Department of Pathology, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China.
| | - Bei Sun
- From the Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, China.
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31
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Nagakawa Y, Hosokawa Y, Sahara Y, Takishita C, Nakajima T, Hijikata Y, Tsuchida A. Laparoscopic distal pancreatectomy without needle aspiration before resection for giant mucinous cell neoplasms. Asian J Endosc Surg 2016; 9:75-8. [PMID: 26781533 DOI: 10.1111/ases.12249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 08/05/2015] [Accepted: 08/28/2015] [Indexed: 11/30/2022]
Abstract
Laparoscopic resection of large mucinous cystic neoplasms (MCN) has recently been reported. However, in most reports, needle aspiration of the cyst contents was performed before resection and can cause dissemination. Here, we report two patients with giant MCN: a 26-year-old woman with a 23-cm MCN and a 41-year-old woman with an 18-cm MCN. The MCN were successfully resected without aspiration by laparoscopic surgery. CT revealed no tumor involvement of the origins of the splenic artery and vein in either case. In case 1, we performed hand-assisted laparoscopic surgery while dissecting around the spleen, whereas case 2 underwent pure laparoscopic surgery. No postoperative complications occurred in either case, indicating that laparoscopic distal pancreatectomy for giant MCN is feasible without aspiration in patients without splenic artery and vein origin involvement.
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Affiliation(s)
- Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Hosokawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yatsuka Sahara
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Chie Takishita
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Tetsushi Nakajima
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yousuke Hijikata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
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Di Paola V, Manfredi R, Mehrabi S, Cardobi N, Demozzi E, Belluardo S, Pozzi Mucelli R. Pancreatic mucinous cystoadenomas and cystoadenocarcinomas: differential diagnosis by means of MRI. Br J Radiol 2015; 89:20150536. [PMID: 26529230 DOI: 10.1259/bjr.20150536] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To determine the accuracy of MRI in differentiating mucinous cystoadenomas (MCAs) from mucinous cystoadenocarcinomas (MCACs) of the pancreas, with histopathological analysis as the reference standard, for better surgical planning. METHODS A total of 65 patients with histopathologically proven mucinous cystic neoplasms (MCNs) underwent MRI and surgery. Quantitative image analysis included size, septa and wall thickness and number of loculations. Qualitative image analysis included nodules; hyperintensity of the cystic content on T1 weighted images; compression and/or infiltration of adjacent vessels or organs; and metastases. A comparison between MCAs and MCACs was performed with Student's t-test for quantitative variables and with Fisher test for qualitative variables. Receiver operating characteristic analysis was performed to determine the accuracy in the differential diagnosis between MCAs and MCACs on the basis of a score system obtained by giving 1 point for each quantitative and qualitative variable observed in each patient. RESULTS At histopathology, 43 lesions were MCAs and 22 lesions were MCACs. A statistically significant difference was observed for size >7cm (<0.001), septa and wall thickness >3 mm (<0.0001), number of loculations >4 (<0.0001), nodules (<0.0001), hyperintensity of the cystic content on T1 weighted images (<0.0001), compression (<0.01) and/or infiltration (<0.01) of adjacent vessels or organs and metastases (<0.05). The best cut-off value to discriminate MCAs from MCACs was the presence of three features (p < 0.001), with an accuracy of 91%. CONCLUSION MRI has an accuracy of 91% in the differential diagnosis between MCA and MCAC, helping in identifying forms that could undergo parenchyma-sparing surgery (MCAs), reducing post-surgical morbidity and mortality. ADVANCES IN KNOWLEDGE In this study, the differentiation between MCAs and MCACs of the pancreas by means of MRI is addressed. The differential diagnosis allows selecting benign forms, susceptible of parenchyma-sparing surgery, with the advantage of reducing post-surgical morbidity and stratifying prognosis of MCNs.
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Affiliation(s)
| | | | - Sara Mehrabi
- Departement of Radiology, University of Verona, Verona, Italy
| | - Nicolò Cardobi
- Departement of Radiology, University of Verona, Verona, Italy
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Abstract
BACKGROUND Pancreatic cystic lesions (PCL) are common. They are increasingly detected as an incidental finding of transabdominal ultrasound or cross-sectional imaging. In contrast to other parenchymal organs, dysontogenetic pancreatic cysts are extremely rare. In symptomatic patients the most frequent PCL are acute and chronic pseudocysts. The majority of incidental cystic lesions, however, are neoplasias which have different risks of malignancy. METHODS PubMed was searched for studies, reviews, meta-analyses, and guidelines using the following key words: ('pancreatic cystic lesions' OR 'cystic pancreatic lesions' OR 'intraductal papillary mucinous neoplasia' OR 'mucinous cystic neoplasia' OR 'pancreatic cyst' OR 'pancreatic pseudocyst') AND (management OR treatment OR outcome OR prognosis OR diagnosis OR imaging OR 'endoscopic ultrasound' EUS-FNA OR EUS OR 'endoscopic ultrasonography' OR CT OR MRI). Retrieved papers were reviewed with regard to the diagnostic and therapeutic management of incidental PCL. RESULTS In addition to clinical criteria, transabdominal ultrasonography including contrast-enhanced ultrasonography, cross-sectional radiological imaging, and endoscopic ultrasound (EUS) are used for diagnostic characterization and risk assessment. EUS plays an outstanding role in differential diagnosis and prognostic characterization of incidental PCL. In a single examination it is possible to perform high-resolution morphological description, perfusion imaging, as well as fine-needle aspiration of cyst content, cyst wall, and solid components. An international consensus guideline has defined worrisome and high-risk criteria for the risk assessment of mucinous pancreatic cysts, which are mainly based on the results of EUS and cross-sectional imaging. Nevertheless, despite diagnostic progress and guideline recommendations, differential diagnosis and management decisions remain difficult. This review will discuss problems in and approaches to the diagnosis of incidental PCL. CONCLUSION An evidence-based algorithm for the diagnosis of incidental PCL is proposed.
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Affiliation(s)
- Christian Jenssen
- Department of Internal Medicine, Märkisch Oderland Hospital GmbH, Strausberg/Wriezen, Germany
| | - Stefan Kahl
- Department of Internal Medicine, DRK Kliniken Berlin - Köpenick, Berlin, Germany
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Neuzillet C, Tijeras-Raballand A, Bourget P, Cros J, Couvelard A, Sauvanet A, Vullierme MP, Tournigand C, Hammel P. State of the art and future directions of pancreatic ductal adenocarcinoma therapy. Pharmacol Ther 2015; 155:80-104. [PMID: 26299994 DOI: 10.1016/j.pharmthera.2015.08.006] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 08/17/2015] [Indexed: 12/12/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is expected to become the second cause of cancer-related death in 2030. PDAC is the poorest prognostic tumor of the digestive tract, with 80% of patients having advanced disease at diagnosis and 5-year survival rate not exceeding 7%. Until 2010, gemcitabine was the only validated therapy for advanced PDAC with a modest improvement in median overall survival as compared to best supportive care (5-6 vs 3 months). Multiple phase II-III studies have used various combinations of gemcitabine with other cytotoxics or targeted agents, most in vain, in attempt to improve this outcome. Over the past few years, the landscape of PDAC management has undergone major and rapid changes with the approval of the FOLFIRINOX and gemcitabine plus nab-paclitaxel regimens in patients with metastatic disease. These two active combination chemotherapy options yield an improved median overall survival (11.1 vs 8.5 months, respectively) thus making longer survival a reasonably achievable goal. This breakthrough raises some new clinical questions about the management of PDAC. Moreover, better knowledge of the environmental and genetic events that underpin multistep carcinogenesis and of the microenvironment surrounding cancer cells in PDAC has open new perspectives and therapeutic opportunities. In this new dynamic context of deep transformation in basic research and clinical management aspects of the disease, we gathered updated preclinical and clinical data in a multifaceted review encompassing the lessons learned from the past, the yet unanswered questions, and the most promising research priorities to be addressed for the next 5 years.
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Affiliation(s)
- Cindy Neuzillet
- INSERM UMR1149, Bichat-Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 46 rue Henri Huchard, 75018 Paris, and 100 boulevard du Général Leclerc, 92110 Clichy, France; Department of Digestive Oncology, Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 100 boulevard du Général Leclerc, 92110 Clichy, France; Department of Medical Oncology, Henri Mondor University Hospital, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France.
| | - Annemilaï Tijeras-Raballand
- Department of Translational Research, AAREC Filia Research, 1 place Paul Verlaine, 92100 Boulogne-Billancourt, France
| | - Philippe Bourget
- Department of Clinical Pharmacy, Necker-Enfants Malades University Hospital, 149 Rue de Sèvres, 75015 Paris, France
| | - Jérôme Cros
- INSERM UMR1149, Bichat-Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 46 rue Henri Huchard, 75018 Paris, and 100 boulevard du Général Leclerc, 92110 Clichy, France; Department of Pathology, Bichat-Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 46 rue Henri Huchard, 75018 Paris, and 100 boulevard du Général Leclerc, 92110 Clichy, France
| | - Anne Couvelard
- INSERM UMR1149, Bichat-Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 46 rue Henri Huchard, 75018 Paris, and 100 boulevard du Général Leclerc, 92110 Clichy, France; Department of Pathology, Bichat-Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 46 rue Henri Huchard, 75018 Paris, and 100 boulevard du Général Leclerc, 92110 Clichy, France
| | - Alain Sauvanet
- Department of Biliary and Pancreatic Surgery, Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 100 boulevard du Général Leclerc, 92110 Clichy, France
| | - Marie-Pierre Vullierme
- Department of Radiology, Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 100 boulevard du Général Leclerc, 92110 Clichy, France
| | - Christophe Tournigand
- Department of Medical Oncology, Henri Mondor University Hospital, 51 avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France
| | - Pascal Hammel
- INSERM UMR1149, Bichat-Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 46 rue Henri Huchard, 75018 Paris, and 100 boulevard du Général Leclerc, 92110 Clichy, France; Department of Digestive Oncology, Beaujon University Hospital (AP-HP - PRES Paris 7 Diderot), 100 boulevard du Général Leclerc, 92110 Clichy, France
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Lévy P, Rebours V. Differential Diagnosis of Cystic Pancreatic Lesions Including the Usefulness of Biomarkers. VISZERALMEDIZIN 2015; 31:7-13. [PMID: 26285674 PMCID: PMC4433139 DOI: 10.1159/000371786] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Cystic pancreatic lesions are more and more often found. Malignant risk ranges from nil to more than 60%. A precise diagnosis is required to adapt surveillance or therapeutic strategy. Methods We tried to identify the most difficult differential diagnoses encountered in a tertiary center of pancreatology and to guide the reader as how to reach the correct strategy and diagnosis in these situations. Results We identified eight clinically difficult situations: i) chronic pancreatitis versus intraductal papillary mucinous neoplasms, ii) serous versus mucinous cystic neoplasms, iii) serous cystic neoplasms versus branch-duct intraductal papillary mucinous neoplasms, iv) intraductal papillary mucinous neoplasms versus acinar cell cystadenoma, v) (pseudo-) solid serous cystic neoplasm versus neuroendocrine tumor, vi) pancreatic neuroendocrine tumors versus solid pseudopapillary tumors, vii) cystic forms of a solid tumor, and viii) rare pancreatic or peripancreatic cystic lesions. The work-up should rely on computed tomography scan, pancreatic magnetic resonance imaging, and, only if necessary, endoscopic ultrasound with or without fine needle aspiration. Conclusion An expert analysis of imaging data allows a precise diagnosis in most of the cases. Pancreatic resection should no longer be performed in case of diagnostic doubt.
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Affiliation(s)
- Philippe Lévy
- AP-HP, DHU Unity, Department of Gastroenterology and Pancreatology, Beaujon Hospital, Clichy, France ; DHU Unity, Faculté Denis Diderot, Paris-Diderot University, Paris, France
| | - Vinciane Rebours
- AP-HP, DHU Unity, Department of Gastroenterology and Pancreatology, Beaujon Hospital, Clichy, France ; DHU Unity, Faculté Denis Diderot, Paris-Diderot University, Paris, France
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36
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Kim TS, Fernandez-del Castillo C. Diagnosis and Management of Pancreatic Cystic Neoplasms. Hematol Oncol Clin North Am 2015; 29:655-74. [PMID: 26226903 DOI: 10.1016/j.hoc.2015.04.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Incidentally discovered pancreatic cystic lesions are increasingly common, affecting up to 10% to 15% of patients undergoing cross-sectional imaging. Although some pancreatic cystic neoplasms harbor invasive malignancy or the potential to progress over time, a majority are benign and can be observed safely. Accurate diagnosis is key to appropriate management. Diagnosis requires a multidisciplinary and multimodal approach. This review discusses each type of pancreatic cystic neoplasm and the current data on diagnosis and treatment.
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Affiliation(s)
- Teresa S Kim
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, GRB-425, Boston, MA 02114, USA
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Scheiman JM, Hwang JH, Moayyedi P. American gastroenterological association technical review on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015; 148:824-48.e22. [PMID: 25805376 DOI: 10.1053/j.gastro.2015.01.014] [Citation(s) in RCA: 282] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- James M Scheiman
- Department of Internal Medicine and Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Joo Ha Hwang
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington
| | - Paul Moayyedi
- Division of Gastroenterology, Hamilton Health Sciences, Farncombe Family Digestive Health Research Institute, McMaster University Hamilton, Ontario, Canada
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Management of pancreatic mucinous cystic neoplasms: surgery or surveillance? Pancreatology 2015; 15:97-8. [PMID: 25841313 DOI: 10.1016/j.pan.2015.02.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 02/27/2015] [Indexed: 12/11/2022]
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Becker AE, Hernandez YG, Frucht H, Lucas AL. Pancreatic ductal adenocarcinoma: Risk factors, screening, and early detection. World J Gastroenterol 2014; 20:11182-11198. [PMID: 25170203 PMCID: PMC4145757 DOI: 10.3748/wjg.v20.i32.11182] [Citation(s) in RCA: 217] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 01/15/2014] [Accepted: 04/16/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is the fourth most common cause of cancer-related deaths in the United States, with over 38000 deaths in 2013. The opportunity to detect pancreatic cancer while it is still curable is dependent on our ability to identify and screen high-risk populations before their symptoms arise. Risk factors for developing pancreatic cancer include multiple genetic syndromes as well as modifiable risk factors. Genetic conditions include hereditary breast and ovarian cancer syndrome, Lynch Syndrome, familial adenomatous polyposis, Peutz-Jeghers Syndrome, familial atypical multiple mole melanoma syndrome, hereditary pancreatitis, cystic fibrosis, and ataxia-telangiectasia; having a genetic predisposition can raise the risk of developing pancreatic cancer up to 132-fold over the general population. Modifiable risk factors, which include tobacco exposure, alcohol use, chronic pancreatitis, diet, obesity, diabetes mellitus, as well as certain abdominal surgeries and infections, have also been shown to increase the risk of pancreatic cancer development. Several large-volume centers have initiated such screening protocols, and consensus-based guidelines for screening high-risk groups have recently been published. The focus of this review will be both the genetic and modifiable risk factors implicated in pancreatic cancer, as well as a review of screening strategies and their diagnostic yields.
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40
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Park JW, Jang JY, Kang MJ, Kwon W, Chang YR, Kim SW. Mucinous cystic neoplasm of the pancreas: is surgical resection recommended for all surgically fit patients? Pancreatology 2014; 14:131-6. [PMID: 24650968 DOI: 10.1016/j.pan.2013.12.006] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 12/24/2013] [Accepted: 12/27/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Surgical removal of mucinous cystic neoplasms (MCNs) is usually recommended because of the risk of malignancy. However, increased experience of MCNs suggests that the incidence of invasion is lower than had been thought. This study was designed to establish more reasonable surgical indications for MCN through re-assessment using strict pathologic diagnostic criteria. METHODS Ninety-four patients who underwent surgical removal of MCNs at Seoul National University Hospital from 1991 to 2012 were retrospectively analyzed. Pathologic results were re-evaluated by an experienced pathologist. Medical records and radiologic images were reviewed to determine factors predicting malignancy. RESULTS Of the 94 patients, 4 were found to have intraductal papillary mucinous neoplasms (IPMNs). Of the 90 MCNs, 60 (66.7%) were low-grade, 21 (23.3%) were intermediate-grade, and 5 (5.5%) were high-grade dysplasias; and 4 (4.4%) were invasive carcinoma. Mural nodules on CT scan (p = 0.005) and abnormal serum CA19-9 concentration (p = 0.029) were significant predictors of malignancy. All MCNs less than 3 cm in size with normal serum tumor markers were benign and all malignant MCNs had cyst fluid CA19-9 over 10,000 units/ml. The five year disease specific survival rates were 98.8% for all patients and 75.0% for those with invasive MCNs. CONCLUSION MCNs had a low prevalence of malignancy. Regardless of the histological grade, long-term outcome was excellent. Therefore, in the absence of specific symptoms, surgery may not be indicated for MCNs <3 cm without mural nodules or elevated serum tumor markers. Validation by a prospective study with very careful design is needed.
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Affiliation(s)
- Jae Woo Park
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Mee Joo Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ye Rim Chang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sun-Whe Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Ohtsuka T, Takahata S, Takanami H, Ueda J, Mizumoto K, Shimizu S, Tanaka M. Laparoscopic surgery is applicable for larger mucinous cystic neoplasms of the pancreas. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:343-8. [DOI: 10.1002/jhbp.32] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Takao Ohtsuka
- Department of Surgery and Oncology; Graduate School of Medical Sciences; Kyushu University; 3-1-1 Maidashi, Higashi-ku Fukuoka 812-8582 Japan
| | - Shunichi Takahata
- Department of Surgery and Oncology; Graduate School of Medical Sciences; Kyushu University; 3-1-1 Maidashi, Higashi-ku Fukuoka 812-8582 Japan
| | - Hideki Takanami
- Department of Surgery and Oncology; Graduate School of Medical Sciences; Kyushu University; 3-1-1 Maidashi, Higashi-ku Fukuoka 812-8582 Japan
| | - Junji Ueda
- Department of Surgery and Oncology; Graduate School of Medical Sciences; Kyushu University; 3-1-1 Maidashi, Higashi-ku Fukuoka 812-8582 Japan
| | - Kazuhiro Mizumoto
- Department of Surgery and Oncology; Graduate School of Medical Sciences; Kyushu University; 3-1-1 Maidashi, Higashi-ku Fukuoka 812-8582 Japan
| | - Shuji Shimizu
- Department of Surgery and Oncology; Graduate School of Medical Sciences; Kyushu University; 3-1-1 Maidashi, Higashi-ku Fukuoka 812-8582 Japan
| | - Masao Tanaka
- Department of Surgery and Oncology; Graduate School of Medical Sciences; Kyushu University; 3-1-1 Maidashi, Higashi-ku Fukuoka 812-8582 Japan
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Farrell JJ, Fernández-del Castillo C. Pancreatic cystic neoplasms: management and unanswered questions. Gastroenterology 2013; 144:1303-15. [PMID: 23622140 DOI: 10.1053/j.gastro.2013.01.073] [Citation(s) in RCA: 143] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 01/27/2013] [Accepted: 01/30/2013] [Indexed: 02/08/2023]
Abstract
Approximately 10% of persons 70 years old or older are now diagnosed with pancreatic cysts, but it is not clear which ones require additional analysis, interventions, or follow-up. Primary care doctors rely on gastroenterologists for direction because no one wants to miss a diagnosis of pancreatic cancer, but meanwhile there is pressure to limit use of diagnostic tests and limit costs. We review the different cystic neoplasms of the pancreas and diagnostic strategies based on clinical features and imaging data. We discuss surgical and nonsurgical management of the most common cystic neoplasms, based on the recently revised Sendai guidelines. Intraductal papillary mucinous neoplasm (particularly the branch duct variant) is the lesion most frequently identified incidentally. We report what is known about its pathology, its risk of developing into pancreatic ductal adenocarcinoma, the pros and cons of current guidelines for management, and the potential role of endoscopic ultrasound in determining cancer risk. We also review surgical treatment and strategies for surveillance of pancreatic cysts.
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Affiliation(s)
- James J Farrell
- Yale Pancreas Center and Interventional Endoscopy, Yale School of Medicine, New Haven, Connecticut, USA.
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43
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Abstract
Incidentally discovered cystic tumors of the pancreas (CTP) are an increasingly frequent entity. It is essential to differentiate lesions whose malignant potential is either nil or negligible (pseudocyst, serous cystadenoma, simple cysts) from lesions with intermediate malignant potential (intraductal papillary mucinous tumor of the pancreas [IPMN] involving the secondary ducts, cystic endocrine tumor) or those with high malignant potential (mucinous cystadenoma, solid pseudopapillary tumors and IPMN involving the main pancreatic duct). The approach to defining malignant potential is based on diagnostic CT scan, magnetic resonance imaging (MRI), and endoscopic ultrasound (EUS), often complemented by EUS-guided cyst puncture for biochemical and cytological analysis of cyst fluid. Surgery for diagnostic purposes should be avoided because of its significant morbidity. For pseudocysts, simple cysts and serous cystadenomas, abstention is the general rule. Resection, preserving as much pancreatic parenchyma as possible, is the rule for IPMN involving the main pancreatic duct, mucinous cystadenomas, solid and pseudopapillary tumors, and cystic endocrine tumors. Resection is rarely indicated at the outset for IPMN involving secondary pancreatic ducts; morphologic observation is the general rule and preventive excision may be indicated secondarily. Good collaboration between surgeons, radiologists and endosonographists is necessary for optimal management of CTP.
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44
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Hata T, Sakata N, Motoi F, Unno M. One of the multifocal intraductal papillary mucinous neoplasms with the clinical characteristics of mucinous cystic neoplasm. BMJ Case Rep 2013; 2013:bcr-2012-008276. [PMID: 23420728 DOI: 10.1136/bcr-2012-008276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 74-year-old woman with multiple cystic lesions in the pancreas was first examined at a previous hospital. Many of the lesions in the head and body were diagnosed as a branch duct intraductal papillary mucinous neoplasms (IPMN), but one lesion in the tail was a simple cyst. She had no surgical treatment because there were no signs of malignancy in any of the lesions. After 3 years, solid components appeared only in the tail lesion. Because of its preoperative diagnosis as a mucinous cystic neoplasm (MCN), distal pancreatectomy was performed. Histopathological findings revealed that the cystic tumour in the tail was IPMN with minimally invasive carcinoma and the other lesion in the body was IPMN with low-grade dysplasia. They were IPMNs bridged by a non-dilated main pancreatic duct. There may be some cases in which it is difficult to diagnose between IPMN and MCN.
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Affiliation(s)
- Tatsuo Hata
- Division of Hepato-Biliary-Pancreatic Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
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Intracholecystic papillary-tubular neoplasms (ICPN) of the gallbladder (neoplastic polyps, adenomas, and papillary neoplasms that are ≥1.0 cm): clinicopathologic and immunohistochemical analysis of 123 cases. Am J Surg Pathol 2012; 36:1279-301. [PMID: 22895264 DOI: 10.1097/pas.0b013e318262787c] [Citation(s) in RCA: 163] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The literature on the clinicopathologic characteristics of tumoral intraepithelial neoplasms (neoplastic polyps) of the gallbladder (GB) is fairly limited, due in part to the variability in definition and terminology. Most reported adenomas (pyloric gland type and others) were microscopic and thus regarded as clinically inconsequential, whereas papillary in situ carcinomas have been largely considered a type of invasive adenocarcinoma under the heading of "papillary adenocarcinomas." In this study, 123 GB cases that have a well-defined exophytic preinvasive neoplasm measuring ≥1 cm were analyzed. The patients were predominantly female (F/M=2:1) with a mean age of 61 y and a median tumor size of 2.2 cm. Half of the patients presented with pain, and in the other half the neoplasm was detected incidentally. Other neoplasms, most being gastrointestinal tract malignancies, were present in 22% of cases. Gallstones were identified in only 20% of cases. Radiologically, almost half were diagnosed as "cancer," roughly half with polypoid tumor, and in 10% the lesion was missed. Pathologic findings: (1) The predominant configuration was papillary in 43%, tubulopapillary in 31%, tubular in 26%. (2) Each case was assigned a final lineage type on the basis of the predominant pattern (>75% of the lesion) on morphology, and supported with specific immunohistochemical cell lineage markers. The predominant cell lineage could be identified as biliary in 50% (66% of which were MUC1), gastric foveolar in 16% (all were MUC5AC), gastric pyloric in 20% (92% MUC6), intestinal in 8% (100% CK20; 75% CDX2; 50%, MUC2), and oncocytic in 6% (17% HepPar and 17% MUC6); however, 90% of cases had some amount of secondary or unclassifiable pattern and hybrid immunophenotypes. (3) Of the cases that would have qualified as "pyloric gland adenoma," 21/24 (88%) had at least focal high-grade dysplasia and 18% had associated invasive carcinoma. Conversely, 8 of 47 "papillary adenocarcinoma"-type cases displayed some foci of low-grade dysplasia, and 15/47 (32%) had no identifiable invasion. (4) Overall, 55% of the cases had an associated invasive carcinoma (pancreatobiliary type, 58; others, 10). Factors associated significantly with invasion were the extent of high-grade dysplasia, cell type (biliary or foveolar), and papilla formation. Among systematically analyzed invasive carcinomas, tumoral intraepithelial neoplasia was detected in 6.4% (39/606). (5) The 3-year actuarial survival was 90% for cases without invasion and 60% for those associated with invasion. In contrast, those associated with invasion had a far better clinical outcome compared with pancreatobiliary-type GB carcinomas (3-yr survival, 27%), and this survival advantage persisted even with stage-matched comparison. Death occurred in long-term follow-up even in a few noninvasive cases (4/55; median 73.5 mo) emphasizing the importance of long-term follow-up. In conclusion, tumoral preinvasive neoplasms (≥1 cm) in the GB are analogous to their pancreatic and biliary counterparts (biliary intraductal papillary neoplasms, pancreatic intraductal papillary mucinous neoplasms, and intraductal tubulopapillary neoplasms). They show variable cellular lineages, a spectrum of dysplasia, and a mixture of papillary or tubular growth patterns, often with significant overlap, warranting their classification under 1 unified parallel category, intracholecystic papillary-tubular neoplasm. Intracholecystic papillary-tubular neoplasms are relatively indolent neoplasia with significantly better prognosis compared with pancreatobiliary-type GB carcinomas. In contrast, even seemingly innocuous examples such as those referred to as "pyloric gland adenomas" can progress to carcinoma and be associated with invasion and fatal outcome.
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