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1
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Umar H, Mahnur H, Brooke G, Amitabh C. Management of Cystic Neoplasms of the Pancreas. GASTROINTESTINAL ONCOLOGY ‐ A CRITICAL MULTIDISCIPLINARY TEAM APPROACH 2E 2024:438-454. [DOI: 10.1002/9781119756422.ch22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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2
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Berbís MÁ, Godino FP, Rodríguez-Comas J, Nava E, García-Figueiras R, Baleato-González S, Luna A. Radiomics in CT and MR imaging of the liver and pancreas: tools with potential for clinical application. Abdom Radiol (NY) 2024; 49:322-340. [PMID: 37889265 DOI: 10.1007/s00261-023-04071-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/15/2023] [Accepted: 09/19/2023] [Indexed: 10/28/2023]
Abstract
Radiomics allows the extraction of quantitative imaging features from clinical magnetic resonance imaging (MRI) and computerized tomography (CT) studies. The advantages of radiomics have primarily been exploited in oncological applications, including better characterization and staging of oncological lesions and prediction of patient outcomes and treatment response. The potential introduction of radiomics in the clinical setting requires the establishment of a standardized radiomics pipeline and a quality assurance program. Radiomics and texture analysis of the liver have improved the differentiation of hypervascular lesions such as adenomas, focal nodular hyperplasia, and hepatocellular carcinoma (HCC) during the arterial phase, and in the pretreatment determination of HCC prognostic factors (e.g., tumor grade, microvascular invasion, Ki-67 proliferation index). Radiomics of pancreatic CT and MR images has enhanced pancreatic ductal adenocarcinoma detection and its differentiation from pancreatic neuroendocrine tumors, mass-forming chronic pancreatitis, or autoimmune pancreatitis. Radiomics can further help to better characterize incidental pancreatic cystic lesions, accurately discriminating benign from malignant intrapancreatic mucinous neoplasms. Nonetheless, despite their encouraging results and exciting potential, these tools have yet to be implemented in the clinical setting. This non-systematic review will describe the essential steps in the implementation of the radiomics and feature extraction workflow from liver and pancreas CT and MRI studies for their potential clinical application. A succinct overview of reported radiomics applications in the liver and pancreas and the challenges and limitations of their implementation in the clinical setting is also discussed, concluding with a brief exploration of the future perspectives of radiomics in the gastroenterology field.
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Affiliation(s)
- M Álvaro Berbís
- Department of Radiology, HT Médica, San Juan de Dios Hospital, 14960, Córdoba, Spain.
- Department of Radiology, HT Médica, San Juan de Dios Hospital, Av. del Brillante, 106, 14012, Córdoba, Spain.
| | | | | | - Enrique Nava
- Department of Communications Engineering, University of Málaga, 29016, Málaga, Spain
| | - Roberto García-Figueiras
- Abdominal Imaging Section, University Clinical Hospital of Santiago, 15706, Santiago de Compostela, A Coruña, Spain
| | - Sandra Baleato-González
- Abdominal Imaging Section, University Clinical Hospital of Santiago, 15706, Santiago de Compostela, A Coruña, Spain
| | - Antonio Luna
- Department of Radiology, HT Médica, Clínica las Nieves, 23007, Jaén, Spain
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3
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Rawlani P, Ghosh NK, Kumar A. Role of artificial intelligence in the characterization of indeterminate pancreatic head mass and its usefulness in preoperative diagnosis. Artif Intell Gastroenterol 2023; 4:48-63. [DOI: 10.35712/aig.v4.i3.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/11/2023] [Accepted: 10/08/2023] [Indexed: 12/07/2023] Open
Abstract
Artificial intelligence (AI) has been used in various fields of day-to-day life and its role in medicine is immense. Understanding of oncology has been improved with the introduction of AI which helps in diagnosis, treatment planning, management, prognosis, and follow-up. It also helps to identify high-risk groups who can be subjected to timely screening for early detection of malignant conditions. It is more important in pancreatic cancer as it is one of the major causes of cancer-related deaths worldwide and there are no specific early features (clinical and radiological) for diagnosis. With improvement in imaging modalities (computed tomography, magnetic resonance imaging, endoscopic ultrasound), most often clinicians were being challenged with lesions that were difficult to diagnose with human competence. AI has been used in various other branches of medicine to differentiate such indeterminate lesions including the thyroid gland, breast, lungs, liver, adrenal gland, kidney, etc. In the case of pancreatic cancer, the role of AI has been explored and is still ongoing. This review article will focus on how AI can be used to diagnose pancreatic cancer early or differentiate it from benign pancreatic lesions, therefore, management can be planned at an earlier stage.
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Affiliation(s)
- Palash Rawlani
- Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Nalini Kanta Ghosh
- Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
| | - Ashok Kumar
- Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226014, Uttar Pradesh, India
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Benke M, Zeöld A, Kittel Á, Khamari D, Hritz I, Horváth M, Keczer B, Borka K, Szücs Á, Wiener Z. MiR-200b categorizes patients into pancreas cystic lesion subgroups with different malignant potential. Sci Rep 2023; 13:19820. [PMID: 37963969 PMCID: PMC10646105 DOI: 10.1038/s41598-023-47129-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 11/09/2023] [Indexed: 11/16/2023] Open
Abstract
Extracellular vesicles (EV) carry their cargo in a membrane protected form, however, their value in early diagnostics is not well known. Although pancreatic cysts are heterogeneous, they can be clustered into the larger groups of pseudocysts (PC), and serous and mucinous pancreatic cystic neoplasms (S-PCN and M-PCN, respectively). In contrast to PCs and S-PCNs, M-PCNs may progress to malignant pancreatic cancers. Since current diagnostic tools do not meet the criteria of high sensitivity and specificity, novel methods are urgently needed to differentiate M-PCNs from other cysts. We show that cyst fluid is a rich source of EVs that are positive and negative for the EV markers CD63 and CD81, respectively. Whereas we found no difference in the EV number when comparing M-PCN with other pancreatic cysts, our EV-based biomarker identification showed that EVs from M-PCNs had a higher level of miR-200b. We also prove that not only EV-derived, but also total cyst fluid miR-200b discriminates patients with M-PCN from other pancreatic cysts with a higher sensitivity and specificity compared to other diagnostic methods, providing the possibility for clinical applications. Our results show that measuring miR-200b in cyst fluid-derived EVs or from cyst fluid may be clinically important in categorizing patients.
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Affiliation(s)
- Márton Benke
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Anikó Zeöld
- Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Ágnes Kittel
- Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
- HUN-REN Institute of Experimental Medicine, Budapest, Hungary
| | - Delaram Khamari
- Department of Genetics, Cell and Immunobiology, and HUN-REN-SU Translational Extracellular Vesicle Research Group, Semmelweis University, Budapest, Hungary
| | - István Hritz
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Miklós Horváth
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Bánk Keczer
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Katalin Borka
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Budapest, Hungary
| | - Ákos Szücs
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary.
| | - Zoltán Wiener
- Department of Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary.
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5
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Huang C, Chopra S, Bolan CW, Chandarana H, Harfouch N, Hecht EM, Lo GC, Megibow AJ. Pancreatic Cystic Lesions: Next Generation of Radiologic Assessment. Gastrointest Endosc Clin N Am 2023; 33:533-546. [PMID: 37245934 DOI: 10.1016/j.giec.2023.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Pancreatic cystic lesions are frequently identified on cross-sectional imaging. As many of these are presumed branch-duct intraductal papillary mucinous neoplasms, these lesions generate much anxiety for the patients and clinicians, often necessitating long-term follow-up imaging and even unnecessary surgical resections. However, the incidence of pancreatic cancer is overall low for patients with incidental pancreatic cystic lesions. Radiomics and deep learning are advanced tools of imaging analysis that have attracted much attention in addressing this unmet need, however, current publications on this topic show limited success and large-scale research is needed.
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Affiliation(s)
- Chenchan Huang
- Department of Radiology, NYU Grossman School of Medicine, 660 1st Avenue, 3F, New York, NY 10016, USA.
| | - Sumit Chopra
- Department of Radiology, NYU Grossman School of Medicine, 650 First Avenue, 4th Floor, New York, NY 10016, USA
| | - Candice W Bolan
- Department of Radiology, Mayo Clinic in Florida, 4500 San Pablo Road South, Jacksonville, FL 32224, USA
| | - Hersh Chandarana
- Department of Radiology, NYU Grossman School of Medicine, 660 1st Avenue, 3F, New York, NY 10016, USA
| | - Nassier Harfouch
- Department of Radiology, NYU Grossman School of Medicine, 660 1st Avenue, 3F, New York, NY 10016, USA
| | - Elizabeth M Hecht
- Department of Radiology, New York Presbyterian - Weill Cornell Medicine, 520 East 70th Street, Starr 8a, New York, NY 10021, USA
| | - Grace C Lo
- Department of Radiology, New York Presbyterian - Weill Cornell Medicine, 520 East 70th Street, Starr 7a, New York, NY 10021, USA
| | - Alec J Megibow
- Department of Radiology, NYU Grossman School of Medicine, 660 1st Avenue, 3F, New York, NY 10016, USA
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Xia Q, Li F, Min R, Sun S, Han YX, Feng ZZ, Li N. Malignancy risk factors and prognostic variables of pancreatic mucinous cystic neoplasms in Chinese patients. World J Gastroenterol 2023; 29:3119-3132. [PMID: 37346158 PMCID: PMC10280801 DOI: 10.3748/wjg.v29.i20.3119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/21/2023] [Accepted: 05/04/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Pancreatic mucinous cystic neoplasms (MCNs) represent one of the precursor lesions of pancreatic ductal adenocarcinoma, and their detection has been facilitated by advances in preoperative imaging. Due primarily to the rarity of MCNs, however, there is limited knowledge regarding the prognostic variables and high-risk factors for malignant transformation. A more comprehensive and nuanced approach is necessary to fill this gap and provide a basis for improved treatment decisions and patient outcomes.
AIM To investigate the high-risk factors associated with malignant MCNs and to explore the prognostic factors of MCN with associated invasive carcinoma (MCN-AIC).
METHODS All cases of resected MCNs from a single high-volume institution between January 2012 and January 2022 were retrospectively reviewed. Only cases with ovarian-type stroma verified by progesterone receptor staining were included. Preoperative features, histological findings and postoperative course were documented. Multivariate logistic regression was employed to investigate variables related to malignancy. Survival analysis was performed using the Kaplan-Meier curve, and the prognostic factors were assessed to evaluate the postoperative course of patients with MCN-AIC.
RESULTS Among the 48 patients, 36 had benign MCNs, and 12 had malignant MCNs (1 high-grade atypical hyperplasia and 11 MCN-AIC). Age, tumour size, presence of solid components or mural nodules and pancreatic duct dilatation were identified as independent risk factors associated with malignancy. The follow-up period ranged from 12 mo to 120 mo, with a median overall survival of 58.2 mo. Only three patients with MCN-AIC died, and the 5-year survival rate was 70.1%. All 11 cases of MCN-AIC were stage I, and extracapsular invasion was identified as a prognostic factor for poorer outcomes.
CONCLUSION The risk factors independently associated with malignant transformation of MCNs included age, tumour size, presence of solid components or mural nodules, and pancreatic duct dilatation. Our study also revealed that encapsulated invasion was a favourable prognostic factor in MCN-AIC patients.
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MESH Headings
- Humans
- Carcinoma, Pancreatic Ductal/epidemiology
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Pancreatic Ductal/surgery
- East Asian People
- Neoplasms, Cystic, Mucinous, and Serous/epidemiology
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/surgery
- Pancreatic Neoplasms/epidemiology
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/surgery
- Prognosis
- Receptors, Progesterone
- Retrospective Studies
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Affiliation(s)
- Qing Xia
- Department of Pathology, The First Affiliated Hospital of Bengbu Medical College, Bengbu Medical College, Bengbu 233004, Anhui Province, China
| | - Fan Li
- Department of Pathology, Bengbu Medical College, Bengbu 233030, Anhui Province, China
| | - Rui Min
- Department of Pathology, The First Affiliated Hospital of Bengbu Medical College, Bengbu Medical College, Bengbu 233004, Anhui Province, China
| | - Shuai Sun
- Department of Pathology, Bengbu Medical College, Bengbu 233030, Anhui Province, China
| | - Yue-Xin Han
- School of Clinical Medicine, Bengbu Medical College, Bengbu 233030, Anhui Province, China
| | - Zhen-Zhong Feng
- Department of Pathology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, Anhui Province, China
| | - Nan Li
- Department of Pathology, The First Affiliated Hospital of Bengbu Medical College, Bengbu Medical College, Bengbu 233004, Anhui Province, China
- Department of Pathology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, Anhui Province, China
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Harrison JM, Yala A, Mikhael P, Roldan J, Ciprani D, Michelakos T, Bolm L, Qadan M, Ferrone C, Fernandez-Del Castillo C, Lillemoe KD, Santus E, Hughes K. Successful Development of a Natural Language Processing Algorithm for Pancreatic Neoplasms and Associated Histologic Features. Pancreas 2023; 52:e219-e223. [PMID: 37716007 DOI: 10.1097/mpa.0000000000002242] [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: 09/18/2023]
Abstract
OBJECTIVES Natural language processing (NLP) algorithms can interpret unstructured text for commonly used terms and phrases. Pancreatic pathologies are diverse and include benign and malignant entities with associated histologic features. Creating a pancreas NLP algorithm can aid in electronic health record coding as well as large database creation and curation. METHODS Text-based pancreatic anatomic and cytopathologic reports for pancreatic cancer, pancreatic ductal adenocarcinoma, neuroendocrine tumor, intraductal papillary neoplasm, tumor dysplasia, and suspicious findings were collected. This dataset was split 80/20 for model training and development. A separate set was held out for testing purposes. We trained using convolutional neural network to predict each heading. RESULTS Over 14,000 reports were obtained from the Mass General Brigham Healthcare System electronic record. Of these, 1252 reports were used for algorithm development. Final accuracy and F1 scores relative to the test set ranged from 95% and 98% for each queried pathology. To understand the dependence of our results to training set size, we also generated learning curves. Scoring metrics improved as more reports were submitted for training; however, some queries had high index performance. CONCLUSIONS Natural language processing algorithms can be used for pancreatic pathologies. Increased training volume, nonoverlapping terminology, and conserved text structure improve NLP algorithm performance.
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Affiliation(s)
- Jon Michael Harrison
- From the Department of GI and General Surgery, Massachusetts General Hospital, Boston
| | - Adam Yala
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, Mass
| | - Peter Mikhael
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, Mass
| | - Jorge Roldan
- From the Department of GI and General Surgery, Massachusetts General Hospital, Boston
| | - Debora Ciprani
- From the Department of GI and General Surgery, Massachusetts General Hospital, Boston
| | - Theodoros Michelakos
- From the Department of GI and General Surgery, Massachusetts General Hospital, Boston
| | - Louisa Bolm
- From the Department of GI and General Surgery, Massachusetts General Hospital, Boston
| | - Motaz Qadan
- From the Department of GI and General Surgery, Massachusetts General Hospital, Boston
| | - Cristina Ferrone
- From the Department of GI and General Surgery, Massachusetts General Hospital, Boston
| | | | | | - Enrico Santus
- Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, Cambridge, Mass
| | - Kevin Hughes
- From the Department of GI and General Surgery, Massachusetts General Hospital, Boston
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8
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Granata V, Fusco R, Setola SV, Galdiero R, Maggialetti N, Silvestro L, De Bellis M, Di Girolamo E, Grazzini G, Chiti G, Brunese MC, Belli A, Patrone R, Palaia R, Avallone A, Petrillo A, Izzo F. Risk Assessment and Pancreatic Cancer: Diagnostic Management and Artificial Intelligence. Cancers (Basel) 2023; 15:351. [PMID: 36672301 PMCID: PMC9857317 DOI: 10.3390/cancers15020351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
Pancreatic cancer (PC) is one of the deadliest cancers, and it is responsible for a number of deaths almost equal to its incidence. The high mortality rate is correlated with several explanations; the main one is the late disease stage at which the majority of patients are diagnosed. Since surgical resection has been recognised as the only curative treatment, a PC diagnosis at the initial stage is believed the main tool to improve survival. Therefore, patient stratification according to familial and genetic risk and the creation of screening protocol by using minimally invasive diagnostic tools would be appropriate. Pancreatic cystic neoplasms (PCNs) are subsets of lesions which deserve special management to avoid overtreatment. The current PC screening programs are based on the annual employment of magnetic resonance imaging with cholangiopancreatography sequences (MR/MRCP) and/or endoscopic ultrasonography (EUS). For patients unfit for MRI, computed tomography (CT) could be proposed, although CT results in lower detection rates, compared to MRI, for small lesions. The actual major limit is the incapacity to detect and characterize the pancreatic intraepithelial neoplasia (PanIN) by EUS and MR/MRCP. The possibility of utilizing artificial intelligence models to evaluate higher-risk patients could favour the diagnosis of these entities, although more data are needed to support the real utility of these applications in the field of screening. For these motives, it would be appropriate to realize screening programs in research settings.
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Affiliation(s)
- Vincenza Granata
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Roberta Fusco
- Medical Oncology Division, Igea SpA, 41012 Napoli, Italy
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy
| | - Sergio Venanzio Setola
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Roberta Galdiero
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Nicola Maggialetti
- Department of Medical Science, Neuroscience and Sensory Organs (DSMBNOS), University of Bari “Aldo Moro”, 70124 Bari, Italy
| | - Lucrezia Silvestro
- Division of Clinical Experimental Oncology Abdomen, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Mario De Bellis
- Division of Gastroenterology and Digestive Endoscopy, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Elena Di Girolamo
- Division of Gastroenterology and Digestive Endoscopy, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Giulia Grazzini
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Giuditta Chiti
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Maria Chiara Brunese
- Diagnostic Imaging Section, Department of Medical and Surgical Sciences & Neurosciences, University of Molise, 86100 Campobasso, Italy
| | - Andrea Belli
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Renato Patrone
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Raffaele Palaia
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Antonio Avallone
- Division of Clinical Experimental Oncology Abdomen, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Antonella Petrillo
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Francesco Izzo
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
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Giannone F, Crippa S, Aleotti F, Palumbo D, Belfiori G, Partelli S, Schiavo Lena M, Capurso G, Petrone MC, De Cobelli F, Arcidiacono PG, Falconi M. Improving diagnostic accuracy and appropriate indications for surgery in pancreatic cystic neoplasms: the role of EUS. Gastrointest Endosc 2022; 96:648-656.e2. [PMID: 35618030 DOI: 10.1016/j.gie.2022.05.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 05/14/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Pancreatic cystic neoplasms (PCNs) represent a difficult preoperative diagnosis despite improvements in imaging. In this study, we compared preoperative and final pathologic diagnosis in a large cohort of resected PCNs, evaluating diagnostic accuracy with a specific focus on the value of EUS. METHODS A retrospective analysis of patients undergoing resection between 2009 and 2019 for presumed PCNs was performed. Preoperative workup was reviewed by analyzing the role of imaging and EUS. Patients with a benign histology who did not show absolute indication were categorized as "delayable surgery." RESULTS Of 585 patients who were retrospectively analyzed, in 108 (18.5%) final histology did not confirm preoperative diagnosis. EUS was associated with a lower rate of incorrect diagnosis (16%; P = .03), but the risk of overtreatment was similar regardless of instrumental diagnostic path (33/131 vs 68/328, P = .298). Dilatation of the main pancreatic duct and cytologic sampling were the only variables independently associated with a correct diagnosis (P < .001 and P = .041, respectively). Based on clinical presentation and final histology, pancreatic resection could have been spared or delayed in 101 of 459 patients (22%), and this was influenced by age (odds ratio [OR], .97; P = .002), cyst larger than 30 mm (OR, 1.89; P = .005), and type of operation (OR, 3.46 [P < .001] and 3.18 [P = .023] for distal pancreatectomies and other resections, respectively). CONCLUSIONS The overall risk of unnecessary immediate surgery for PCNs is about 22% in a high-volume referral center. EUS with cytologic sampling is a useful procedure in the diagnostic management of PCNs, improving their diagnostic accuracy.
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Affiliation(s)
- Fabio Giannone
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Stefano Crippa
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita Salute San Raffaele University, Milan, Italy
| | - Francesca Aleotti
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Diego Palumbo
- Pancreas Translational and Clinical Research Center, Radiology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Belfiori
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita Salute San Raffaele University, Milan, Italy
| | - Marco Schiavo Lena
- Department of Pathology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Chiara Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco De Cobelli
- Vita Salute San Raffaele University, Milan, Italy; Pancreas Translational and Clinical Research Center, Radiology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Vita Salute San Raffaele University, Milan, Italy; Pancreato-Biliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita Salute San Raffaele University, Milan, Italy
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10
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Pușcașu CI, Rimbaş M, Mateescu RB, Larghi A, Cauni V. Advances in the Diagnosis of Pancreatic Cystic Lesions. Diagnostics (Basel) 2022; 12:diagnostics12081779. [PMID: 35892490 PMCID: PMC9394320 DOI: 10.3390/diagnostics12081779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
Pancreatic cystic lesions (PCLs) are a heterogenous group of lesions ranging from benign to malignant. There has been an increase in PCLs prevalence in recent years, mostly due to advances in imaging techniques, increased awareness of their existence and population aging. Reliable discrimination between neoplastic and non-neoplastic cystic lesions is paramount to ensuring adequate treatment and follow-up. Although conventional diagnostic techniques such as ultrasound (US), magnetic resonance imaging (MRI) and computer tomography (CT) can easily identify these lesions, assessing the risk of malignancy is limited. Endoscopic ultrasound (EUS) is superior to cross-sectional imaging in identifying potentially malignant lesions due to its high resolution and better imaging characteristics, and the advantage of allowing for cyst fluid sampling via fine-needle aspiration (FNA). More complex testing, such as cytological and histopathological analysis and biochemical and molecular testing of the aspirated fluid, can ensure an accurate diagnosis.
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Affiliation(s)
- Claudia Irina Pușcașu
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.I.P.); (R.B.M.)
| | - Mihai Rimbaş
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.I.P.); (R.B.M.)
- Department of Internal Medicine, Carol Davila University of Medicine, 050474 Bucharest, Romania
- Correspondence: ; Tel.: +40-723-232-052
| | - Radu Bogdan Mateescu
- Gastroenterology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania; (C.I.P.); (R.B.M.)
- Department of Internal Medicine, Carol Davila University of Medicine, 050474 Bucharest, Romania
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy;
| | - Victor Cauni
- Urology Department, Colentina Clinical Hospital, 020125 Bucharest, Romania;
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11
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Robles-Medranda C, Olmos JI, Puga-Tejada M, Oleas R, Baquerizo-Burgos J, Arevalo-Mora M, Del Valle Zavala R, Nebel JA, Calle Loffredo D, Pitanga-Lukashok H. Endoscopic ultrasound-guided through-the-needle microforceps biopsy and needle-based confocal laser-endomicroscopy increase detection of potentially malignant pancreatic cystic lesions: A single-center study. World J Gastrointest Endosc 2022; 14:129-141. [PMID: 35432747 PMCID: PMC8984536 DOI: 10.4253/wjge.v14.i3.129] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 12/15/2021] [Accepted: 02/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Currently, there is insufficient data about the accuracy in the diagnosing of pancreatic cystic lesions (PCLs), especially with novel endoscopic techniques such as with direct intracystic micro-forceps biopsy (mFB) and needle-based confocal laser-endomicroscopy (nCLE).
AIM To compare the accuracy of endoscopic ultrasound (EUS) and associated techniques for the detection of potentially malignant PCLs: EUS-guided fine needle aspiration (EUS-FNA), contrast-enhanced EUS (CE-EUS), EUS-guided fiberoptic probe cystoscopy (cystoscopy), mFB, and nCLE.
METHODS This was a single-center, retrospective study. We identified patients who had undergone EUS, with or without additional diagnostic techniques, and had been diagnosed with PCLs. We determined agreement among malignancy after 24-mo follow-up findings with detection of potentially malignant PCLs via the EUS-guided techniques and/or EUS-guided biopsy when available (EUS malignancy detection).
RESULTS A total of 129 patients were included, with EUS performed alone in 47/129. In 82/129 patients, EUS procedures were performed with additional EUS-FNA (21/82), CE-EUS (20/82), cystoscopy (27/82), mFB (36/82), nCLE (44/82). Agreement between EUS malignancy detection and the 24-mo follow-up findings was higher when associated with additional diagnostic techniques than EUS alone [62/82 (75.6%) vs 8/47 (17%); OR 4.35, 95%CI: 2.70-7.37; P < 0.001]. The highest malignancy detection accuracy was reached when nCLE and direct intracystic mFB were both performed, with a sensitivity, specificity, positive predictive value, negative predictive value and observed agreement of 100%, 89.4%, 77.8%, 100% and 92.3%, respectively (P < 0.001 compared with EUS-alone).
CONCLUSION The combined use of EUS-guided mFB and nCLE improves detection of potentially malignant PCLs compared with EUS-alone, EUS-FNA, CE-EUS or cystoscopy.
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Affiliation(s)
- Carlos Robles-Medranda
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Juan I Olmos
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Miguel Puga-Tejada
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Roberto Oleas
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Jorge Baquerizo-Burgos
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Martha Arevalo-Mora
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Raquel Del Valle Zavala
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Joao Autran Nebel
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Daniel Calle Loffredo
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Hannah Pitanga-Lukashok
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
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12
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Robles-Medranda C, Olmos JI, Puga-Tejada M, Oleas R, Baquerizo-Burgos J, Arevalo-Mora M, Del ValleZavala R, Nebel JA, Calle Loffredo D, Pitanga-Lukashok H. Endoscopic ultrasound-guided through-the-needle microforceps biopsy and needle-based confocal laser-endomicroscopy increase detection of potentially malignant pancreatic cystic lesions: A single-center study. World J Gastrointest Endosc 2022; 14:130-142. [DOI: 10.4253/wjge.v14.i3.130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Currently, there is insufficient data about the accuracy in the diagnosing of pancreatic cystic lesions (PCLs), especially with novel endoscopic techniques such as with direct intracystic micro-forceps biopsy (mFB) and needle-based confocal laser-endomicroscopy (nCLE).
AIM To compare the accuracy of endoscopic ultrasound (EUS) and associated techniques for the detection of potentially malignant PCLs: EUS-guided fine needle aspiration (EUS-FNA), contrast-enhanced EUS (CE-EUS), EUS-guided fiberoptic probe cystoscopy (cystoscopy), mFB, and nCLE.
METHODS This was a single-center, retrospective study. We identified patients who had undergone EUS, with or without additional diagnostic techniques, and had been diagnosed with PCLs. We determined agreement among malignancy after 24-mo follow-up findings with detection of potentially malignant PCLs via the EUS-guided techniques and/or EUS-guided biopsy when available (EUS malignancy detection).
RESULTS A total of 129 patients were included, with EUS performed alone in 47/129. In 82/129 patients, EUS procedures were performed with additional EUS-FNA (21/82), CE-EUS (20/82), cystoscopy (27/82), mFB (36/82), nCLE (44/82). Agreement between EUS malignancy detection and the 24-mo follow-up findings was higher when associated with additional diagnostic techniques than EUS alone [62/82 (75.6%) vs 8/47 (17%); OR 4.35, 95%CI: 2.70-7.37; P < 0.001]. The highest malignancy detection accuracy was reached when nCLE and direct intracystic mFB were both performed, with a sensitivity, specificity, positive predictive value, negative predictive value and observed agreement of 100%, 89.4%, 77.8%, 100% and 92.3%, respectively (P < 0.001 compared with EUS-alone).
CONCLUSION The combined use of EUS-guided mFB and nCLE improves detection of potentially malignant PCLs compared with EUS-alone, EUS-FNA, CE-EUS or cystoscopy.
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Affiliation(s)
- Carlos Robles-Medranda
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Juan I Olmos
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Miguel Puga-Tejada
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Roberto Oleas
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Jorge Baquerizo-Burgos
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Martha Arevalo-Mora
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Raquel Del ValleZavala
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Joao Autran Nebel
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Daniel Calle Loffredo
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
| | - Hannah Pitanga-Lukashok
- Gastroenterology and Endoscopy Division, Instituto Ecuatoriano de Enfermedades Digestivas, Guayaquil 090505, Ecuador
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13
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Gao J, Han F, Wang X, Duan S, Zhang J. Multi-Phase CT-Based Radiomics Nomogram for Discrimination Between Pancreatic Serous Cystic Neoplasm From Mucinous Cystic Neoplasm. Front Oncol 2021; 11:699812. [PMID: 34926238 PMCID: PMC8672034 DOI: 10.3389/fonc.2021.699812] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 11/15/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose This study aimed to develop and verify a multi-phase (MP) computed tomography (CT)-based radiomics nomogram to differentiate pancreatic serous cystic neoplasms (SCNs) from mucinous cystic neoplasms (MCNs), and to compare the diagnostic efficacy of radiomics models for different phases of CT scans. Materials and Methods A total of 170 patients who underwent surgical resection between January 2011 and December 2018, with pathologically confirmed pancreatic cystic neoplasms (SCN=115, MCN=55) were included in this single-center retrospective study. Radiomics features were extracted from plain scan (PS), arterial phase (AP), and venous phase (VP) CT scans. Algorithms were performed to identify the optimal features to build a radiomics signature (Radscore) for each phase. All features from these three phases were analyzed to develop the MP-Radscore. A combined model comprised the MP-Radscore and imaging features from which a nomogram was developed. The accuracy of the nomogram was evaluated using receiver operating characteristic (ROC) curves, calibration tests, and decision curve analysis. Results For each scan phase, 1218 features were extracted, and the optimal ones were selected to construct the PS-Radscore (11 features), AP-Radscore (11 features), and VP-Radscore (12 features). The MP-Radscore (14 features) achieved better performance based on ROC curve analysis than any single phase did [area under the curve (AUC), training cohort: MP-Radscore 0.89, PS-Radscore 0.78, AP-Radscore 0.83, VP-Radscore 0.85; validation cohort: MP-Radscore 0.88, PS-Radscore 0.77, AP-Radscore 0.83, VP-Radscore 0.84]. The combination nomogram performance was excellent, surpassing those of all other nomograms in both the training cohort (AUC, 0.91) and validation cohort (AUC, 0.90). The nomogram also performed well in the calibration and decision curve analyses. Conclusions Radiomics for arterial and venous single-phase models outperformed the plain scan model. The combination nomogram that incorporated the MP-Radscore, tumor location, and cystic number had the best discriminatory performance and showed excellent accuracy for differentiating SCN from MCN.
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Affiliation(s)
- Jiahao Gao
- Department of Radiology, Huashan Hospital North, Fudan University, Shanghai, China.,Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Fang Han
- Department of Radiology, Huashan Hospital North, Fudan University, Shanghai, China.,Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoshuang Wang
- Department of Radiology, Huashan Hospital North, Fudan University, Shanghai, China
| | - Shaofeng Duan
- Department of Life Sciences, GE Healthcare, Shanghai, China
| | - Jiawen Zhang
- Department of Radiology, Huashan Hospital North, Fudan University, Shanghai, China.,Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
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14
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Preliminary evaluation of 18F-FDG-PET/MRI for differentiation of serous from nonserous pancreatic cystic neoplasms: a pilot study. Nucl Med Commun 2021; 41:1257-1264. [PMID: 32925829 DOI: 10.1097/mnm.0000000000001277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of the study was to evaluate preliminary feasibility of 18F-FDG-PET/MRI in differentiation of pancreatic serous cystic neoplasms (SCNs) from non-SCNs. METHODS From August 2017 to June 2019, 10 patients (3 men, 7 women; mean age, 63 years) previously diagnosed with pancreatic cystic neoplasm underwent simultaneous 18F-FDG-PET/MRI prospectively on an integrated 3-Tesla hybrid PET/MRI scanner. PET images were analyzed visually and semiquantitatively measuring standardized uptake values (SUV) including lesion SUVmax and SUVmean, lesion to pancreas and lesion to liver SUVmax and SUVmean ratio independent of MRI diagnosis. The reference standard for lesion diagnosis was by MRI features and interval follow-up. RESULTS Visual assessment of PET images demonstrated uptake in 57% of SCNs. Lesion to liver SUVmax ratio of ≥0.5 showed the highest accuracy (90%) and area under the curve (0.9) followed by lesion SUVmax of ≥1.6 and lesion to pancreas SUVmax ratio of ≥0.77 for diagnosis of SCN. The sensitivity for lesion SUVmax of ≥1.6 was less than two other ones (71 versus 100%). All non-SCNs exhibited SUVmax value less than 1.6 while 33 and 66% demonstrated lesion to liver SUVmax ratio of >0.5 and lesion to pancreas SUVmax ratio of >0.77, respectively. PET/MRI specificity was 67, 100, 67 and 33% through lesion to liver SUVmax ratio, lesion SUVmax, lesion SUVmean and lesion to pancreas SUVmax ratio, respectively, for diagnosis of SCN. CONCLUSION Preliminary results show that PET/MRI utilization is promising for differentiation of pancreatic SCN from non-SCN lesions. This could reduce need for surveillance imaging or avoidance of unnecessary intervention in pancreatic cystic neoplasms with uncertain diagnoses.
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15
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Satoh T, Ishiwatari H, Kawaguchi S, Sato J, Kaneko J, Kanemoto H, Sugiura T, Sasaki K, Matsubayashi H, Uesaka K, Ono H. Can regular follow-up imaging contribute to the determination of appropriate timing of surgery in patients with undiagnosed mucinous cystic neoplasm? A multicenter retrospective study. Jpn J Clin Oncol 2021; 51:1423-1429. [PMID: 34212179 DOI: 10.1093/jjco/hyab103] [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: 03/15/2021] [Accepted: 06/17/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Guidelines suggest that patients with undiagnosed pancreatic cystic lesions should be monitored despite a lack of evidence supporting surveillance for undiagnosed mucinous cystic neoplasms (MCNs). We aimed to investigate the pre- and post-operative clinical course of patients with MCN and the utility of follow-up for patients who were not diagnosed with MCN at initial examination. PATIENTS AND METHODS This multicenter retrospective study enrolled 28 patients with resected pathology-proven MCN; 12 and 16 patients underwent surgery within and after 6 months from the initial examination (Groups A and B, respectively). Outcome measures included changes in imaging findings until surgery in Group B, pathological findings between both groups and differences in pathological findings between patients with and without regular follow-up imaging in Group B. RESULTS In Group B, the median cyst size was 30 and 48 mm at the initial examination and immediately before surgery, respectively. The incidence of mural cysts, thickened walls and mural nodules were 25, 19 and 0%, respectively, at the initial examination and 69, 56 and 31%, respectively, immediately before surgery. There were no significant differences in the invasive carcinoma rates between Groups A and B (13 vs. 17%). Regular follow-up imaging was offered to Group B. Among these, invasive carcinoma was found in one patient exhibiting no recurrence. One patient without follow-up imaging had invasive carcinoma recurrence post-operatively. CONCLUSIONS MCNs increased in size, and typical imaging findings appeared over time. For undiagnosed MCN, regular follow-up examination contributed to the determination of the appropriate surgical timing.
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Affiliation(s)
- Tatsunori Satoh
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Shinya Kawaguchi
- Department of Gastroenterology, Shizuoka General Hospital, Shizuoka, Japan
| | - Junya Sato
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Junichi Kaneko
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hideyuki Kanemoto
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Shizuoka, Japan
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Keiko Sasaki
- Division of Pathology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroyuki Matsubayashi
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan.,Division of Genetic Medicine Promotion, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
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16
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Schmitz D, Kazdal D, Allgäuer M, Trunk M, Vornhusen S, Nahm AM, Doll M, Weingärtner S, Endris V, Penzel R, Kirchner M, Brandt R, Neumann O, Sültmann H, Budczies J, Kienle P, Magdeburg R, Hetjens S, Schirmacher P, Bergmann F, Rudi J, Stenzinger A, Volckmar AL. KRAS/GNAS-testing by highly sensitive deep targeted next generation sequencing improves the endoscopic ultrasound-guided workup of suspected mucinous neoplasms of the pancreas. Genes Chromosomes Cancer 2021; 60:489-497. [PMID: 33686791 DOI: 10.1002/gcc.22946] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 12/28/2022] Open
Abstract
Pancreatic cysts or dilated pancreatic ducts are often found by cross-sectional imaging, but only mucinous lesions can become malignant. Therefore, distinction between mucinous and non-mucinous lesions is crucial for adequate patient management. We performed a prospective study including targeted next generation sequencing (NGS) of cell-free DNA in the diagnostic endoscopic ultrasound (EUS)-guided workup. Pancreatic cyst(s) or main duct fluid obtained by EUS-guided FNA was analysed by carcinoembryonic antigen (CEA), cytology and deep targeted NGS of 14 known gastrointestinal cancer genes (AKT1, BRAF, CTNNB1, EGFR, ERBB2, FBXW7, GNAS, KRAS, MAP2K1, NRAS, PIK3CA, SMAD4, TP53, APC) with a limit of detection down to variant allele frequency of 0.01%. Results were correlated to histopathology and clinical follow-up. One hundred and thirteen patients with pancreatic cyst(s) and/or a dilated pancreatic main duct (≥5 mm) were screened. Sixty-six patients had to be excluded, mainly due to inoperability or small cyst size (≤10 mm). Forty-seven patients were enrolled for further analysis. A final diagnosis was available in 27 cases including 8 negative controls. In 43/47 (91.5%) of patients a KRAS- and/or GNAS-mutation was diagnosed by NGS. 27.0% of the KRAS-mutated and 10.0% of the GNAS-mutated lesions harbored multiple mutations. KRAS/GNAS-testing by NGS, cytology, and CEA had a sensitivity and specificity of 94.7/100%, 38.1/100%, and 42.1/75.0%, respectively. KRAS/GNAS-testing was significantly superior to CEA (P = .0209) and cytology (P = .0016). In conclusion, KRAS/GNAS-testing by deep targeted NGS is a suitable method to distinguish mucinous from non-mucinous pancreatic lesions, suggesting its usage as a single diagnostic test. Results must be confirmed in a larger cohort.
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MESH Headings
- Aged
- Aged, 80 and over
- Chromogranins/genetics
- Endoscopic Ultrasound-Guided Fine Needle Aspiration/methods
- Endoscopic Ultrasound-Guided Fine Needle Aspiration/standards
- Female
- GTP-Binding Protein alpha Subunits, Gs/genetics
- Genetic Testing/methods
- Genetic Testing/standards
- High-Throughput Nucleotide Sequencing/methods
- High-Throughput Nucleotide Sequencing/standards
- Humans
- Male
- Middle Aged
- Neoplasms, Cystic, Mucinous, and Serous/diagnostic imaging
- Neoplasms, Cystic, Mucinous, and Serous/genetics
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Pancreatic Cyst/diagnostic imaging
- Pancreatic Cyst/genetics
- Pancreatic Cyst/pathology
- Pancreatic Neoplasms/diagnostic imaging
- Pancreatic Neoplasms/genetics
- Pancreatic Neoplasms/pathology
- Proto-Oncogene Proteins p21(ras)/genetics
- Sensitivity and Specificity
- Sequence Analysis, DNA/methods
- Sequence Analysis, DNA/standards
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Affiliation(s)
- Daniel Schmitz
- Department of Gastroenterology, Oncology and Diabetology, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Heidelberg, Germany
| | - Daniel Kazdal
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Michael Allgäuer
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Marcus Trunk
- Institute of Pathology, SYNLAB GmbH Mannheim, Mannheim, Germany
| | - Sylke Vornhusen
- Institute of Pathology, SYNLAB GmbH Mannheim, Mannheim, Germany
| | - Anna-Maria Nahm
- Department of Gastroenterology, Oncology and Diabetology, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Heidelberg, Germany
| | - Matthias Doll
- Department of Gastroenterology, Oncology and Diabetology, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Heidelberg, Germany
| | - Simon Weingärtner
- Department of Gastroenterology, Oncology and Diabetology, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Heidelberg, Germany
| | - Volker Endris
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Roland Penzel
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Martina Kirchner
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Regine Brandt
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Olaf Neumann
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Holger Sültmann
- German Cancer Consortium (DKTK), Partner Site Heidelberg, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jan Budczies
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Peter Kienle
- Department of General and Visceral Surgery, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Mannheim, Germany
| | - Richard Magdeburg
- Department of General and Visceral Surgery, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Mannheim, Germany
| | - Svetlana Hetjens
- Medical Statistics, Biomathematics and Information Processing of Mannheim University Hospital, University Hospital of Heidelberg, Mannheim, Germany
| | - Peter Schirmacher
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Frank Bergmann
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Jochen Rudi
- Department of Gastroenterology, Oncology and Diabetology, Theresienkrankenhaus and St. Hedwigsklinik, University of Heidelberg, Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Anna-Lena Volckmar
- Institute of Pathology, University Hospital of Heidelberg, Heidelberg, Germany
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Gorris M, Hoogenboom SA, Wallace MB, van Hooft JE. Artificial intelligence for the management of pancreatic diseases. Dig Endosc 2021; 33:231-241. [PMID: 33065754 PMCID: PMC7898901 DOI: 10.1111/den.13875] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/29/2020] [Accepted: 10/11/2020] [Indexed: 12/16/2022]
Abstract
Novel artificial intelligence techniques are emerging in all fields of healthcare, including gastroenterology. The aim of this review is to give an overview of artificial intelligence applications in the management of pancreatic diseases. We performed a systematic literature search in PubMed and Medline up to May 2020 to identify relevant articles. Our results showed that the development of machine-learning based applications is rapidly evolving in the management of pancreatic diseases, guiding precision medicine in clinical, endoscopic and radiologic settings. Before implementation into clinical practice, further research should focus on the external validation of novel techniques, clarifying the accuracy and robustness of these models.
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Affiliation(s)
- Myrte Gorris
- Department of Gastroenterology and HepatologyAmsterdam Gastroenterology Endocrinology MetabolismAmsterdam University Medical CentersUniversity of AmsterdamAmsterdamThe Netherlands
| | - Sanne A. Hoogenboom
- Department of Gastroenterology and HepatologyAmsterdam Gastroenterology Endocrinology MetabolismAmsterdam University Medical CentersUniversity of AmsterdamAmsterdamThe Netherlands
| | - Michael B. Wallace
- Department of Gastroenterology and HepatologyMayo Clinic JacksonvilleJacksonvilleUSA
| | - Jeanin E. van Hooft
- Department of Gastroenterology and HepatologyAmsterdam Gastroenterology Endocrinology MetabolismAmsterdam University Medical CentersUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Gastroenterology and HepatologyLeiden University Medical CenterLeidenThe Netherlands
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18
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Schmitz D. Endoscopic ablation of pancreatic cysts: not yet ready for general application. Gastrointest Endosc 2020; 92:1138. [PMID: 33160495 DOI: 10.1016/j.gie.2020.05.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 05/30/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Daniel Schmitz
- Department of Gastroenterology, Oncology, and Diabetology, Theresienkrankenhaus and St Hedwigsklinik, University of Heidelberg, Mannheim, Germany
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19
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Total Pancreatectomy for Malignant Intraductal Papillary Mucinous Neoplasm (IPMN) Complicated by Gastropancreatic Fistulae. Case Rep Surg 2020; 2020:8547526. [PMID: 32274240 PMCID: PMC7132345 DOI: 10.1155/2020/8547526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 03/17/2020] [Indexed: 11/17/2022] Open
Abstract
Background Intraductal papillary mucinous neoplasms (IPMN) of the pancreas complicated by fistula formation to adjacent organs are an uncommon phenomenon. We present an IPMN of the pancreas with malignant transformation and multiple fistulae to the stomach and duodenum. Case Presentation. A 50-year-old female was referred for investigation of recent epigastric pain and a past history of recurrent pancreatitis. Imaging with computed tomography showed a gross dilatation of the entire pancreatic duct with a heterogeneous enhancement of the periductal parenchyma. A passage of oral contrast was noted from the greater curvature and pylorus of the stomach into the dilated duct suggestive of fistulae formation. Gastroduodenoscopy demonstrated these fistulae in the stomach and the proximal duodenum and an exophytic growth at the ampulla obliterating the view of ampullary opening. Endosonography- (EUS-) guided fine-needle aspiration cytology (FNAC) showed cells with high-grade atypia. A total pancreatectomy, distal gastrectomy, and splenectomy were performed, and recovery was uneventful. Histology revealed a ductal adenocarcinoma arising from an intestinal type intraductal papillary mucinous neoplasm with high-grade dysplasia. A year and a half after surgery, she is healthy with good glycaemic control and nutritional status. Conclusion This case highlights the importance investigating patients for the aetiology in recurrent acute pancreatitis and their follow-up. Awareness of cystic pancreatic neoplasms including IPMN is important to avoid misdiagnosis or delayed diagnosis. Referral of these patients to centres with facilities for multidisciplinary input and specialised management is strongly recommended.
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Ge N, Brugge WR, Saxena P, Sahai A, Adler DG, Giovannini M, Pausawasdi N, Santo E, Mishra G, Tam W, Kida M, de la Mora-Levy JG, Sharma M, Umar M, Katanuma A, Lee L, Garg PK, Eloubeidi MA, Yu HK, Raijman I, Arturo Arias BL, Bhutani M, Carrara S, Rai P, Mukai S, Palazzo L, Dietrich CF, Nguyen NQ, El-Nady M, Poley JW, Guaraldi S, Kalaitzakis E, Sabbagh LC, Lariño-Noia J, Gress FG, Lee YT, Rana SS, Fusaroli P, Hocke M, Dhir V, Lakhtakia S, Ratanachu-ek T, Chalapathi Rao AS, Vilmann P, Okasha HH, Irisawa A, Ponnudurai R, Leong AT, Artifon E, Iglesias-Garcia J, Saftoiu A, Larghi A, Robles-Medranda C, Sun S. An international, multi-institution survey of the use of EUS in the diagnosis of pancreatic cystic lesions. Endosc Ultrasound 2019; 8:418-427. [PMID: 31552915 PMCID: PMC6927137 DOI: 10.4103/eus.eus_61_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/04/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Currently, pancreatic cystic lesions (PCLs) are recognized with increasing frequency and have become a more common finding in clinical practice. EUS is challenging in the diagnosis of PCLs and evidence-based decisions are lacking in its application. This study aimed to develop strong recommendations for the use of EUS in the diagnosis of PCLs, based on the experience of experts in the field. METHODS A survey regarding the practice of EUS in the evaluation of PCLs was drafted by the committee member of the International Society of EUS Task Force (ISEUS-TF). It was disseminated to experts of EUS who were also members of the ISEUS-TF. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized. RESULTS Fifteen questions were extracted and disseminated among 60 experts for the survey. Fifty-three experts completed the survey within the specified time frame. The average volume of EUS cases at the experts' institutions is 988.5 cases per year. CONCLUSION Despite the limitations of EUS alone in the morphologic diagnosis of PCLs, the results of the survey indicate that EUS-guided fine-needle aspiration is widely expected to become a more valuable method.
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Affiliation(s)
- Nan Ge
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - William R. Brugge
- Department of Gastroenterology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Payal Saxena
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Anand Sahai
- Center Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Douglas G. Adler
- Division of Gastroenterology and Hepatology, Huntsman Cancer Center, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Marc Giovannini
- Endoscopic Unit, Institut Paoli-Calmettes, Marseille, France
| | | | - Erwin Santo
- Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Girish Mishra
- Department of Gastroenterology, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States
| | - William Tam
- Lyell McEwin Hospital, Elizabeth Vale, Adelaide, Australia
| | - Mitsuhiro Kida
- Department of Gastroenterology, Kitasato University East Hospital, Sagamihara, Japan
| | | | - Malay Sharma
- Department of Gastroenterology, Jaswant Rai Speciality Hospital, Meerut, Uttar Pradesh, India
| | | | - Akio Katanuma
- Center for Gastroenterology, Teine-Kenjinkai Hospital, Sapporo, Japan
| | - Linda Lee
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Pramod Kumar Garg
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Ho Khek Yu
- National University of Singapore, Singapore
| | - Isaac Raijman
- Digestive Associates of Houston, University of Texas, Houston, Texas, USA
| | | | - Manoop Bhutani
- Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Silvia Carrara
- Digestive Endoscopy Unit, Humanitas Research Hospital, Milan, Italy
| | - Praveer Rai
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | | | - Christoph F. Dietrich
- Medical Department, Caritas-Krankenhaus, Uhlandstr 7, D-97980 Bad Mergentheim, Germany
| | - Nam Q. Nguyen
- Department of Gastroenterology, Royal Adelaide Hospital, Adelaide, Australia
| | - Mohamed El-Nady
- Department of Internal Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Jan Werner Poley
- Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Simone Guaraldi
- Participants of the Nucleus of Endoscopy of the Brazilian Society of Digestive Endoscopy (SOBED), São Paulo, Brazil
| | - Evangelos Kalaitzakis
- Division of Endoscopy, Gastro Unit, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Jose Lariño-Noia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Yuk-tong Lee
- Departments of Medicine & Therapeutics and Surgery, The Chinese University of Hong Kong, Hong Kong, China
| | - Surinder S. Rana
- Departments of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pietro Fusaroli
- Department of Medical and Surgical Sciences, Gastroenterology Unit, University of Bologna, Bologna, Italy
| | - Michael Hocke
- Department of Medical, Hospital Meiningen, Thuringia, Germany
| | - Vinay Dhir
- Department of Gastroenterology and Endoscopy, S L Raheja Hospital, Mumbai, Maharashtra, India
| | | | | | | | - Peter Vilmann
- GastroUnit, Department of Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hussein Hassan Okasha
- Department of Internal Medicine and Gastroenterology, Cairo University, Cairo, Egypt
| | - Atsushi Irisawa
- Fukushima Medical University Aizu Medical Center, Aizuwakamatsu, Japan
| | | | - Ang Tiing Leong
- Departments of Gastroenterology and Hepatology, Changi General Hospital, Singapore
| | - Everson Artifon
- Department of Surgery, Ana Costa Hospital, Sao Paulo, Brazil
| | - Julio Iglesias-Garcia
- Department of Gastroenterology and Hepatology, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
| | - Adrian Saftoiu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy, Craiova, Romania
| | - Alberto Larghi
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
| | - Carlos Robles-Medranda
- Head of the Endoscopy Division, Ecuadorian Institute of Digestive Disease, Guayaquil, Ecuador
| | - Siyu Sun
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
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Sun L, Wang Y, Jiang F, Qian W, Shao C, Jin Z. Prevalence of pancreatic cystic lesions detected by magnetic resonance imaging in the Chinese population. J Gastroenterol Hepatol 2019; 34:1656-1662. [PMID: 30883900 DOI: 10.1111/jgh.14658] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/08/2019] [Accepted: 03/10/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIM Incidental pancreatic cystic lesions (PCLs) are being diagnosed more frequently. However, little is known about the prevalence of PCLs in the Chinese population. The aim of the study was to assess the crude prevalence of PCLs in individuals who underwent magnetic resonance imaging (MRI). METHODS Data from consecutive patients who underwent MRI without pancreatic indications were included. MRI images were reviewed for the presence of pancreatic cysts. The prevalence of PCLs and high-risk PCLs in different gender and age groups was calculated. To assess the crude prevalence, the prevalence and demographic data were standardized on the basis of Chinese national population data in 2017. RESULTS A total of 10 987 individuals were included (7344 men). Incidental PCLs were identified in 212 individual (128 men). The prevalence of PCLs was 1.93%, and PCLs were more often discovered in women (1.74% vs 2.31%, P = 0.043). Prevalence increased with age (r = 0.804, P < 0.001). The prevalence of high-risk PCLs was 0.12% (n = 13). Gender predominance and age distribution showed no difference between high-risk PCLs and low-risk PCLs (P = 0.234 and P = 0.855), but cysts located in the pancreatic head were more likely to develop into high-risk PCLs (P = 0.001). After data standardization, the crude prevalence of PCLs was 1.31%, and PCLs were more often discovered in women (1.11% vs 1.5%, P < 0.001). The crude prevalence of high-risk PCLs was 0.07%. CONCLUSION Pancreatic cystic lesions in the Chinese population are not rare. The prevalence of PCLs increased with age and is higher in the female population. The prevalence of high-risk PCLs should not be ignored.
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Affiliation(s)
- Liqi Sun
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yang Wang
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Fei Jiang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Wei Qian
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Chengwei Shao
- Department of Radiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhendong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
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22
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Rosendahl J, Michl P. [Cystic lesions of the pancreas : Differential diagnostics and treatment]. Internist (Berl) 2019; 60:219-225. [PMID: 30617702 DOI: 10.1007/s00108-018-0547-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Cystic space-occupying lesions of the pancreas represent incidental findings in most cases. As there is a potential risk of malignant transformation further evaluation of the lesions as well as a follow-up of these patients is usually recommended. Before this work-up is initiated the clinical situation of the patient as a whole and comorbidities, age and personal preferences have to be taken into account. So far there are no biomarkers that reliably predict the risk of malignant transformation. Imaging by magnetic resonance tomography (MRI) in combination with magnetic resonance cholangiopancreatography (MRCP) is more accurate than computed tomography to identify worrisome features. During follow-up, endoscopic ultrasound (EUS) can be used as complementary method to MRI/MRCP. Using contrast enhancement or endoscopic fine needle aspiration (EUS-FNA) may influence the therapeutic strategy in some patients. Whereas for some cystic pancreatic lesions consensus has been reached, varying recommendations exist for intraductal papillary mucinous neoplasms (IPMN). There is consensus that in main-duct as well as in mixed-type IPMN surgery is recommended. The management of branch-duct type IPMN, however, remains controversial. A multidisciplinary expert panel including gastroenterologists, visceral surgeons, radiologists and pathologists is essential to discuss all cases of patients with cystic pancreatic lesions and to guarantee an optimal, patient-centered treatment recommendation.
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Affiliation(s)
- J Rosendahl
- Klinik für Innere Medizin I, Universitätsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland.
| | - P Michl
- Klinik für Innere Medizin I, Universitätsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06120, Halle (Saale), Deutschland
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23
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Tumor growth rate of pancreatic serous cystadenomas: Endosonographic follow-up with volume measurement to predict cyst enlargement. Pancreatology 2019; 19:122-126. [PMID: 30503637 DOI: 10.1016/j.pan.2018.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 09/07/2018] [Accepted: 11/16/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Serous cystadenomas are benign lesions of the pancreas. Usually they are diagnosed incidentally on cross-sectional imaging studies. Endosonography is a valuable tool in the diagnosis and follow-up of these cystic lesions. Given its benign nature, surgical resection is advised only in symptomatic patients. The interval and length of surveillance is not well established. METHODS A retrospective single center study was done. All the patients with a pancreatic serous cystadenoma sent for an endosonographic evaluation, between December 2008 and December 2015 were included. The lesions were follow-up endosonographically at least once, in a 12 months interval. Volume was measured with the formula π/6 × (d1 x d1 x d2). Two groups were evaluated: patients with a volume under 10 mL (Group 1) and those with a volume of 10 mL or more at presentation (Group 2). Growth rate between these two groups was compared. RESULTS Thirty-one patients were analyzed, with a mean age of 58.2 years. Patients were mainly women (87%). Twenty-four patients in Group 1 had a mean enlargement of 0.67 ml per year, whereas patients in Group 2 had a mean enlargement of 9.8 ml per year. The growth rate difference between these two groups was statistically significant (p = 0.0001). CONCLUSION Asymptomatic patients with pancreatic serous cystadenomas should be follow-up for enlargement. Small volume lesions have a low risk of enlargement compared with high volume and macrocystic serous cystadenomas. Volume at presentation is a feature to analyze when defining surveillance interval.
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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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25
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Mohamed E, Jackson R, Halloran CM, Ghaneh P. Role of Radiological Imaging in the Diagnosis and Characterization of Pancreatic Cystic Lesions: A Systematic Review. Pancreas 2018; 47:1055-1064. [PMID: 30199486 DOI: 10.1097/mpa.0000000000001134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The evidence on the ability of radiological tests to predict a specific diagnosis and also their aptitude in identifying pathological markers indicative of malignancy in cystic lesions of the pancreas remains inconclusive. We conducted a systematic review on MEDLINE for the use of computed tomography (CT), magnetic resonance imaging, and positron emission tomography/CT (PET/CT) in the diagnosis and characterization of these cysts. The accuracy of CT scan for reaching a specific diagnosis was 39% to 61.4%, whereas its accuracy for differentiating benign from malignant lesions was 61.9% to 80%. Magnetic resonance imaging showed a better accuracy in identifying a specific diagnosis of 50% to 86%, whereas its accuracy in differentiating benign from malignant lesions was 55.6% to 87%. The use of magnetic resonance imaging was superior to CT scan in identifying septations, mural nodules, and ductal communication. The sensitivity of PET/CT in diagnosing malignancy was 85.7% to 100% with a reported accuracy of 88% to 95%. The evidence gathered from this review suggests that the adequacy of CT imaging in full characterization of pancreatic cysts is suboptimal, and therefore a low threshold for supplementary imaging is advised. The use of PET/CT should be considered in high-risk patients with equivocal findings.
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Affiliation(s)
- Eyas Mohamed
- From the Department of Molecular and Clinical Cancer Medicine and
| | - Richard Jackson
- Liverpool Cancer Research UK Cancer Trials Unit, Liverpool Cancer Research UK Centre, University of Liverpool, Liverpool, United Kingdom
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Abstract
PURPOSE OF REVIEW With recent advances in radiographic testing, there have been increases in the incidental identification of pancreatic cysts. Determining management, specifically, which cysts can be watched versus intervened upon has significant impact on at the patient-physician level as well as globally on resource allocation and healthcare expenditures. This review focuses on the three main guidelines (Fukuoka guidelines, European consensus, and American Gastroenterological Association recommendations) for management of pancreatic cystic disease after incidental identification. RECENT FINDINGS There are iterant revisions to each set of recommendations every few years as new data is published on the subject. This review encompasses the most up-to-date recommendations for management while also providing a framework for conceptualizing work-up for varying types of pancreatic cystic disease before and after incidental identification. SUMMARY Pancreatic cystic disease should be approached in thoughtful clinical manner, and each cyst should be evaluated in the context of patient's health and healthcare goals. All cysts, however, should be considered malignant until proven otherwise. Applications of different diagnostic modalities like MRI and EUS with FNA can better characterize cystic lesions and assess malignant potential. Resection should always be considered in cysts with concerning features. If deferred, surveillance should be continued indefinitely. Early termination of surveillance risks future malignant progression.
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27
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Abstract
Pancreatic cystic lesions are being detected with increasing frequency because of increased use and improved quality of cross-sectional imaging techniques. Pancreatic cystic lesions encompass non-neoplastic lesions (such as pancreatitis-related collections) and neoplastic tumors. Common cystic pancreatic neoplasms include serous cystadenomas, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, and solid pseudopapillary tumors. These cystic pancreatic neoplasms may have typical morphology, but at times show overlapping imaging features on cross-sectional examinations. This article reviews the classical and atypical imaging features of commonly encountered cystic pancreatic neoplasms and presents the limitations of current cross-sectional imaging techniques in accurately classifying pancreatic cystic lesions.
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Affiliation(s)
- Thomas L Bollen
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Frank J Wessels
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
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Paik WH, Lee SH, Jang S. Future Perspectives on Endoscopic Ultrasonography-Guided Therapy for Pancreatic Neoplasm. Clin Endosc 2018; 51:229-234. [PMID: 29774696 PMCID: PMC5997079 DOI: 10.5946/ce.2018.063] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 04/26/2018] [Accepted: 04/27/2018] [Indexed: 02/07/2023] Open
Abstract
Endoscopic ultrasonography (EUS)-guided therapy with ethanol injection or catheter-based radiofrequency ablation for pancreatic neoplasm has been conducted as a potential alternate treatment modality for patients who are not eligible for surgery. On the basis of the limited number of studies available, EUS-guided ablation therapy with the aforementioned methods for small pancreatic neoplasms has demonstrated promising technical feasibility and safety profiles. To be considered as a legitimate alternative option to surgery, however, EUS-guided ablation therapy must provide a long-term efficacy profile along with the consensus among experts regarding its treatment parameter. This review focuses on the clinical issues and future perspectives of EUS-guided therapy for pancreatic neoplasm.
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Affiliation(s)
- Woo Hyun Paik
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sunguk Jang
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
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The European Study Group on Cystic Tumours of the Pancreas. European evidence-based guidelines on pancreatic cystic neoplasms. Gut 2018; 67:789-804. [PMID: 29574408 PMCID: PMC5890653 DOI: 10.1136/gutjnl-2018-316027] [Citation(s) in RCA: 869] [Impact Index Per Article: 124.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 02/13/2018] [Accepted: 02/13/2018] [Indexed: 02/07/2023]
Abstract
Evidence-based guidelines on the management of pancreatic cystic neoplasms (PCN) are lacking. This guideline is a joint initiative of the European Study Group on Cystic Tumours of the Pancreas, United European Gastroenterology, European Pancreatic Club, European-African Hepato-Pancreato-Biliary Association, European Digestive Surgery, and the European Society of Gastrointestinal Endoscopy. It replaces the 2013 European consensus statement guidelines on PCN. European and non-European experts performed systematic reviews and used GRADE methodology to answer relevant clinical questions on nine topics (biomarkers, radiology, endoscopy, intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystic neoplasm, rare cysts, (neo)adjuvant treatment, and pathology). Recommendations include conservative management, relative and absolute indications for surgery. A conservative approach is recommended for asymptomatic MCN and IPMN measuring <40 mm without an enhancing nodule. Relative indications for surgery in IPMN include a main pancreatic duct (MPD) diameter between 5 and 9.9 mm or a cyst diameter ≥40 mm. Absolute indications for surgery in IPMN, due to the high-risk of malignant transformation, include jaundice, an enhancing mural nodule >5 mm, and MPD diameter >10 mm. Lifelong follow-up of IPMN is recommended in patients who are fit for surgery. The European evidence-based guidelines on PCN aim to improve the diagnosis and management of PCN.
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30
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Choi JH, Lee SH, Choi YH, Kang J, Paik WH, Ahn DW, Ryu JK, Kim YT. Clinical outcomes of endoscopic ultrasound-guided ethanol ablation for pancreatic cystic lesions compared with the natural course: a propensity score matching analysis. Therap Adv Gastroenterol 2018; 11:1756284818759929. [PMID: 29535793 PMCID: PMC5844525 DOI: 10.1177/1756284818759929] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Endoscopic ultrasound-guided ethanol ablation (EUS-EA) is a recently introduced treatment for pancreatic cystic lesions (PCLs). However, clinical benefits such as survival gain and maintenance of quality of life (QOL) have not been fully established. The aim of this study was to evaluate the clinical benefits of EUS-EA compared with the natural course (NC) of PCLs. METHODS This retrospective comparative study of patients with PCLs investigated an EUS-EA group (n = 118) and an NC group (n = 428). Propensity score matching (PSM) analysis was applied to minimize the effects of selection bias. The overall survival as the primary outcome and the surgical resection rate and complete remission (CR) rate as the secondary outcomes were evaluated. RESULTS Between 84 matched pairs of both groups, there were no significant differences in the baseline clinical characteristics and the mean follow-up duration (78.88 ± 38.86, 75.90 ± 57.46 months, p = 0.694). Overall survival did not differ significantly (194.12 ± 5.60, 247.54 ± 12.70 months, p = 0.235). The surgical resection rate (4.8% versus 26.2%, p < 0.001) was significantly lower in the EUS-EA group. CR was observed only in the EUS-EA group and the CR rate was 32.1%. CONCLUSIONS EUS-EA for PCLs with low risk of malignancy might not be able to obtain a survival benefit, but showed maintenance of QOL by avoidance of unnecessary surgery, and a certain level of CR when compared to the NC. EUS-EA could be considered a useful treatment option for these, but careful application is needed because of the limited effects in some types of PCLs.
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Affiliation(s)
- Jin Ho Choi
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | | | - Young Hoon Choi
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jinwoo Kang
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Dong-Won Ahn
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ji Kon Ryu
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yong-Tae Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Han Y, Lee H, Kang JS, Kim JR, Kim HS, Lee JM, Lee KB, Kwon W, Kim SW, Jang JY. Progression of Pancreatic Branch Duct Intraductal Papillary Mucinous Neoplasm Associates With Cyst Size. Gastroenterology 2018; 154:576-584. [PMID: 29074452 DOI: 10.1053/j.gastro.2017.10.013] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 10/05/2017] [Accepted: 10/12/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUNDS & AIMS Most guidelines for management of patients with intraductal papillary mucinous neoplasms (IPMN) vary in proposed surveillance intervals and durations-these are usually determined based on expert opinions rather than substantial evidence. The progression of and optimal surveillance intervals for branch-duct IPMNs (BD-IPMN) has not been widely studied. We evaluated the progression of BD-IPMN under surveillance at a single center, and determined optimal follow-up intervals and duration. METHODS We performed a retrospective analysis of 1369 patients with BD-IPMN seen at Seoul National University Hospital in Korea from January 2001 through December 2016. We included only patients whose imaging studies showed classical features of BD-IPMN, and collected data from each patient over time periods of at least 3 years. We reviewed radiologic and pathologic findings, and performed linear and binary logistic regressions to estimate cyst growth. RESULTS The median annual growth rate of the cyst was 0.8 mm over a median follow-up time of 61 months. During surveillance, 46 patients (3.4%) underwent surgery because of disease progression after a median follow-up time (in this group) of 62 months. Worrisome features were observed in 209 patients (15.3%) during surveillance, including cyst size of 3 cm or more (n = 109, 8.0%), cyst wall thickening (n = 51, 3.7%), main pancreatic duct dilatation (n = 77, 5.6%), and mural nodule (n = 43, 3.1%). Along with annual rate of cyst growth, incidences of main pancreatic duct dilatation and mural nodules associated with the sizes of cysts at detection (P < .001). CONCLUSIONS In a retrospective analysis of patients with BD-IPMN followed for more than 5 years, we found most cysts to be indolent, but some rapidly grew and progressed. Surveillance protocols should therefore be individualized based on initial cyst size and rate of growth.
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Affiliation(s)
- Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hongeun Lee
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Seung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Ri Kim
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeong Seok Kim
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Min Lee
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kyoung-Bun Lee
- Department of Pathology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
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Lan C, Li X, Wang X, Hao J, Ren H. A new combined criterion to better predict malignant lesions in patients with pancreatic cystic neoplasms. Cancer Biol Med 2018; 15:70-78. [PMID: 29545970 PMCID: PMC5842337 DOI: 10.20892/j.issn.2095-3941.2017.0152] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective: Cystic lesions of the pancreas have been increasingly recognized. Some lesions exhibit benign behavior, while others have unequivocal malignant potential. Thus, accurate identification of malignancy in patients diagnosed with pancreatic cystic neoplasms (PCNs) remains a major challenge. The aim of this study was to define a combined criterion to better predict malignant lesions in patients with PCNs. Methods: We retrospectively analyzed 165 patients who underwent resection of PCNs from October 2011 to May 2017. The relationship among malignancy and serum carbohydrate antigen 19-9 (CA19-9), preoperative neutrophil-to-lymphocyte ratio (NLR), and the presence of enhanced solid component on imaging was analyzed. Results: NLR before surgery in patients with malignant PCNs (2.81±2.14) was significantly higher than that in patients diagnosed with pancreatic neuroendocrine tumor (1.90±0.69, P=0.013) or healthy volunteers (1.40±0.48; P<0.001). Serum CA19-9 ≥39 U/mL, NLR >1.976 and presence of enhanced solid component were independent predictors of PCN malignancy. A combined criterion meeting any two or more of the three elements including CA19-9 ≥39 U/mL, NLR >1.976, and presence of enhanced solid component on computed tomography imaging is an indicator with a high positive predictive value of 80.5% and a high negative predictive value of 87.9%, and thus, represents a highly accurate test (86.1%).
Conclusions: The new combined criterion is an effective predictor of tumor malignancy in patients with PCNs.
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Affiliation(s)
- Chungen Lan
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Xin Li
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Xiuchao Wang
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Jihui Hao
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - He Ren
- Department of Pancreatic Cancer, Tianjin Medical University Cancer Institute and Hospital; National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
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Pausawasdi N, Ratanachu-Ek T. Endoscopic ultrasonography evaluation for pancreatic cysts: Necessity or overkill? Dig Endosc 2017; 29:444-454. [PMID: 28321928 DOI: 10.1111/den.12873] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/16/2017] [Indexed: 02/06/2023]
Abstract
Incidental pancreatic cysts have become gradually more recognized in clinical practice as a result of increased use of transabdominal ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI). These lesions consist of inflammatory cysts (pseudocysts) and pancreatic cystic neoplasms (PCN) which have been classified as benign, premalignant and malignant. The diagnosis and management strategy of incidentally discovered pancreatic cysts can be challenging as the majority of them are PCN and CT or MRI alone may not be sufficient to provide an accurate diagnosis. Endoscopic ultrasound (EUS)-guided fine-needle aspiration provides a method to obtain cyst fluid for analysis and the recently developed EUS-based technology including contrast-enhanced ultrasound, cystoscopy and needle-based confocal laser endomicroscopy allows endosonographers to gain additional useful information. The current data suggest that EUS evaluation of pancreatic cysts offers some benefits especially in cases of inconclusive CT or MRI.
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Affiliation(s)
- Nonthalee Pausawasdi
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine Siriraj Hospital, Siriraj Endoscopy Center, Mahidol Univeristy, Bangkok, Thailand
| | - Thawee Ratanachu-Ek
- Department of Surgery, Digestive Endoscopy Center, Rajavithi Hospital, Bangkok, Thailand
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Best LMJ, Rawji V, Pereira SP, Davidson BR, Gurusamy KS, Cochrane Upper GI and Pancreatic Diseases Group. 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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