1
|
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.
Collapse
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
| |
Collapse
|
2
|
Megibow AJ. Pancreatic Cysts: Radiology. Gastrointest Endosc Clin N Am 2023; 33:519-531. [PMID: 37245933 DOI: 10.1016/j.giec.2023.03.008] [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: 05/30/2023]
Abstract
This article reviews the types of pancreatic cysts encountered in Radiologic practice. It summarizes the malignancy risk of each of the following: serous cystadenoma, mucinous cystic tumor, intraductal papillary mucinous neoplasm main duct and side branch, and some miscellaneous cysts such as neuroendocrine tumor and solid pseudopapillary epithelial neoplasm. Specific reporting recommendations are given. The choice between radiology follow-up versus endoscopic analysis is discussed.
Collapse
Affiliation(s)
- Alec J Megibow
- Department of Radiology, NYU-Langone Health, 550 1st Avenue, Room HCC 232, New York, NY 10016, USA.
| |
Collapse
|
3
|
Hesse F, Ritter J, Hapfelmeier A, Braren R, Phillip V. Comparison of Magnetic Resonance Imaging and Endoscopic Ultrasound in the Sizing of Intraductal Papillary Mucinous Neoplasia of the Pancreas. Pancreas 2023; 52:e315-e320. [PMID: 37906550 DOI: 10.1097/mpa.0000000000002264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
OBJECTIVES Because IPMNs are potentially malignant, surveillance of IPMN is recommended by magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS). The aim of the study was the evaluation of the concordance between EUS and MRI regarding cyst size. METHODS Retrospective data analysis was done for patients with IPMN in whom EUS and MRI were performed simultaneously (≤60 days). The measured cyst size of both procedures was compared by Bland-Altman plots. Agreement of cyst localization and dilation of main pancreatic duct was assessed using kappa statistics. RESULTS Fifty-nine cases were evaluated (median age, 71 years; 65% female; median time interval between both investigations, 17 days). The mean difference of IPMN maximal diameter between EUS and MRI was 0.55 mm with a prediction interval of -9.20 to +10.29 mm for 95% of the expected differences. There was strong interobserver agreement regarding cyst localization ( κ = 0.669, P = 1.06e -13 ) and the width of main pancreatic duct (<5, 5-9, and ≥10 mm; κ = 0.676 caput, κ = 0.823 corpus). CONCLUSIONS We found a clinically relevant difference in cyst size comparing EUS and MRI. Therefore, alternating EUS and MRI for follow-up of the "worrisome feature" size growth is not reasonable.
Collapse
Affiliation(s)
| | - Jessica Ritter
- Institute of Diagnostic and Interventional Radiology, Technical University of Munich, School of Medicine and Health, Department Clinical Medicine, University Hospital rechts der Isar
| | | | - Rickmer Braren
- Institute of Diagnostic and Interventional Radiology, Technical University of Munich, School of Medicine and Health, Department Clinical Medicine, University Hospital rechts der Isar
| | | |
Collapse
|
4
|
Dong W, Zhen D, Xiaoyan W, Bin C, Ruifeng W, Shanyu Q, Zhuoran L, Kai S, Wenming W, Aiming Y, Xi W. The effectiveness of endoscopic ultrasonography findings to distinguish benign and malignant intraductal papillary mucinous neoplasm. Surg Endosc 2023:10.1007/s00464-022-09752-3. [PMID: 36881188 DOI: 10.1007/s00464-022-09752-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/29/2022] [Indexed: 03/08/2023]
Abstract
BACKGROUND AND AIMS Accurate evaluation of intraductal papillary mucinous neoplasm (IPMN) is necessary to inform clinical decision-making. But it is still difficult to distinguish benign and malignant IPMN preoperatively. This study aims to evaluate the utility of EUS to predict the pathology of IPMN. METHODS Patients with IPMN who underwent endoscopic ultrasound within 3 months before surgery were collected from six centers. Logistic regression model and random forest model were used to determine risk factors associated with malignant IPMN. In both models, 70% and 30% of patients were randomly assigned to the exploratory group and validation group, respectively. Sensitivity, specificity, and ROC were used in model assessment. RESULTS Of the 115 patients, 56 (48.7%) had low-grade dysplasia (LGD), 25 (21.7%) had high-grade dysplasia (HGD), and 34 (29.6%) had invasive cancer (IC). Smoking history (OR = 6.95, 95%CI: 1.98-24.44, p = 0.002), lymphadenopathy (OR = 7.91, 95%CI: 1.60-39.07, p = 0.011), MPD > 7 mm (OR = 4.75, 95%CI: 1.56-14.47, p = 0.006) and mural nodules > 5 mm (OR = 8.79, 95%CI: 2.40-32.24, p = 0.001) were independent risk factors predicting malignant IPMN according to the logistic regression model. The sensitivity, specificity, and AUC were 0.895, 0.571, and 0.795 in the validation group. In the random forest model, the sensitivity, specificity, and AUC were 0.722, 0.823, and 0.773, respectively. In patients with mural nodules, random forest model could reach a sensitivity of 0.905 and a specificity of 0.900. CONCLUSIONS Using random forest model based on EUS data is effective to differentiate benign and malignant IPMN in this cohort, especially in patients with mural nodules.
Collapse
Affiliation(s)
- Wu Dong
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Ding Zhen
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Wang Xiaoyan
- Department of Gastroenterology, Third Xiangya Hospital, Central South University, Changsha, 410013, China
| | - Cheng Bin
- Department of Gastroenterology and Hepatology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Wang Ruifeng
- Department of Gastroenterology, The Fourth Hospital of Harbin Medical University, Harbin, 150001, China
| | - Qin Shanyu
- Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, China
| | - Li Zhuoran
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Song Kai
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Wu Wenming
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yang Aiming
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Wu Xi
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing, 100730, China.
| |
Collapse
|
5
|
Li H, Feng X, Gao F, Chen Q, Linghu E. Diagnostic value of EUS-guided SF6 pancreatography for pancreatic cystic lesions on cyst communication with the pancreatic duct. Endosc Ultrasound 2023; 12:245-250. [PMID: 37148136 PMCID: PMC10237612 DOI: 10.4103/eus-d-22-00064] [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] [Received: 04/02/2022] [Accepted: 10/09/2022] [Indexed: 05/07/2023] Open
Abstract
Background and Objectives ERCP remains the reliable method to determine whether pancreatic cystic lesions (PCLs) and pancreatic duct communicate when other modalities (computed tomography, magnetic resonance imaging, and EUS) fail. However, complications after ERCP are still a risk that should not be ignored. In this study, we evaluated the value of EUS-guided SF6 pancreatography (ESP) for the diagnosis of PCLs focusing on pancreatic cyst communication with the pancreatic duct. Patients and Methods We reviewed the database of medical records to retrieve the clinicopathological data of the patients with PCLs who had undergone ESP, and analyzed the diagnostic value of ESP to determine communication between the cyst and the pancreatic duct. The inclusion criteria were as follows: (1) PCLs were pathologically diagnosed by postsurgery specimen or through-the-needle biopsy and (2) ESP was performed to determine communication between the pancreatic cyst and the pancreatic duct. Results Pathological diagnosis confirmed communication with the pancreatic duct in all eight patients with positive pancreatography, among whom seven were branch-duct-intraductal papillary mucinous neoplasm (BD-IPMN) and one was the main duct-IPMN. Pathological diagnosis confirmed noncommunication with the pancreatic duct in 20 of the 21 patients with negative pancreatography, among whom 11 were mucinous cystic neoplasm, 7 were serous cystic neoplasm, 1 was solid pseudopapillary neoplasm, 1 was pancreatic pseudocyst, and 1 was BD-IPMN. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of ESP to determine communication between the pancreatic cyst and the pancreatic duct were 96.6% (28/29), 88.9% (8/9), 100% (20/20), 100% (8/8), and 95.2% (20/21), respectively. Conclusions ESP achieved high accuracy to determine communication between the pancreatic cyst and the pancreatic duct.
Collapse
Affiliation(s)
- Huikai Li
- Department of Gastroenterology and Hepatology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiuxue Feng
- Department of Gastroenterology and Hepatology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Fei Gao
- Department of Gastroenterology and Hepatology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Qianqian Chen
- Department of Gastroenterology and Hepatology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Enqiang Linghu
- Department of Gastroenterology and Hepatology, First Medical Center of Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
6
|
Pancreatic Cystic Neoplasms: Diagnosis and Management. Diagnostics (Basel) 2023; 13:diagnostics13020207. [PMID: 36673017 PMCID: PMC9857870 DOI: 10.3390/diagnostics13020207] [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: 12/16/2022] [Revised: 12/31/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023] Open
Abstract
Pancreatic cancer is one of the most lethal cancers, largely related to the difficulties with early detection, as it typically presents in later stages. Pancreatic cystic neoplasms (PCN) are commonly diagnosed as incidental findings on routine imaging. PCN is becoming more frequently detected with the increasing ease and frequency of obtaining cross-sectional images. Certain subtypes of pancreatic cysts have the potential to progress to malignancy, and therefore, clinicians are tasked with creating a patient-centered management plan. The decision of whether to undergo surgical resection or interval surveillance can be challenging given the criteria, including PCN size, pancreatic duct dilation, presence of a mural nodule, and clinical symptoms that play a potential role in risk stratification. Furthermore, the guidelines available from the major gastrointestinal societies all differ in their management recommendations. In this review, we detail an overview of the different types of PCNs and compare major guidelines for both diagnosis and management. We include emerging evidence for next-generation sequencing as well as confocal needle endomicroscopy to aid in the diagnosis and determination of malignancy potential and diagnosis.
Collapse
|
7
|
Standardization of MRI Screening and Reporting in Individuals With Elevated Risk of Pancreatic Ductal Adenocarcinoma: Consensus Statement of the PRECEDE Consortium. AJR Am J Roentgenol 2022; 219:903-914. [PMID: 35856454 DOI: 10.2214/ajr.22.27859] [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: 12/14/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive malignancies, with a dismal survival rate. Screening the general population for early detection of PDAC is not recommended, but because early detection improves survival, high-risk individuals, defined as those meeting criteria based on a family history of PDAC and/or the presence of known pathogenic germline variant genes with PDAC risk, are recommended to undergo screening with MRI and/or endoscopic ultrasound at regular intervals. The Pancreatic Cancer Early Detection (PRECEDE) Consortium was formed in 2018 and is composed of gastroenterologists, geneticists, pancreatic surgeons, radiologists, statisticians, and researchers from 40 sites in North America, Europe, and Asia. The overarching goal of the PRECEDE Consortium is to facilitate earlier diagnosis of PDAC for high-risk individuals to increase survival of the disease. A standardized MRI protocol and reporting template are needed to enhance the quality of screening examinations, improve consistency of clinical management, and facilitate multiinstitutional research. We present a consensus statement to standardize MRI screening and reporting for individuals with elevated risk of pancreatic cancer.
Collapse
|
8
|
Facciorusso A, Kovacevic B, Yang D, Vilas-Boas F, Martínez-Moreno B, Stigliano S, Rizzatti G, Sacco M, Arevalo-Mora M, Villarreal-Sanchez L, Conti Bellocchi MC, Bernardoni L, Gabbrielli A, Barresi L, Gkolfakis P, Robles-Medranda C, De Angelis C, Larghi A, Di Matteo FM, Aparicio JR, Macedo G, Draganov PV, Vilmann P, Pecchia L, Repici A, Crinò SF. Predictors of adverse events after endoscopic ultrasound-guided through-the-needle biopsy of pancreatic cysts: a recursive partitioning analysis. Endoscopy 2022; 54:1158-1168. [PMID: 35451041 DOI: 10.1055/a-1831-5385] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND STUDY AIMS : Endoscopic ultrasound-guided through-the-needle biopsy (TTNB) of pancreatic cystic lesions (PCLs) is associated with a non-negligible risk for adverse events (AEs). We aimed to identify the hierarchic interaction among independent predictors for TTNB-related AEs and to generate a prognostic model using recursive partitioning analysis (RPA). PATIENTS AND METHODS : Multicenter retrospective analysis of 506 patients with PCLs who underwent TTNB. RPA of predictors for AEs was performed and the model was validated by means of bootstrap resampling. RESULTS : Mean cysts size was 36.7 mm. Most common diagnoses were intraductal papillary mucinous neoplasm (IPMN, 45 %), serous cystadenoma (18.8 %), and mucinous cystadenoma (12.8 %). Fifty-eight (11.5 %) AEs were observed. At multivariate analysis, age (odds ratio [OR] 1.32, 1.09-2.14; p = 0.05), number of TTNB passes (OR from 2.17, 1.32-4.34 to OR 3.16, 2.03-6.34 with the increase of the number of passes), complete aspiration of the cyst (OR 0.56, 0.31-0.95; p = 0.02), and diagnosis of IPMN (OR 4.16, 2.27-7.69; p < 0.001) were found to be independent predictors of AEs, as confirmed by logistic regression and random forest analyses. RPA identified three risk classes: high-risk (IPMN sampled with multiple microforceps passes, 28 % AEs rate), low-risk (1.4 % AE rate, including patients < 64 years with other-than-IPMN diagnosis sampled with ≤ 2 microforceps passes and with complete aspiration of the cyst) and middle-risk class (6.1 % AEs rate, including the remaining patients). CONCLUSION : TTNB should be selectively used in the evaluation of patients with IPMN. The present model could be applied during patient selection as to optimize the benefit/risk of TTNB.
Collapse
Affiliation(s)
- Antonio Facciorusso
- Department of Medical and Surgical Sciences, Section of Gastroenterology, University of Foggia, Foggia, Italy.,Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Bojan Kovacevic
- Division of Endoscopy, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | - Dennis Yang
- Center of Interventional Endoscopy, AdventHealth, Orlando, Florida, USA
| | - Filipe Vilas-Boas
- Department of Gastroenterology, Centro Hospitalar e Universitário de São João-Porto, Porto, Portugal
| | - Belén Martínez-Moreno
- Unidad de Endoscopia. ISABIAL, Hospital General Universitario de Alicante, Alicante, Spain
| | - Serena Stigliano
- Operative Endoscopy Department, Campus Bio-Medico University Hospital, Rome, Italy
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco Sacco
- Gastroenterology Division, AOU Cittá della Salute e della Scienza di Torino, Turin, Italy
| | | | | | - Maria Cristina Conti Bellocchi
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Laura Bernardoni
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Armando Gabbrielli
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Luca Barresi
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT (Mediterranean Institute for Transplantation and Highly Specialized Therapies), Palermo, Italy
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Claudio De Angelis
- Gastroenterology Division, AOU Cittá della Salute e della Scienza di Torino, Turin, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - José R Aparicio
- Unidad de Endoscopia. ISABIAL, Hospital General Universitario de Alicante, Alicante, Spain
| | - Guilherme Macedo
- Department of Gastroenterology, Centro Hospitalar e Universitário de São João-Porto, Porto, Portugal
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Peter Vilmann
- Division of Endoscopy, Copenhagen University Hospital Herlev and Gentofte, Copenhagen, Denmark
| | | | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Stefano Francesco Crinò
- Department of Medicine, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| |
Collapse
|
9
|
Jiang D, Chen ZX, Ma FX, Gong YY, Pu T, Chen JM, Liu XQ, Zhao YJ, Xie K, Hou H, Wang C, Geng XP, Liu FB. Online calculator for predicting the risk of malignancy in patients with pancreatic cystic neoplasms: A multicenter, retrospective study. World J Gastroenterol 2022; 28:5469-5482. [PMID: 36312834 PMCID: PMC9611704 DOI: 10.3748/wjg.v28.i37.5469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/25/2022] [Accepted: 09/07/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Efficient and practical methods for predicting the risk of malignancy in patients with pancreatic cystic neoplasms (PCNs) are lacking.
AIM To establish a nomogram-based online calculator for predicting the risk of malignancy in patients with PCNs.
METHODS In this study, the clinicopathological data of target patients in three medical centers were analyzed. The independent sample t-test, Mann–Whitney U test or chi-squared test were used as appropriate for statistical analysis. After univariable and multivariable logistic regression analysis, five independent factors were screened and incorporated to develop a calculator for predicting the risk of malignancy. Finally, the concordance index (C-index), calibration, area under the curve, decision curve analysis and clinical impact curves were used to evaluate the performance of the calculator.
RESULTS Enhanced mural nodules [odds ratio (OR): 4.314; 95% confidence interval (CI): 1.618–11.503, P = 0.003], tumor diameter ≥ 40 mm (OR: 3.514; 95%CI: 1.138–10.849, P = 0.029), main pancreatic duct dilatation (OR: 3.267; 95%CI: 1.230–8.678, P = 0.018), preoperative neutrophil-to-lymphocyte ratio ≥ 2.288 (OR: 2.702; 95%CI: 1.008–7.244, P = 0.048], and preoperative serum CA19-9 concentration ≥ 34 U/mL (OR: 3.267; 95%CI: 1.274–13.007, P = 0.018) were independent risk factors for a high risk of malignancy in patients with PCNs. In the training cohort, the nomogram achieved a C-index of 0.824 for predicting the risk of malignancy. The predictive ability of the model was then validated in an external cohort (C-index: 0.893). Compared with the risk factors identified in the relevant guidelines, the current model showed better predictive performance and clinical utility.
CONCLUSION The calculator demonstrates optimal predictive performance for identifying the risk of malignancy, potentially yielding a personalized method for patient selection and decision-making in clinical practice.
Collapse
Affiliation(s)
- Dong Jiang
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Zi-Xiang Chen
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Fu-Xiao Ma
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Yu-Yong Gong
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Tian Pu
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Jiang-Ming Chen
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Xue-Qian Liu
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Yi-Jun Zhao
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Kun Xie
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Hui Hou
- Department of General Surgery, The Second Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Cheng Wang
- Department of General Surgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei 230000, Anhui Province, China
| | - Xiao-Ping Geng
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| | - Fu-Bao Liu
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230000, Anhui Province, China
| |
Collapse
|
10
|
Lee SW, Shim SR, Jeong SY, Kim SJ. Comparison of Preoperative Imaging Modalities for the Assessment of Malignant Potential of Pancreatic Cystic Lesions: A Network Meta-analysis. Clin Nucl Med 2022; 47:849-855. [PMID: 35713890 DOI: 10.1097/rlu.0000000000004323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The aims of this study are to compare the performance of various preoperative imaging modalities for assessing the malignant potential of pancreatic cystic lesions (PCLs) through a network meta-analysis (NMA) and to clarify the role of 18 F-FDG PET in the management of patients with PCL. METHODS PubMed, EMBASE, and Cochrane Library were searched for the studies evaluating the performance of preoperative imaging modalities for identifying malignant PCLs. The NMA was performed for 4 representative categories of various imaging modalities in terms of diagnostic performance for differentiating malignant from benign PCL and intraductal papillary mucinous neoplasms only as a subgroup analysis. To calculate the probability of each imaging modality being the most effective diagnostic method, the surface under the cumulative ranking curve values were obtained. RESULTS A total of 1018 patients from 17 direct comparison studies using 2 or more preoperative imaging modalities were included for differentiating malignant from benign PCL. The positive predictive value (PPV) and accuracy of 18 F-FDG PET were significantly higher than that of CT (PPV: odds ratio [OR], 2.66; 95% credible interval [CrI], 1.21-6.17; accuracy: OR, 2.63; 95% CrI, 1.41-5.38) or MRI (PPV: OR, 2.50; 95% CrI, 1.09-6.26; accuracy: OR, 2.50; 95% CrI, 1.28-5.47) in all PCLs, as well as in the subgroup analysis for intraductal papillary mucinous neoplasm only. 18 F-FDG PET showed the highest surface under the cumulative ranking curve values in all diagnostic performance areas of sensitivity, specificity, PPV, negative predictive value, and accuracy, followed by MRI or CT. CONCLUSIONS The results from this NMA suggest that 18 F-FDG PET is the best preoperative imaging modality for differentiating malignant from benign PCLs and that it can be used for the preoperative evaluation of PCLs.
Collapse
Affiliation(s)
- Sang-Woo Lee
- From the Department of Nuclear Medicine, School of Medicine and Chilgok Hospital, Kyungpook National University, Daegu
| | - Sung Ryul Shim
- Department of Health and Medical Informatics, Kyungnam University College of Health Sciences, Changwon
| | - Shin Young Jeong
- From the Department of Nuclear Medicine, School of Medicine and Chilgok Hospital, Kyungpook National University, Daegu
| | | |
Collapse
|
11
|
Abstract
Despite advances in noninvasive techniques for imaging the pancreaticobiliary system, several disease processes including indeterminate biliary strictures as well as neuroendocrine tumors, inflammatory pseudotumors, and complex cysts of the pancreas remain difficult to characterize. New endoscopic imaging technologies have emerged to address these challenges. Cholangioscopy and intraductal ultrasound (IDUS) are powerful tools to characterize subtle biliary concretions and strictures. Confocal Laser Endomicroscopy (CLE) and Optical Coherence Tomography (OCT) are emerging approaches for the most difficult biliary lesions. Contrast harmonic endoscopic ultrasound (CH-EUS), elastography, and 3D-EUS are improving the approach to subtle pancreatic lesions, particularly in the context of indeterminate tissue sampling. Pancreatoscopy, pancreatic IDUS, and intracystic CLE hold promise to further improve the assessment of pancreatic cysts. We aim to comprehensively review the emerging clinical evidence for these innovative endoscopic imaging techniques.
Collapse
|
12
|
Epidemiological Factors Associated With Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Dual Center Case-Control Study. Pancreas 2022; 51:250-255. [PMID: 35584382 DOI: 10.1097/mpa.0000000000002007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The present study aimed to identify epidemiological factors associated with the development of intraductal papillary mucinous neoplasms (IPMN) of the pancreas comparing patients after IPMN resection with population-based controls. METHODS Preoperative data of 811 patients undergoing pancreatic resection for IPMN were matched in a 1:1 ratio with a random sample of volunteers from the Study of Health in Pomerania, which showed no pancreatic cyst greater than 2 mm in magnetic resonance cholangiopancreaticography. RESULTS A total of 811 controls with a mean age of 61.9 years (standard deviation, 8.4 years) were matched to cases with a mean age of 66.1 years (standard deviation, 9.3 years). A previous history of pancreatitis, endocrine pancreatic insufficiency was significantly more frequent in IPMN patients compared with controls (P = 0.001). Moreover, adjusted data revealed that urogenital cancer (P = 0.034), colorectal cancer (P = 0.021), as well as first-degree family history of colorectal cancer (P = 0.001) were significantly more frequent in IPMN patients. CONCLUSIONS A history of urogenital and colorectal cancer often coincides with IPMN, which have an indication for surgery and are associated with preoperative episodes of pancreatitis and with endocrine insufficiency. Prospective studies are needed to investigate the role of these factors in IPMN development.
Collapse
|
13
|
Cystic pancreatic lesions: MR imaging findings and management. Insights Imaging 2021; 12:115. [PMID: 34374885 PMCID: PMC8355307 DOI: 10.1186/s13244-021-01060-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/17/2021] [Indexed: 12/14/2022] Open
Abstract
Cystic pancreatic lesions (CPLs) are frequently casual findings in radiological examinations performed for other reasons in patients with unrelated symptoms. As they require different management according to their histological nature, differential diagnosis is essential. Radiologist plays a key role in the diagnosis and management of these lesions as imaging is able to correctly characterize most of them and thus address to a correct management. The first step for a correct characterization is to look for a communication between the CPLs and the main pancreatic duct, and then, it is essential to evaluate the morphology of the lesions. Age, sex and a history of previous pancreatic pathologies are important information to be used in the differential diagnosis. As some CPLs with different pathologic backgrounds can show the same morphological findings, differential diagnosis can be difficult, and thus, the final diagnosis can require other techniques, such as endoscopic ultrasound, endoscopic ultrasound-fine needle aspiration and endoscopic ultrasound-through the needle biopsy, and multidisciplinary management is important for a correct management.
Collapse
|
14
|
Udare A, Agarwal M, Alabousi M, McInnes M, Rubino JG, Marcaccio M, van der Pol CB. Diagnostic Accuracy of MRI for Differentiation of Benign and Malignant Pancreatic Cystic Lesions Compared to CT and Endoscopic Ultrasound: Systematic Review and Meta-analysis. J Magn Reson Imaging 2021; 54:1126-1137. [PMID: 33847435 DOI: 10.1002/jmri.27606] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Differentiation of benign and malignant pancreatic cystic lesions on MRI, computed tomography (CT), and endoscopic ultrasound (EUS) is critical for determining management. PURPOSE To perform a systematic review evaluating the diagnostic accuracy of MRI for diagnosing malignant pancreatic cystic lesions, and to compare the accuracy of MRI to CT and EUS. STUDY TYPE Systematic review and meta-analysis. DATA SOURCES MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus were searched until February 2020 for studies reporting MRI accuracy for assessing pancreatic cystic lesions. FIELD STRENGTH 1.5T or 3.0T. ASSESSMENT Methodologic and outcome data were extracted by two reviewers (AU and MA, 2 years of experience each). All studies of pancreatic cystic lesions on MRI were identified. Studies with incomplete MRI technique were excluded. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. STATISTICAL TESTS Sensitivity/specificity was pooled using bivariate random-effects meta-analysis with 95% confidence intervals (95%CI). Pairwise-comparison of MRI to CT and EUS was performed. The impact of gadolinium-based contrast agents, mucinous lesions, and risk of bias were explored using meta-regression. RESULTS MRI pooled sensitivity was 76% (95%CI 67% to 84%) and specificity was 80% (95%CI 74% to 85%) for distinguishing benign and malignant lesions. MRI and CT had similar sensitivity (P = 0.822) and specificity (P = 0.096), but MRI was more specific than EUS (80% vs. 75%, P < 0.05). Studies including only contrast-enhanced MRI were more sensitive than those including unenhanced exams (P < 0.05). MRI sensitivity and specificity did not differ for mucinous lesions (P = 0.537 and P = 0.384, respectively) or for studies at risk of bias (P = 0.789 and P = 0.791, respectively). DATA CONCLUSION MRI and CT demonstrate comparable accuracy for diagnosing malignant pancreatic cystic lesions. EUS is less specific than MRI, which suggests that, in some cases, management should be guided by MRI findings rather than EUS. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY STAGE: 2.
Collapse
Affiliation(s)
- Amar Udare
- Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Minu Agarwal
- Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Mostafa Alabousi
- Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Matthew McInnes
- Department of Radiology and Epidemiology, Ottawa Hospital Research Institute Clinical Epidemiology Program, University of Ottawa, Ottawa, Ontario, Canada
| | - Julian G Rubino
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Michael Marcaccio
- Department of Surgery, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Christian B van der Pol
- Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
15
|
Transabdominal Ultrasound for Follow-Up of Incidentally Detected Low-Risk Pancreatic Cysts: A Prospective Multicenter Study. AJR Am J Roentgenol 2021; 216:1521-1529. [PMID: 33826357 DOI: 10.2214/ajr.20.22965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE. The purpose of this study is to investigate the detection rate of transabdominal ultrasound (TAUS) for pancreatic cysts incidentally detected on CT or MRI as well as the factors that influence detection rates. SUBJECTS AND METHODS. Fifty-seven patients with low-risk pancreatic cysts (n = 77; cyst size, 5 mm to 3 cm) that were incidentally detected on CT or MRI were prospectively enrolled at five institutions. At each institution, TAUS was independently performed by two radiologists who assessed detection of cysts, cyst location and size, and the diameter of the main pancreatic duct (MPD). Cyst detection rates based on cyst size, location, and multiplicity and the body mass index of the patient were compared using the Mann-Whitney test. Kappa statistics and the interclass correlation coefficient were used to evaluate interobserver agreement regarding cyst detection and consistency of cyst size and the diameter of the MPD on TAUS versus prior CT or MRI. RESULTS. The detection rate for known low-risk pancreatic cysts was 81.8% (63/77) and 83.1% (64/77) for TAUS conducted by each of the two radiologists. The detection rate for larger (≥ 10 mm) cysts was significantly higher than that for smaller cysts (89.0% vs 63.6% for TAUS performed and interpreted by radiologist 1 [TAUS 1] and 89.0% vs 68.2% for TAUS conducted and interpreted by radiologist 2 [TAUS 2]; p < .05). A higher detection rate was noted for cysts located outside the tail of the pancreas compared with those located in the tail (89.5% vs 65.0% for TAUS 2; p = .01), and the detection rate was also significantly higher for single cysts than for multiple cysts (90.9% vs 69.7% for TAUS 1; p = .02). However, no significant difference was observed for body mass index. Interobserver agreement was excellent regarding the size of the detected cysts (inter-class correlation coefficient: 0.964 [95% CI, 0.940-0.979] for CT, TAUS 1, and TAUS 2 and 0.965 [95% CI. 0.924-986] for MRI, TAUS 1, and TAUS 2) and the diameter of the MPD (interclass correlation coefficient, 0.934; 95% CI, 0.898-0.959). CONCLUSION. TAUS could be a useful alternative imaging tool for surveillance of known low-risk pancreatic cysts, especially single pancreatic cysts and those that are of larger size (≥ 1 cm) or are located outside the tail.
Collapse
|
16
|
Hecht EM, Khatri G, Morgan D, Kang S, Bhosale PR, Francis IR, Gandhi NS, Hough DM, Huang C, Luk L, Megibow A, Ream JM, Sahani D, Yaghmai V, Zaheer A, Kaza R. Intraductal papillary mucinous neoplasm (IPMN) of the pancreas: recommendations for Standardized Imaging and Reporting from the Society of Abdominal Radiology IPMN disease focused panel. Abdom Radiol (NY) 2021; 46:1586-1606. [PMID: 33185741 DOI: 10.1007/s00261-020-02853-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 02/07/2023]
Abstract
There have been many publications detailing imaging features of malignant transformation of intraductal papillary mucinous neoplasms (IPMN), management and recommendations for imaging follow-up of diagnosed or presumed IPMN. However, there is no consensus on several practical aspects of imaging IPMN that could serve as a clinical guide for radiologists and enable future data mining for research. These aspects include how to measure IPMN, define reporting terminology, standardize reporting and unify guidelines for surveillance. The Society of Abdominal Radiology (SAR) created multiple Disease-Focused Panels (DFP) comprised multidisciplinary panel members who focus on a particular disease, with the goal to develop ways for radiologists to improve patient care, education, and research. DFP members met to identify the current controversies and limitations of imaging pancreatic IPMN. This paper aims to provide a practical review of the key imaging characteristics of IPMN for trainees and practicing radiologists, to guide uniformity of performance and interpretation of surveillance imaging studies, and to improve communication with clinicians by providing a lexicon and reporting template based on the experience of the SAR-DFP panel members.
Collapse
Affiliation(s)
- Elizabeth M Hecht
- Department of Radiology, New York Presbyterian-Weill Cornell Medicine, New York, NY, USA.
| | - Gaurav Khatri
- Department of Diagnostic Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Desiree Morgan
- Department of Radiology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Stella Kang
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Priya R Bhosale
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Isaac R Francis
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Namita S Gandhi
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - David M Hough
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Chenchan Huang
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Lyndon Luk
- Department of Radiology, New York Presbyterian-Columbia University Medical Center, New York, NY, USA
| | - Alec Megibow
- Department of Radiology, NYU Grossman School of Medicine, New York, NY, USA
| | - Justin M Ream
- Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Dushyant Sahani
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Vahid Yaghmai
- Department of Radiological Sciences, University of California, Irvine, Orange, CA, USA
| | - Atif Zaheer
- Department of Radiology, John Hopkins Medicine, Baltimore, MD, USA
| | - Ravi Kaza
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
17
|
Lee ES, Kim JH, Yu MH, Choi SY, Kang HJ, Park HJ, Park YS, Byun JH, Shin SS, Lee CH. Diagnosis and Surveillance of Incidental Pancreatic Cystic Lesions: 2017 Consensus Recommendations of the Korean Society of Abdominal Radiology. Korean J Radiol 2020; 20:542-557. [PMID: 30887737 PMCID: PMC6424832 DOI: 10.3348/kjr.2018.0640] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 11/30/2018] [Indexed: 02/06/2023] Open
Abstract
The occurrence of incidentally detected pancreatic cystic lesions (PCLs) is continuously increasing. Radiologic examinations including computed tomography and magnetic resonance imaging with magnetic resonance cholangiopancreatography have been widely used as the main diagnostic and surveillance methods for patients with incidental PCLs. Although most incidentally detected PCLs are considered benign, they have the potential to become malignant. Currently, we have several guidelines for the management of incidental PCLs. However, there is still debate over proper management, in terms of accurate diagnosis, optimal follow-up interval, and imaging tools. Because imaging studies play a crucial role in the management of incidental PCLs, the 2017 consensus recommendations of the Korean Society of Abdominal Radiology for the diagnosis and surveillance of incidental PCLs approved 11 out of 16 recommendations. Although several challenges remain in terms of optimization and standardization, these consensus recommendations might serve as useful tools to provide a more standardized approach and to optimize care of patients with incidental PCLs.
Collapse
Affiliation(s)
- Eun Sun Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Jung Hoon Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.
| | - Mi Hye Yu
- Department of Radiology, Konkuk University Medical Center, Seoul, Korea
| | - Seo Youn Choi
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Hyo Jin Kang
- Department of Radiology, Seoul National University Hospital, Seoul, Korea.
| | - Hyun Jeong Park
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Yang Shin Park
- Department of Radiology, Korea University Guro Hospital, Seoul, Korea
| | - Jae Ho Byun
- Department of Radiology, Asan Medical Center, Seoul, Korea
| | - Sang Soo Shin
- Department of Radiology, Chonnam National University Hospital, Gwangju, Korea
| | - Chang Hee Lee
- Department of Radiology, Korea University Guro Hospital, Seoul, Korea
| | | |
Collapse
|
18
|
Lim J, Allen PJ. The diagnosis and management of intraductal papillary mucinous neoplasms of the pancreas: has progress been made? Updates Surg 2019; 71:209-216. [PMID: 31175628 DOI: 10.1007/s13304-019-00661-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 05/31/2019] [Indexed: 12/12/2022]
Abstract
Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are premalignant mucin-producing epithelial tumors that arise from the pancreatic ductal system. These cystic tumors represent 15-30% of cystic lesions of the pancreas [Basturk et al. in Am J Surg Pathol 39(12):1730-1741, 1; Ferrone et al. in Arch Surg (Chicago, Ill: 1960) 144(5):448-454, 2, Kosmahl et al. in Virchows Arch Int J Pathol 445(2):168-178, 3; Spinelli et al. in Ann Surg. 239(5):651-657, 4]. It is believed that IPMN can progress from low-grade dysplasia to high-grade dysplasia to invasive cancer, and this pathway of progression accounts for 20-30% of pancreatic cancer [Adsay et al. in Am J Surg Pathol 28(7):839-848, 5; Tanaka et al. in J Gastroenterol 40(7):669-675, 6; Wu et al. in Sci Transl Med 3(92):92ra66, 7]. Furthermore, it is also widely believed that IPMN represent a field defect of the pancreas in which the entire ductal system is at risk of developing invasive carcinoma, not only in the area of radiographically detectable IPMN, and thus the remaining gland should undergo surveillance after partial pancreatectomy [Salvia et al. in Ann Surg 239(5):678-685, 8; Izawa et al. in Cancer 92(7):1807-1817, 9; Yamaguchi and Tanaka in Jpn J Clin Oncol 41(7):836-840, 10]. Increasingly, surgeons are faced with the dilemma between recommending highly complex resections-that have significant morbidity and mortality-in patients who may have low-risk IPMN (low-grade dysplasia), or alternatively, recommending observation for those who could possibly be harboring a radiographically occult malignancy. Given the complexity of the management decisions for patients with IPMN, the purpose of this paper is to review the current literature and to provide a summary of how accurate we are currently with the identification of high-grade dysplasia or progression to carcinoma in patients who present with IPMN.
Collapse
Affiliation(s)
- Jenny Lim
- Department of Surgical Oncology, Duke University, Durham, NC, 27710, USA.
| | - Peter J Allen
- Department of Surgical Oncology, Duke University, Durham, NC, 27710, USA
- Duke Cancer Institute, Duke Health System, Durham, NC, 27710, USA
| |
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
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: 0.8] [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.
Collapse
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
| |
Collapse
|
21
|
Abstract
PET/MR imaging has the potential to markedly alter pancreatic care in both the malignant, and premalignant states with the ability to perform robust, high-resolution, quantitative molecular imaging. The ability of PET/MR imaging to monitor disease processes, potentially correct for motion in the upper abdomen, and provide novel biomarkers that may be a combination of MR imaging and PET biomarkers, offers a unique, precise interrogation of the pancreatic milieu going forward.
Collapse
Affiliation(s)
- Nadine Mallak
- Department of Diagnostic Radiology, Oregon Health & Sciences University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 505 Parnassus Avenue, M391, San Francisco, CA 94158, USA
| | - Alexander R Guimaraes
- Department of Diagnostic Radiology, Oregon Health & Sciences University, 3181 Southwest Sam Jackson Park Road, Portland, OR 97239, USA.
| |
Collapse
|
22
|
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: 1.2] [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.
Collapse
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
| | | | | |
Collapse
|
23
|
Current concepts in molecular genetics and management guidelines for pancreatic cystic neoplasms: an essential update for radiologists. Abdom Radiol (NY) 2018; 43:2351-2368. [PMID: 29404638 DOI: 10.1007/s00261-017-1452-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Cystic neoplasms in the pancreas are encountered frequently on imaging, often detected incidentally during evaluation for other conditions. They can have a variety of clinical and imaging presentations, and similarly, wide-ranging prognostic and treatment implications. In the majority, imaging helps in diagnosis of pancreatic cystic neoplasms (PCNs) and guides management decisions. But, a significant minority of the PCNs remain indeterminate. There have been multiple recent advances in biomarkers and molecular genetics which will likely prove helpful in risk stratification of PCNs. Several prominent national and international societies, as well as consensus groups have put forth recommendations to help guide management of PCNs. The purpose of this article is to discuss the role of imaging in evaluation of PCNs, review the recent advances in molecular genetics and pancreatic cyst fluid analysis, and analyze the pros and cons of major evidence-based and consensus guidelines for management of PCNs.
Collapse
|
24
|
McIntyre CA, Allen PJ. How Long Should Patients with Cystic Lesions of the Pancreas Be Followed? Adv Surg 2018; 52:223-233. [PMID: 30098614 DOI: 10.1016/j.yasu.2018.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Caitlin A McIntyre
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Peter J Allen
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| |
Collapse
|
25
|
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.
Collapse
|
26
|
Comparison between MRI with MR cholangiopancreatography and endoscopic ultrasonography for differentiating malignant from benign mucinous neoplasms of the pancreas. Eur Radiol 2017; 28:179-187. [PMID: 28779397 DOI: 10.1007/s00330-017-4926-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/01/2017] [Accepted: 06/05/2017] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To compare diagnostic performance of magnetic resonance imaging (MRI) and endoscopic ultrasonography (EUS) for differentiating malignant from benign intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN) of the pancreas. METHODS This retrospective study included 55 patients with 47 surgically confirmed IPMNs (12 malignant, 35 benign) and eight MCNs (two malignant, six benign) who underwent contrast-enhanced pancreas MRI and EUS. Contrast enhancement was not routinely used at EUS examination. Two observers independently evaluated the MRIs, and another reviewed EUS images. They recorded their confidence for malignancy with each imaging modality. We calculated diagnostic performance using the area under the receiver operating characteristic curves (A z ), and to determine the accuracy, sensitivity, specificity, and positive (PPV) and negative predictive (NPV) values. RESULTS The A z values of MRI were higher than those of EUS (0.712 and 0.688 for MRI vs. 0.543 for EUS; p = 0.007). The diagnostic accuracies (74.5%), specificity (78.0% and 80.5%) and PPV (50.0%) of MRI in two observers were higher than those (56.4%, 58.5% and 29.2%, respectively) of EUS (p = 0.013-0.049). CONCLUSION MRI showed better diagnostic performance than EUS for differentiating malignant from benign pancreatic IPMN and MCN. KEY POINTS • The A z values of MRI were higher than those of EUS. • The diagnostic accuracies of MRI were higher than those of EUS. • The specificities of MRI were higher than those of EUS.
Collapse
|
27
|
Describing Peripancreatic Collections According to the Revised Atlanta Classification of Acute Pancreatitis: An International Interobserver Agreement Study. Pancreas 2017; 46:850-857. [PMID: 28697123 DOI: 10.1097/mpa.0000000000000863] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Severe acute pancreatitis is associated with peripancreatic morphologic changes as seen on imaging. Uniform communication regarding these morphologic findings is crucial for accurate diagnosis and treatment. For the original 1992 Atlanta classification, interobserver agreement is poor. We hypothesized that for the revised Atlanta classification, interobserver agreement will be better. METHODS An international, interobserver agreement study was performed among expert and nonexpert radiologists (n = 14), surgeons (n = 15), and gastroenterologists (n = 8). Representative computed tomographies of all stages of acute pancreatitis were selected from 55 patients and were assessed according to the revised Atlanta classification. The interobserver agreement was calculated among all reviewers and subgroups, that is, expert and nonexpert reviewers; interobserver agreement was defined as poor (≤0.20), fair (0.21-0.40), moderate (0.41-0.60), good (0.61-0.80), or very good (0.81-1.00). RESULTS Interobserver agreement among all reviewers was good (0.75 [standard deviation, 0.21]) for describing the type of acute pancreatitis and good (0.62 [standard deviation, 0.19]) for the type of peripancreatic collection. Expert radiologists showed the best and nonexpert clinicians the lowest interobserver agreement. CONCLUSIONS Interobserver agreement was good for the revised Atlanta classification, supporting the importance for widespread adaption of this revised classification for clinical and research communications.
Collapse
|
28
|
Abstract
Pancreatic cysts, especially incidental asymptomatic ones seen on noninvasive imaging such as CT or MR imaging, remain a clinical challenge. The etiology of such cysts may range from benign cysts without any malignant potential such as pancreatic pseudocysts and serous cystadenomas to premalignant or frankly malignant cysts such as mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, cystic degeneration associated with solid tumors such as pancreatic ductal adenocarcinoma or pancreatic endocrine neoplasms, and solid pseudopapillary neoplasms. The clinical challenge in 2017 is to accurately preoperatively diagnose them and their malignant potential before deciding about surgery, surveillance or doing nothing. This review will focus on the currently available clinical guidelines for doing so.
Collapse
Affiliation(s)
- James J Farrell
- Yale Center for Pancreatic Diseases, Interventional Endoscopy, Yale School of Medicine, New Haven, CT, USA. .,Section of Digestive Diseases, Yale University School of Medicine, LMP 1080, 15 York Street, New Haven, CT, 06510-3221, USA.
| |
Collapse
|
29
|
Megibow AJ, Baker ME, Morgan DE, Kamel IR, Sahani DV, Newman E, Brugge WR, Berland LL, Pandharipande PV. Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2017; 14:911-923. [PMID: 28533111 DOI: 10.1016/j.jacr.2017.03.010] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 02/27/2017] [Accepted: 03/13/2017] [Indexed: 12/12/2022]
Abstract
The ACR Incidental Findings Committee (IFC) presents recommendations for managing pancreatic cysts that are incidentally detected on CT or MRI. These recommendations represent an update from the pancreatic component of the JACR 2010 white paper on managing incidental findings in the adrenal glands, kidneys, liver, and pancreas. The Pancreas Subcommittee-which included abdominal radiologists, a gastroenterologist, and a pancreatic surgeon-developed this algorithm. The recommendations draw from published evidence and expert opinion, and were finalized by informal iterative consensus. Algorithm branches successively categorize pancreatic cysts based on patient characteristics and imaging features. They terminate with an ascertainment of benignity and/or indolence (sufficient to discontinue follow-up), or a management recommendation. The algorithm addresses most, but not all, pathologies and clinical scenarios. Our goal is to improve quality of care by providing guidance on how to manage incidentally detected pancreatic cysts.
Collapse
Affiliation(s)
- Alec J Megibow
- Department of Radiology, NYU-Langone Medical Center, New York, New York.
| | - Mark E Baker
- Department of Radiology, Cleveland Clinic, Cleveland, Ohio
| | - Desiree E Morgan
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ihab R Kamel
- Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Dushyant V Sahani
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Elliot Newman
- Department of Surgery, NYU-Langone Medical Center, New York, New York
| | - William R Brugge
- Gastrointestinal Unit, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lincoln L Berland
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Pari V Pandharipande
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts; Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
30
|
Du C, Chai NL, Linghu EQ, Li HK, Sun LH, Jiang L, Wang XD, Tang P, Yang J. Comparison of endoscopic ultrasound, computed tomography and magnetic resonance imaging in assessment of detailed structures of pancreatic cystic neoplasms. World J Gastroenterol 2017; 23:3184-3192. [PMID: 28533675 PMCID: PMC5423055 DOI: 10.3748/wjg.v23.i17.3184] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 02/20/2017] [Accepted: 03/15/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the advantages of endoscopic ultrasound (EUS) in the assessment of detailed structures of pancreatic cystic neoplasms (PCNs) compared to computed tomography (CT) and magnetic resonance imaging (MRI).
METHODS All patients with indeterminate PCNs underwent CT, MRI, and EUS. The detailed information, including size, number, the presence of a papilla/nodule, the presence of a septum, and the morphology of the pancreatic duct of PCNs were compared among the three imaging modalities. The size of each PCN was determined using the largest diameter measured. A cyst consisting of several small cysts was referred to as a mother-daughter cyst. Disagreement among the three imaging modalities regarding the total number of mother cysts resulted in the assumption that the correct number was the one in which the majority of imaging modalities indicated.
RESULTS A total of 52 females and 16 males were evaluated. The median size of the cysts was 42.5 mm by EUS, 42.0 mm by CT and 38.0 mm by MRI; there was no significant difference in size as assessed among the three imaging techniques. The diagnostic sensitivity and ability of EUS to classify PCNs were 98.5% (67/68) and 92.6% (63/68), respectively. These percentages were higher than those of CT (73.1%, P < 0.001; 17.1%, P < 0.001) and MRI (81.3%, P = 0.001; 20.3%, P < 0.001). EUS was also able to better assess the number of daughter cysts in mother cysts than CT (P = 0.003); however, there was no significant difference between EUS and MRI in assessing mother-daughter cysts (P = 0.254). The papilla/nodule detection rate by EUS was 35.3% (24/68), much higher than those by CT (5.8%, 3/52) and MRI (6.3%, 4/64). The detection rate of the septum by EUS was 60.3% (41/68), which was higher than those by CT (34.6%, 18/52) and by MRI (46.9%, 30/64); the difference between EUS and CT was significant (P = 0.02). The rate of visualizing the pancreatic duct using EUS was 100%, whereas using CT and MRI it was less than 10%.
CONCLUSION EUS helps visualize the detailed structures of PCNs and has many advantages over CT and MRI. EUS is valuable in the diagnosis and assessment of PCNs.
Collapse
|
31
|
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: 2.0] [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.
Collapse
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
| |
Collapse
|
32
|
Best LMJ, Rawji V, Pereira SP, Davidson BR, Gurusamy KS. Imaging modalities for characterising focal pancreatic lesions. Cochrane Database Syst Rev 2017; 4:CD010213. [PMID: 28415140 PMCID: PMC6478242 DOI: 10.1002/14651858.cd010213.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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.
Collapse
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
| | | | | |
Collapse
|
33
|
Farrell JJ. Prevalence, Diagnosis and Management of Pancreatic Cystic Neoplasms: Current Status and Future Directions. Gut Liver 2016; 9:571-89. [PMID: 26343068 PMCID: PMC4562774 DOI: 10.5009/gnl15063] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cystic neoplasms of the pancreas are found with increasing prevalence, especially in elderly asymptomatic individuals. Although the overall risk of malignancy is very low, the presence of these pancreatic cysts is associated with a large degree of anxiety and further medical investigation due to concerns about malignancy. This review discusses the different cystic neoplasms of the pancreas and reports diagnostic strategies based on clinical features and imaging data. Surgical and nonsurgical management of the most common cystic neoplasms, based on the recently revised Sendai guidelines, is also discussed, with special reference to intraductal papillary mucinous neoplasm (IPMN; particularly the branch duct variant), which is the lesion most frequently identified incidentally. IPMN pathology, its risk for development into pancreatic ductal adenocarcinoma, the pros and cons of current guidelines for management, and the potential role of endoscopic ultrasound in determining cancer risk are discussed. Finally, surgical treatment, strategies for surveillance of pancreatic cysts, and possible future directions are discussed.
Collapse
Affiliation(s)
- James J Farrell
- Yale Center for Pancreatic Diseases, Interventional Endoscopy, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
34
|
Abstract
Cystic neoplasms of the pancreas are being identified at an increasing frequency largely due to the increased use of abdominal cross-sectional imaging. These neoplasms represent a heterogeneous group of tumors with various genetic alterations, molecular features, and risks of malignancy. Despite the use of high-resolution radiographic studies, endoscopic evaluation, cyst fluid analysis, and novel molecular diagnostics, many of these lesions remain difficult to classify without operative resection. These diagnostic challenges are coupled with an improving but limited understanding of the natural history of these neoplasms. Treatment of pancreatic cystic neoplasms therefore remains controversial but consists largely of a selective tumor-specific approach to surgical resection. Future research remains necessary to better discriminate the biological behavior of these tumors in order to more appropriately select patients for operative intervention.
Collapse
Affiliation(s)
- Rohit Chandwani
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065; ,
| | - Peter J Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065; ,
| |
Collapse
|
35
|
Buscarini E, Pezzilli R, Cannizzaro R, De Angelis C, Gion M, Morana G, Zamboni G, Arcidiacono P, Balzano G, Barresi L, Basso D, Bocus P, Calculli L, Capurso G, Canzonieri V, Casadei R, Crippa S, D'Onofrio M, Frulloni L, Fusaroli P, Manfredi G, Pacchioni D, Pasquali C, Rocca R, Ventrucci M, Venturini S, Villanacci V, Zerbi A, Falconi M. Italian consensus guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms. Dig Liver Dis 2014; 46:479-93. [PMID: 24809235 DOI: 10.1016/j.dld.2013.12.019] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Revised: 12/07/2013] [Accepted: 12/30/2013] [Indexed: 12/11/2022]
Abstract
This report contains clinically oriented guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms in patients fit for treatment. The statements were elaborated by working groups of experts by searching and analysing the literature, and then underwent a consensus process using a modified Delphi procedure. The statements report recommendations regarding the most appropriate use and timing of various imaging techniques and of endoscopic ultrasound, the role of circulating and intracystic markers and the pathologic evaluation for the diagnosis and follow-up of cystic pancreatic neoplasms.
Collapse
Affiliation(s)
| | | | | | - Raffaele Pezzilli
- Pancreas Unit, Department of Digestive Diseases and Internal Medicine, S. Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Claudio De Angelis
- Gastroenterology and Hepatology Department, A.O. San Giovanni Battista/Molinette, University of Turin, Turin, Italy
| | - Massimo Gion
- Department of Clinical Pathology, AULSS 12, Venice, Italy
| | - Giovanni Morana
- Department of Diagnostic Radiology, Ospedale Cà Foncello, Treviso, Italy
| | | | - Paolo Arcidiacono
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute, Italy
| | - Gianpaolo Balzano
- Department of Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Luca Barresi
- Gastroenterology and Endoscopy Unit, ISMETT, Palermo, Italy
| | - Daniela Basso
- Department of Laboratory Medicine, University Hospital, Padua, Italy
| | - Paolo Bocus
- Gastroenterology Unit, Ospedale Sacro Cuore-Don Calabria, Negrar, Verona, Italy
| | - Lucia Calculli
- Department of Radiology, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Gabriele Capurso
- Digestive and Liver Disease Unit, Faculty of Medicine and Psychology, Sapienza University of Rome at S. Andrea Hospital, Rome, Italy
| | | | - Riccardo Casadei
- Department of Surgery, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Stefano Crippa
- Department of Surgery, Pancreas Unit, Università Politecnica delle Marche, Ancona, Italy
| | - Mirko D'Onofrio
- Department of Radiology, University Hospital G.B. Rossi, University of Verona, Verona, Italy
| | - Luca Frulloni
- Department of Surgical and Gastroenterological Sciences, University of Verona, Verona, Italy
| | - Pietro Fusaroli
- Department of Clinical Medicine, University of Bologna, Bologna, Italy
| | | | | | - Claudio Pasquali
- Surgery Unit IV, Department of Medical and Surgical Sciences, University of Padua, Padua, Italy
| | - Rodolfo Rocca
- Gastroenterology Unit, Mauriziano Hospital, Turin, Italy
| | - Maurizio Ventrucci
- Department of Internal Medicine and Gastroenterology, Bentivoglio Hospital, Bologna, Italy
| | - Silvia Venturini
- Department of Diagnostic Radiology, Ospedale Cà Foncello, Treviso, Italy
| | | | - Alessandro Zerbi
- Pancreatic Surgery, Department of Surgery, Humanitas Clinical and Research Center, Milan, Italy
| | - Massimo Falconi
- Department of Surgery, Pancreas Unit, Università Politecnica delle Marche, Ancona, Italy
| | | |
Collapse
|
36
|
Kelvin YMC, Park JS, Seo DW. Role of endosonography in the management of incidental pancreatic cystic lesions. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
37
|
Chen F, Liang JY, Zhao QY, Wang LY, Li J, Deng Z, Jiang TA. Differentiation of branch duct intraductal papillary mucinous neoplasms from serous cystadenomas of the pancreas using contrast-enhanced sonography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:449-455. [PMID: 24567456 DOI: 10.7863/ultra.33.3.449] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES The purpose of this study was to determine whether contrast-enhanced sonography can improve the ability to differentiate branch duct intraductal mucinous neoplasms from serous cystadenomas of the pancreas compared to conventional (unenhanced) sonography alone. METHODS Between March 2008 and May 2012, there were 20 patients with branch duct intraductal mucinous neoplasms and 25 with serous cystadenomas in our institute, for whom preoperative conventional and contrast-enhanced sonographic results were available. The final diagnosis was obtained by histopathology. Various conventional and contrast-enhanced sonographic characteristics were retrospectively evaluated by 2 radiologists in consensus. A receiver operating characteristic curve analysis was used to evaluate the diagnostic value of conventional and contrast-enhanced sonography for discriminating between the two entities. RESULTS Three conventional sonographic characteristics (microcysts, cysts with internal echoes, and main pancreatic duct dilatation) and 2 contrast-enhanced sonographic characteristics (communication between the lesion and main pancreatic duct and enhancement of mural nodules) significantly improved the ability to differentiate branch duct intraductal mucinous neoplasms from serous cystadenomas. The area under the receiver operating characteristic curve increased from 0.691 with conventional sonography to 0.859 with combined contrast-enhanced and conventional ultrasonography (P = .043). CONCLUSIONS In this series of patients, the addition of contrast-enhanced sonography to conventional sonography improved the ability to differentiate branch duct intraductal mucinous neoplasms from serous cystadenomas.
Collapse
Affiliation(s)
- Fen Chen
- Hepatobiliary and Pancreatic Intervention Center, First Affiliated Hospital, College of Medicine, Zhejiang University, 310003 Hangzhou, China.
| | | | | | | | | | | | | |
Collapse
|
38
|
Abstract
AbstractPancreatic cysts involve a wide spectrum of pathologies from post-inflammatory cysts to malignant neoplasms. Pancreatic pseudocysts, serous cystadenomas, mucinous cystadenomas, intraductal papillary mucinous neoplasms (IPMNs) and solid pseudopapillary tumors occur most frequently. Differential diagnosis involves the following imaging investigations: transabdominal ultrasonography (TUS), contrast enhanced ultrasonography (CEUS) and endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance (MR) and magnetic resonance cholangiopancretography (MRCP), endoscopic retrograde cholangiopancretography (ERCP). The cyst fluid cytology is performed in difficult differential diagnosis between pseudocysts and benign and potentially malignant or malignant tumors. Most frequently, viscosity, amylase, CEA and CA 19-9 levels are determined. Imaging findings should be correlated with cytology. The management depends on the cyst type and size. Small asymptomatic pseudocysts, serous cystadenomas and branchduct IPMNs should be carefully observed, whereas symptomatic large or uncertain serous cystadenomas and cystadenocarcinomas, mucinous cystadenomas and cystadenocarcinomas, main-duct IPMNs and large branch-duct IPMNs with malignant features, serous and mucinous cystadenocarcinomas, and solid pseudopapillary tumors require surgery. Pseudocysts are usually drained. Percutaneous / EUS-guided or surgical cyst drainage can be performed. Complicated and uncertain pseudocysts and cystic tumors need surgical resection. The type of surgery depends on cyst location and size and includes proximal, central, distal, total pancreatectomies and enucleation.
Collapse
|
39
|
Imaging of indeterminate pancreatic cystic lesions: a systematic review. Pancreatology 2013; 13:436-42. [PMID: 23890144 DOI: 10.1016/j.pan.2013.05.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 03/15/2013] [Accepted: 05/24/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic cystic lesions are an increasing problem and investigation of these cysts can be fraught with difficulty. There is currently no gold standard for diagnosis or surveillance. This review was undertaken to determine the present reliability of the characterisation, assessment of malignant potential and diagnosis of pancreatic cystic lesions using available imaging modalities. METHODS A Medline search using the terms 'pancreatic', 'pancreas', 'cyst', 'cystic', 'lesions', 'imaging', 'PET'. 'CT', 'MRI' and 'EUS' was performed. Publications were screened to include studies examining the performance of CT, MRI, MRCP, EUS and 18-FDG PET in the determination of benign or malignant cysts, cyst morphology and specific diagnoses. RESULTS Nineteen studies were identified that met the inclusion criteria. 18-FDG PET had a sensitivity and specificity of 57.0-94.0% and 65.0-97.0% and an accuracy of 94% in determining benign versus malignant cysts. CT had a sensitivity and specificity of 36.3-71.4% and 63.9-100% in determining benign disease but had an accuracy of making a specific diagnosis of 39.0-44.7%. MRI had a sensitivity and specificity of 91.4-100.0% and 89.7% in assessing main pancreatic duct communication. CONCLUSION CT is a good quality initial investigation to be used in conjunction with clinical data. MRCP can add useful information regarding MPD communication but should be used judiciously. PET may have a role in equivocal cases to determine malignancy. Further examination of CT-PET in this patient group is warranted.
Collapse
|
40
|
Farrell JJ, Fernández-del Castillo C. Pancreatic cystic neoplasms: management and unanswered questions. Gastroenterology 2013; 144:1303-15. [PMID: 23622140 DOI: 10.1053/j.gastro.2013.01.073] [Citation(s) in RCA: 181] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 01/27/2013] [Accepted: 01/30/2013] [Indexed: 02/08/2023]
Abstract
Approximately 10% of persons 70 years old or older are now diagnosed with pancreatic cysts, but it is not clear which ones require additional analysis, interventions, or follow-up. Primary care doctors rely on gastroenterologists for direction because no one wants to miss a diagnosis of pancreatic cancer, but meanwhile there is pressure to limit use of diagnostic tests and limit costs. We review the different cystic neoplasms of the pancreas and diagnostic strategies based on clinical features and imaging data. We discuss surgical and nonsurgical management of the most common cystic neoplasms, based on the recently revised Sendai guidelines. Intraductal papillary mucinous neoplasm (particularly the branch duct variant) is the lesion most frequently identified incidentally. We report what is known about its pathology, its risk of developing into pancreatic ductal adenocarcinoma, the pros and cons of current guidelines for management, and the potential role of endoscopic ultrasound in determining cancer risk. We also review surgical treatment and strategies for surveillance of pancreatic cysts.
Collapse
Affiliation(s)
- James J Farrell
- Yale Pancreas Center and Interventional Endoscopy, Yale School of Medicine, New Haven, Connecticut, USA.
| | | |
Collapse
|