New onset diabetes predicts progression of low risk pancreatic mucinous cysts

Pancreatic Cancer: A Review of Risk Factors

Pancreatic adenocarcinoma is one of the most lethal types of gastrointestinal cancer despite the latest medical advances. Its incidence has continuously increased in recent years in developed countries. The location of the pancreas can result in the initial symptoms of neoplasia being overlooked, which can lead to a delayed diagnosis and a subsequent reduction in the spectrum of available therapeutic options. The role of modifiable risk factors in pancreatic cancer has been extensively studied in recent years, with smoking and alcohol consumption identified as key contributors. However, the few screening programs that have been developed focus exclusively on genetic factors, without considering the potential impact of modifiable factors on disease occurrence. Thus, fully understanding and detecting the risk factors for pancreatic cancer represents an important step in the prevention and early diagnosis of this type of neoplasia. This review reports the available evidence on different risk factors and identifies the areas that could benefit the most from additional studies.

Surveillance of Pancreatic Cystic Neoplasms

Pancreatic cystic neoplasms (PCNs) are increasingly detected because of the widespread use of cross-sectional imaging and overall aging population. While the majority of these cysts are benign, some can progress to advanced neoplasia (defined as high-grade dysplasia and invasive cancer). As the only widely accepted treatment for PCNs with advanced neoplasia is surgical resection, accurate preoperative diagnosis, and stratification of malignant potential for deciding about surgery, surveillance or doing nothing remains a clinical challenge. Surveillance strategies for pancreatic cysts (PCNs) combine clinical evaluation and imaging to assess changes in cyst morphology and symptoms that may indicate advanced neoplasia. PCN surveillance heavily relies on various consensus clinical guidelines that focus on high-risk morphology, surgical indications, and surveillance intervals and modalities. This review will focus on current concepts in the surveillance of newly diagnosed PCNs, especially on low-risk presumed intraductal papillary mucinous neoplasms (those without worrisome features and high-risk stigmata), and appraise current clinical surveillance guidelines.

Glycemic Abnormalities in Pancreatic Cystic Lesions—A Single-Center Retrospective Analysis

Background and Objectives: Glucose metabolism alterations are very common in solid pancreatic lesions, particularly in pancreatic cancer. Similarly, diabetes and especially new-onset diabetes (NOD) have been associated with the malignant transformation of pancreatic cysts. We aimed to assess the prevalence and relevant associations of glycemic abnormalities in pancreatic cystic lesions (PCLs) in a retrospective analysis. Materials and Methods: We retrospectively recruited all patients who underwent endoscopic ultrasound for a PCL over a period of 36 months (January 2018 to December 2021). Final diagnosis was set by means of tissue acquisition, surgery, follow-up, or board decision. Demographic and clinical data, laboratory workup, and imaging features were extracted from the patients’ charts according to a predefined protocol. We considered fasting blood glucose (FBG) and HbA1c values and stratified the patients as nondiabetic (FBG ≤ 99 mg/dL, HbA1c ≤ 5.6%, no history of glycemic abnormalities), prediabetic (FBG 100–125 mg/dL, HbA1c 5.7–6.4%), or diabetic (long-lasting diabetes or NOD). Results: Altogether, 81 patients were included, with a median age of 66 years, and 54.3% of them were male. The overall prevalence of fasting hyperglycemia was 54.3%, comprising 34.6% prediabetes and 22.2% diabetes, of which 16.7% had NOD. The mean FBG and HbA1c levels were higher in malignant and premalignant PCLs (intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), cystadenocarcinoma, and cystic neuroendocrine tumor) compared to the benign lesions (pseudocysts, walled-off necrosis, and serous cystadenoma): 117.0 mg/dL vs. 108.3 mg/dL and 6.1% vs. 5.5%, respectively. Conclusions: Hyperglycemia and diabetes are common in PCLs, with a high prevalence in premalignant and malignant cysts. Screening and follow-up for glycemic abnormalities should be routinely conducted for PCLs, as they can contribute to a tailored risk assessment of cysts.

Diabetes mellitus and the risk of progression or malignancy of pancreatic cystic neoplasms in patients undergoing surveillance: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Patients with pancreatic cystic neoplasms (PCN) generally undergo surveillance by cross-sectional imaging or endoscopic-ultrasound due to their pre-malignant potential. Appearance of certain cyst characteristics during surveillance is associated with aggressive behavior or presence of malignancy. Patient characteristics associated with progression or induction of malignancy in PCN is unclear from current studies. We performed this meta-analysis to determine the patient characteristics associated with progression or malignancy in patients with PCN who undergo surveillance.

METHODS

We performed a systematic research of several electronic databases for all the studies on surveillance of PCN which reported demographic data of patients who had progression or malignancy and controls. We calculated Risk ratio (RR) or Hazard ratio (HR) with 95% confidence interval (CI) for each variable. Mantel- Haenszel method or Inverse-variance model was used to pool data of progression or malignant transformation into fixed or random effect model meta-analysis.

RESULTS

11observational studies, 4 assessing risk factors for malignancy (3955 patients) and 7 evaluating risk factors for progression of PCN (3144 patients) were included in the meta-analysis. Diabetes mellitus was associated with higher risk for malignant transformation as well as progression of PCN (RR = 1.54, CI 1.23, 1.92). Advanced age was associated with higher risk of progression. Male gender had higher risk for malignant transformation but not progression of PCN.

CONCLUSION

Diabetes is associated with an increased risk of both malignancy and progression of PCN in patients who undergo surveillance. Advanced age is also associated with higher risk of progression of PCN.

New-Onset Diabetes Is a Potential Marker for the Malignant Transformation of Pancreatic Cysts: A Real-World Population Cohort Study

OBJECTIVES

New-onset diabetes mellitus has been shown to be associated with pancreatic cancer (PC) in the general population. Our objective was to leverage real-world data to assess the association of new-onset diabetes (NODM) with malignant transformation in a large longitudinal cohort of pancreatic cyst patients.

METHODS

A retrospective longitudinal cohort study was conducted using IBM's MarketScan claims databases from 2009 to 2017. From 200 million database subjects, we selected patients with newly diagnosed cysts without prior pancreatic pathology.

RESULTS

Of the 137,970 patients with a pancreatic cyst, 14,279 had a new diagnosis. Median follow-up was 41.6 months. Patients with NODM progressed to PC at nearly 3 times the rate of patients without a diabetes history (hazard ratio, 2.80; 95% confidence interval, 2.05-3.83) and at a significantly higher rate than patients with preexisting diabetes (hazard ratio, 1.59; 95% confidence interval, 1.14-2.21). The mean interval between NODM and cancer diagnosis was 7.5 months.

CONCLUSIONS

Cyst patients who developed NODM progressed to PC at 3 times the rate of nondiabetics and at a greater rate than preexisting diabetics. The diagnosis of NODM preceded cancer detection by several months. These results support the inclusion of diabetes mellitus screening in cyst surveillance algorithms.

The Role of Diabetes Mellitus in the Malignant Pancreatic Cyst Neoplasm Diagnosis and Prognosis

Purpose

Pancreatic cyst neoplasm (PCN) is a precursor of pancreatic cancer. Previous studies reported PCN was often concurrent with diabetes. We aim to examine the association between diabetes with PCN malignancy and to detect the potential role of diabetes in PCN management and treatment.

Patients and Methods

A total of 224 patients who were diagnosed with the three major types of PCN (IPMN, MCN, and SCN) and underwent surgical resection were selected. Patients were divided into three groups (normal group, new-onset diabetes group (NODM) (<4years), and long-standing diabetes group (LSDM) (>4years)) according to diabetic history and diagnostic time interval. Diabetes, fast blood glucose level, HbA1c, and insulin resistance level were measured. Malignant PCN (mPCN) radiological features (worrisome features and high-risk stigmata) were analyzed. Pathological features (PCN type, dysplasia grade, tumor stage, and tumor volume) and immunohistology of Ki67 and SMAD4 were performed. Diagnostic efficacy of each variable was determined by the ROC curve. mPCN diagnosis was the main outcome in diagnostic prediction and overall survival as the glucose controlling outcome variables.

Results

Diabetes groups (NODM and LSDM) showed difference with the normal group in age, weight loss, malignancy, CA19-9 value, CEA value, Ki-67 value, tumor volume, pathological grade, and a lowered pancreatic fistula risk. NODM was related to insulin resistance, weight loss, and SMAD4 mutation. NODM (87.3%) and high insulin resistance rate (93.6%) significantly increased the sensitivity of radiological evidence-based mPCN diagnosis. Moreover, long-standing diabetes and elevated HbA1c led to reduced survival in mPCN patients than the normal PCN group. Anti-diabetic drugs showed limited influence on PCN malignancy and tumor volume.

Conclusion

NODM in PCN patients was associated with malignancy, insulin resistance, weight loss, and SMAD4 mutation. Prediabetic status and NODM diagnosis enhanced the diagnostic accuracy of radiological standards (worrisome features and high-risk stigmata). Stable glucose surveillance is necessary for mPCN patients’ survival.

Current Evidence in the Management of Premalignant Cystic Lesions of the Pancreas in Patients Undergoing Liver Transplantation

ABSTRACT

Incidental premalignant pancreatic cystic lesions (pPCLs) are increasingly being detected in patients undergoing orthotopic liver transplantation (OLT). The impact of chronic immunosuppression upon pPCLs may elevate risk of progression to pancreatic cancer. This systematic review assesses prevalence, outcome, and management of pPCLs in patients undergoing OLT. Systematic literature searches were performed in accordance with Cochrane review guidelines. Data on 658 patients were identified from 13 articles. Median age was 59 years with a prevalence of 6.2%. Most studies focused on branch-duct intraductal papillary mucinous neoplasms. Average cyst size at diagnosis was 10.3 mm. Six patients (0.9%) underwent pancreatic resection, post-OLT, for suspected "worrisome features" on imaging. One death was due to pancreatic-related cancer, post-OLT. Based on the review, the authors suggest the following: (1) patients with pPCLs undergoing OLT, without "worrisome features," should be followed conservatively; (2) presence of pPCLs alone should not preclude eligibility for OLT, nor should chronic immunosuppression be altered; (3) follow-up should parallel standard approach applied in immunocompetent patients, as development of "worrisome features" of cancer is rare and does not appear to be hastened by immunosuppression; (4) resection is recommended for surgically fit patients without portal hypertension that develop "worrisome features."

A Review of the Diagnosis and Management of Premalignant Pancreatic Cystic Lesions

Pancreatic cystic lesions are an increasingly common clinical finding. They represent a heterogeneous group of lesions that include two of the three known precursors of pancreatic cancer, intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN). Given that approximately 8% of pancreatic cancers arise from these lesions, careful surveillance and timely surgery offers an opportunity for early curative resection in a disease with a dismal prognosis. This review summarizes the current evidence and guidelines for the diagnosis and management of IPMN/MCN. Current pre-operative diagnostic tests in pancreatic cysts are imperfect and a proportion of patients continue to undergo unnecessary surgical resection annually. Balancing cancer prevention while preventing surgical overtreatment, continues to be challenging when managing pancreatic cysts. Cyst fluid molecular markers, such as KRAS, GNAS, VHL, PIK3CA, SMAD4 and TP53, as well as emerging endoscopic technologies such as needle-based confocal laser endomicroscopy and through the needle microbiopsy forceps demonstrate improved diagnostic accuracy. Differences in management and areas of uncertainty between the guidelines are also discussed, including indications for surgery, surveillance protocols and if and when surveillance can be discontinued.