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Kazmi SZ, Jung HS, Han Y, Yun WG, Cho YJ, Lee M, Kwon W, Castillo CFD, Del Chiaro M, Marchegiani G, Goh BKP, Hijioka S, Majumder S, Nakai Y, Shin A, Jang JY. Systematic review on surveillance for non-resected branch-duct intraductal papillary mucinous neoplasms of the pancreas. Pancreatology 2024; 24:463-488. [PMID: 38480047 DOI: 10.1016/j.pan.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 01/08/2024] [Accepted: 02/24/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND The management of branch-duct type intraductal papillary mucinous neoplasms (BD-IPMN) varies in existing guidelines. This study investigated the optimal surveillance protocol and safe discontinuation of surveillance considering natural history in non-resected IPMN, by systematically reviewing the published literature. METHODS This review was guided by PRISMA. Research questions were framed in PICO format "CQ1-1: Is size criteria helpful to determine surveillance period? CQ1-2: How often should surveillance be carried out? CQ1-3: When should surveillance be discontinued? CQ1-4: Is nomogram predicting malignancy useful during surveillance?". PubMed was searched from January-April 2022. RESULTS The search generated 2373 citations. After screening, 83 articles were included. Among them, 33 studies were identified for CQ1-1, 19 for CQ1-2, 26 for CQ1-3 and 12 for CQ1-4. Cysts <1.5 or 2 cm without worrisome features (WF) were described as more indolent, and most studies advised an initial period of surveillance. The median growth rate of cysts <2 cm ranged from 0.23 to 0.6 mm/year. Patients with cysts <2 cm showing no morphological changes and no WF after 5-years of surveillance have minimal malignancy risk of 0-2%. Two nomograms created with over 1000 patients had AUCs of around 0.8 and appear to be feasible in a real-world practice. CONCLUSIONS For patients with suspected BD-IPMN <2 cm and no other WF, less frequent surveillance is recommended. Surveillance may be discontinued for cysts that remain stable during 5-year surveillance, with consideration of patient condition and life expectancy. With this updated surveillance strategy, patients with non-worrisome BD-IPMN should expect more streamlined management and decreased healthcare utilization.
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Affiliation(s)
- Sayada Zartasha Kazmi
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hye-Sol Jung
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Won-Gun Yun
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Young Jae Cho
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Mirang Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Giovanni Marchegiani
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Padova University Hospital, Padova, Italy
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital & National Cancer Centre Singapore, Singapore
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Aesun Shin
- Department of Preventive Medicine and Cancer Research Institute, Seoul National University, Seoul, South Korea.
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea.
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2
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Crippa S, Marchegiani G, Belfiori G, Rancoita PVM, Pollini T, Burelli A, Apadula L, Scarale MG, Socci D, Biancotto M, Vanella G, Arcidiacono PG, Capurso G, Salvia R, Falconi M. Impact of age, comorbidities and relevant changes on surveillance strategy of intraductal papillary mucinous neoplasms: a competing risk analysis. Gut 2024:gutjnl-2023-329961. [PMID: 38653539 DOI: 10.1136/gutjnl-2023-329961] [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: 03/28/2023] [Accepted: 04/14/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Cost-effectiveness of surveillance for branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) is debated. We combined different categories of risks of IPMN progression and of IPMN-unrelated mortality to improve surveillance strategies. DESIGN Retrospective analysis of 926 presumed BD-IPMNs lacking worrisome features (WFs)/high-risk stigmata (HRS) under surveillance. Charlson Comorbidity Index (CACI) defined the severity of comorbidities. IPMN relevant changes included development of WF/HRS, pancreatectomy or death for IPMN or pancreatic cancer. Pancreatic malignancy-unrelated death was recorded. Cumulative incidence of IPMN relevant changes were estimated using the competing risk approach. RESULTS 5-year cumulative incidence of relevant changes was 17.83% and 1.6% developed pancreatic malignancy. 5-year cumulative incidences for IPMN relevant changes were 13.73%, 19.93% and 25.04% in low-risk, intermediate-risk and high-risk groups, respectively. Age ≥75 (HR: 4.15) and CACI >3 (HR: 3.61) were independent predictors of pancreatic malignancy-unrelated death. 5-year cumulative incidence for death for other causes was 15.93% for age ≥75+CACI >3 group and 1.49% for age <75+CACI ≤3. 5-year cumulative incidence of IPMN relevant changes were 13.94% in patients with age <75+CACI ≤3 compared with 29.60% in those with age ≥75+CACI >3. In this group 5-year rate of malignancy-free patients was 95.56% with a 5-year survival of 79.51%. CONCLUSION Although it is not uncommon the occurrence of changes considered by current guidelines as relevant during surveillance of low risk BD-IPMNs, malignancy rate is low and survival is significantly affected by competing patients' age and comorbidities. IPMN surveillance strategy should be tailored based on these features and modulated over time.
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Affiliation(s)
- Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Giovanni Marchegiani
- Division of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, GB Rossi Hospital, Verona, Italy
| | - Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | | | - Tommaso Pollini
- Division of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, GB Rossi Hospital, Verona, Italy
| | - Anna Burelli
- Division of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, GB Rossi Hospital, Verona, Italy
| | - Laura Apadula
- Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Maria Giovanna Scarale
- University Center of Statistics in the Biomedical Sciences, Vita Salute San Raffaele University, Milan, Italy
| | - Davide Socci
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Marco Biancotto
- Division of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, GB Rossi Hospital, Verona, Italy
| | - Giuseppe Vanella
- Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Gabriele Capurso
- Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
| | - Roberto Salvia
- Division of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, GB Rossi Hospital, Verona, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy
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3
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Ahn DW, Lee SH, Choi JH, Cho IR, Jang DK, Paik WH, Jeong JB, Ryu JK, Kim YT. Optimal Follow-up of Incidental Pancreatic Cystic Lesions without Worrisome Features: Clinical Outcome after Long-term Follow-up. Gut Liver 2024; 18:328-337. [PMID: 37840221 PMCID: PMC10938161 DOI: 10.5009/gnl230017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 10/17/2023] Open
Abstract
Background/Aims : The optimal duration and interval of follow-up for cystic lesions of the pancreas (CLPs) is not well established. This study was performed to investigate the optimal duration and interval of follow-up for CLPs in clinical practice. Methods : Patients with CLPs without worrisome features or high-risk stigmata underwent follow-up with computed tomography at 6, 12, 18, and 24 months and then every 12 months thereafter. A retrospective analysis of prospectively collected data was performed. Results : A total of 227 patients with CLPs detected from 2000 to 2008 (mean initial diameter, 1.3±0.6 cm) underwent follow-up for a median of 120 months. Twenty-two patients (9.7%) underwent surgery after a median of 47.5 months. Malignancies developed in four patients (1.8%), one within 5 years and three within 10 years. One hundred and fourteen patients (50.2%) were followed up for more than 10 years. No malignancy developed after 10 years of follow-up. During surveillance, 37 patients (16.3%) experienced progression to surgical indication. In patients with CLPs less than 2 cm in diameter, development of surgical indications did not occur within 24 months of follow-up. Conclusions : CLPs should be continuously monitored after 5 years because of the persistent potential for malignant transformation of CLPs. An interval of 24 months for initial follow-up might be enough for CLPs with initial size of less than 2 cm in clinical practice.
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Affiliation(s)
- Dong-Won Ahn
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jin Ho Choi
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - In Rae Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dong Kee Jang
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ji Bong Jeong
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ji Kon Ryu
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yong-Tae Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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4
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Gardner TB, Park WG, Allen PJ. Diagnosis and Management of Pancreatic Cysts. Gastroenterology 2024:S0016-5085(24)00248-8. [PMID: 38442782 DOI: 10.1053/j.gastro.2024.02.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 01/01/2024] [Accepted: 02/18/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Walter G Park
- Section of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, California
| | - Peter J Allen
- Division of Surgical Oncology, Duke University Medical Center, Durham, North Carolina
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5
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Elmi N, McEvoy D, McInnes MDF, Alabousi M, Hecht EM, Luk L, Asghar S, Jajodia A, de Carvalho TL, Warnica WJ, Zha N, Ullah S, van der Pol CB. Percentage of Pancreatic Cysts on MRI With a Pancreatic Carcinoma: Systematic Review and Meta-Analysis. J Magn Reson Imaging 2023. [PMID: 38053468 DOI: 10.1002/jmri.29168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Pancreatic cystic lesions (PCLs) are frequent on MRI and are thought to be associated with pancreatic adenocarcinoma (PDAC) necessitating long-term surveillance based on older studies suffering from selection bias. PURPOSE To establish the percentage of patients with PCLs on MRI with a present or future PDAC. STUDY TYPE Systematic review, meta-analysis. POPULATION Adults with PCLs on MRI and a present or future diagnosis of PDAC were eligible. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus were searched to April 2022 (PROSPERO:CRD42022320502). Studies limited to PCLs not requiring surveillance, <100 patients, or those with a history/genetic risk of PDAC were excluded. FIELD STRENGTH/SEQUENCE ≥1.5 T with ≥1 T2-weighted sequence. ASSESSMENT Two investigators extracted data, with discrepancies resolved by a third. QUADAS-2 assessed bias. PDAC was diagnosed using a composite reference standard. STATISTICAL TESTS A meta-analysis of proportions was performed at the patient-level with 95% confidence intervals (95% CI). RESULTS Eight studies with 1289 patients contributed to the percentage of patients with a present diagnosis of PDAC, and 10 studies with 3422 patients to the percentage with a future diagnosis. Of patients with PCLs on MRI, 14.8% (95% CI 2.4-34.9) had a PDAC at initial MRI, which decreased to 6.0% (2.2-11.3) for studies at low risk of bias. For patients without PDAC on initial MRI, 2.0% (1.1-3.2) developed PDAC during surveillance, similar for low risk of bias studies at 1.9% (0.7-3.6), with no clear trend of increased PDAC for longer surveillance durations. For patients without worrisome features or high-risk stigmata, 0.9% (0.1-2.2) developed PDAC during surveillance. Of 10, eight studies had a median surveillance ≥3 years (range 3-157 months). Sources of bias included retrospectively limiting PCLs to those with histopathology and inconsistent surveillance protocols. DATA CONCLUSION A low percentage of patients with PCLs on MRI develop PDAC while on surveillance. The first MRI revealing a PCL should be scrutinized for PDAC. LEVEL OF EVIDENCE 3 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Nika Elmi
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - David McEvoy
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Matthew D F McInnes
- Department of Radiology and Epidemiology, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medical Imaging, Ottawa Hospital Research Institute Clinical Epidemiology Program, The Ottawa Hospital-Civic Campus, Ottawa, Ontario, Canada
| | - Mostafa Alabousi
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Elizabeth M Hecht
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - Lyndon Luk
- Department of Radiology, New York Presbyterian-Columbia University Medical Center, New York, New York, USA
| | - Sunna Asghar
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Ankush Jajodia
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Tiago Lins de Carvalho
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - William J Warnica
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Nanxi Zha
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sadaf Ullah
- Library Services, Unity Health Toronto St. Michael's Hospital, East Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Christian B van der Pol
- Department of Medical Imaging, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Diagnostic Imaging, Juravinski Hospital and Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
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6
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Minelli C, Balducci F, Cavalleri C, Milanetto AC, Ferrara F, Crimì F, Quaia E, Vernuccio F. Intraductal papillary mucinous neoplasms of the pancreas: Uncommon imaging presentation, evolution and comparison of guidelines. Eur J Radiol Open 2023; 11:100531. [PMID: 37920680 PMCID: PMC10618428 DOI: 10.1016/j.ejro.2023.100531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/29/2023] [Accepted: 10/10/2023] [Indexed: 11/04/2023] Open
Abstract
Pancreatic cystic lesions are often asymptomatic, incidentally detected and include a range of entities with varying degrees of concern for malignancy. Among these, intraductal papillary mucinous neoplasms (IPMN) are considered premalignant pancreatic lesions, with a broad pathological spectrum ranging from lesions without dysplasia, which can be managed conservatively, to malignant lesions that require surgical resection. The increasing use of CT and MRI has led to increased recognition of this entity incidentally, with branch-duct IPMN representing the most common subtype and the most challenging lesions in terms of patient management. The main imaging modality involved in diagnosis and surveillance of IPMN is MRI. Radiologists play an important role in the management of patients with IPMN, including lesion detection, characterization, follow-up and prognostication, allowing early MRI identification of features that are concerning for malignancy. The main aim of this pictorial review is to illustrate MRI features of IPMN and to discuss risk stratification scores based on different guidelines, with a main focus on branch-duct IPMN. The secondary aims include the presentation of common and uncommon imaging evolution of BD-IPMN as well as the discussion on current controversies on the appropriate management of IPMN.
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Affiliation(s)
- Chiara Minelli
- Institute of Radiology, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Federico Balducci
- Institute of Radiology, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Cristina Cavalleri
- Institute of Radiology, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Anna Caterina Milanetto
- Chirurgia Generale 3, Department of Surgery, Oncology and Gastroenterology - University of Padova, 35128, Padova, Italy
| | - Francesco Ferrara
- Gastroenterology Unit - University Hospital of Padova, 35128 Padova, Italy
| | - Filippo Crimì
- Institute of Radiology, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Emilio Quaia
- Institute of Radiology, Department of Medicine-DIMED, University of Padova, 35128 Padova, Italy
| | - Federica Vernuccio
- Department of Radiology, University Hospital of Padova, 35128 Padova, Italy
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7
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Lattimore CM, Kane WJ, Subbarao S, Venitti C, Cramer CL, Turkheimer LM, Bauer TW, Turrentine FE, Zaydfudim VM. Long-term surveillance of branch-duct intraductal papillary mucinous neoplasms without worrisome or high-risk features. J Surg Oncol 2023; 128:1087-1094. [PMID: 37530526 PMCID: PMC10592219 DOI: 10.1002/jso.27414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Long-term data evaluating clinical outcomes in patients with branch-duct Intraductal papillary mucinous neoplasms (BD-IPMN) without high-risk stigmata (HRS) or worrisome features (WF) remain limited. METHODS This observational cohort study included all patients diagnosed with BD-IPMN without HRS or WF between 2003 and 2019 who were enrolled in a prospective surveillance program. Time-to-progression analysis was performed using a cumulative incidence function plot and survival analysis was conducted using Kaplan-Meier. RESULTS The median follow-up time for the 267 patient cohort was 44.5 months (interquartile range [IQR]: 24.1-72.2). Radiographic cyst growth was observed in 123 (46.1%) patients; 65 (24.3%) patients progressed to WF/HRS. Twenty-six (9.7%) patients were selected for resection during surveillance: 21 (80.8%) WF, 4 (15.4%) HRS; 1 (3.9%) transformed to mixed-duct. Of all the patients who underwent resection, 5 (19.2%) had adenocarcinoma, and 1 (3.8%) had carcinoma-in-situ. The probability of any radiographic progression was 21.3% (5-year) and 51.3% (10-year). For the entire cohort, there was 1.1% mortality secondary to pancreatic adenocarcinoma and 8.2% all-cause mortality. The 5-year overall survival rate was 91.5%, and at 10 years, 81.5%. CONCLUSION Approximately one in four patients with nonworrisome BD-IPMN have progression to WF/HRS stigmata during surveillance. However, the risk of malignant transformation remains low. Surveillance strategy remains prudent in this patient population.
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Affiliation(s)
- Courtney M. Lattimore
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - William J. Kane
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | | | | | - Christopher L. Cramer
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - Lena M. Turkheimer
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | | | - Florence E. Turrentine
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
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8
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Chhoda A, Schmidt J, Farrell JJ. Surveillance of Pancreatic Cystic Neoplasms. Gastrointest Endosc Clin N Am 2023; 33:613-640. [PMID: 37245939 DOI: 10.1016/j.giec.2023.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Pancreatic cystic 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.
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Affiliation(s)
- Ankit Chhoda
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Julie Schmidt
- Yale Multidisciplinary Pancreatic Cyst Clinic (Yale MPaCC), Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University School of Medicine, New Haven, CT, USA
| | - James J Farrell
- Yale Multidisciplinary Pancreatic Cyst Clinic (Yale MPaCC), Yale Center for Pancreatic Disease, Section of Digestive Disease, Yale University School of Medicine, New Haven, CT, USA.
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9
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Raut P, Nimmakayala RK, Batra SK, Ponnusamy MP. Clinical and Molecular Attributes and Evaluation of Pancreatic Cystic Neoplasm. Biochim Biophys Acta Rev Cancer 2023; 1878:188851. [PMID: 36535512 PMCID: PMC9898173 DOI: 10.1016/j.bbcan.2022.188851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/08/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs) are all considered "Pancreatic cystic neoplasms (PCNs)" and show a varying risk of developing into pancreatic ductal adenocarcinoma (PDAC). These lesions display different molecular characteristics, mutations, and clinical manifestations. A lack of detailed understanding of PCN subtype characteristics and their molecular mechanisms limits the development of efficient diagnostic tools and therapeutic strategies for these lesions. Proper in vivo mouse models that mimic human PCNs are also needed to study the molecular mechanisms and for therapeutic testing. A comprehensive understanding of the current status of PCN biology, mechanisms, current diagnostic methods, and therapies will help in the early detection and proper management of patients with these lesions and PDAC. This review aims to describe all these aspects of PCNs, specifically IPMNs, by describing the future perspectives.
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Affiliation(s)
- Pratima Raut
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE 68198-5870, USA
| | - Rama Krishna Nimmakayala
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE 68198-5870, USA
| | - Surinder K Batra
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE 68198-5870, USA; Eppley Institute for Research in Cancer and Allied Diseases, Fred & Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE 68198-5870, USA.
| | - Moorthy P Ponnusamy
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE 68198-5870, USA; Eppley Institute for Research in Cancer and Allied Diseases, Fred & Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE 68198-5870, USA.
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10
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Cucchetti A, Crippa S, Binda C, Fabbri C, Falconi M, Ercolani G. Evolution of knowledge about pancreatic cystic neoplasms: A bibliometric analysis. Dig Liver Dis 2022; 54:1730-1733. [PMID: 36167712 DOI: 10.1016/j.dld.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/02/2022] [Accepted: 09/07/2022] [Indexed: 12/30/2022]
Affiliation(s)
- Alessandro Cucchetti
- Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum - University of Bologna, Italy; Morgagni - Pierantoni Hospital, Forlì, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific institute, Vita-Salute San Raffaele University, Milan, Italy
| | | | | | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences - DIMEC, Alma Mater Studiorum - University of Bologna, Italy; Morgagni - Pierantoni Hospital, Forlì, Italy
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11
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Giaccherini M, Gentiluomo M, Arcidiacono PG, Falconi M, Testoni SGG, Apadula L, Lauri G, Di Franco G, Fatucchi LM, Petrone MC, Corradi C, Crippa S, Morelli L, Capurso G, Campa D. A polymorphic variant in telomere maintenance is associated with worrisome features and high-risk stigmata development in IPMNs. Carcinogenesis 2022; 43:728-735. [PMID: 35675759 DOI: 10.1093/carcin/bgac051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 05/06/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) are nonobligatory precursor lesions of pancreatic ductal adenocarcinoma (PDAC). The identification of molecular biomarkers able to predict the risk of progression of IPMNs toward malignancy is largely lacking and sorely needed. Telomere length (TL) is associated with the susceptibility of developing cancers, including PDAC. Moreover, several PDAC risk factors have been shown to be associated with IPMN transition to malignancy. TL is genetically determined, and the aim of this study was to use 11 SNPs, alone or combined in a score (teloscore), to estimate the causal relation between genetically determined TL and IPMNs progression. For this purpose, 173 IPMN patients under surveillance were investigated. The teloscore did not show any correlation, however, we observed an association between PXK-rs6772228-A and an increased risk of IPMN transition to malignancy (HR = 3.17; 95%CI 1.47-6.84; P = 3.24 × 10-3). This effect was also observed in a validation cohort of 142 IPMNs even though the association was not statistically significant. The combined analysis was consistent showing an association between PXK-rs6772228-A and increased risk of progression. The A allele of this SNP is strongly associated with shorter LTL that in turn have been reported to be associated with increased risk of developing PDAC. These results clearly highlight the importance of looking for genetic variants as potential biomarkers in this setting in order to further our understanding the etiopathogenesis of PDAC and suggest that genetically determined TL might be an additional marker of IPMN prognosis.
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Affiliation(s)
| | | | - Paolo Giorgio Arcidiacono
- Pancreatico-Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Sabrina Gloria Giulia Testoni
- Pancreatico-Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Laura Apadula
- Pancreatico-Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Gaetano Lauri
- Pancreatico-Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Gregorio Di Franco
- General Surgery Unit, Cisanello Hospital, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Lorenzo Maria Fatucchi
- General Surgery Unit, Cisanello Hospital, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Maria Chiara Petrone
- Pancreatico-Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Morelli
- General Surgery Unit, Cisanello Hospital, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Gabriele Capurso
- Pancreatico-Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Daniele Campa
- Department of Biology, University of Pisa, Pisa, Italy
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12
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Abstract
Early detection of high-risk pancreatic cystic lesions enables potentially curative surgical resection, and early detection of lesions without worrisome features may lead to appropriate surveillance. Regrettably, differentiating premalignant and malignant cysts from nonmalignant ones remains challenging. However, emerging additional diagnostic tools, including the needle biopsy with microforceps and needle-based confocal laser endomicroscopy, are of exciting potential along with cyst fluid analysis".
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Affiliation(s)
- Sahin Coban
- Department of Gastroenterology, Mount Auburn Hospital, 330 Mt Auburn St, Cambridge, MA 02138, USA.
| | - Omer Basar
- Department of Gastroenterology, The University of Missouri, Columbia, MO 65211, USA
| | - William R Brugge
- Department of Gastroenterology, Harvard Medical School, Mount Auburn Hospital, 330 Mt Auburn St, Cambridge, MA 02138, USA
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13
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Tamburrino D, de Pretis N, Pérez-Cuadrado-Robles E, Uribarri-Gonzalez L, Ateeb Z, Belfiori G, Maisonneuve P, Capurso G, Vanella G, Petrone MC, Arcidiacono PG, Vaalavuo Y, Frulloni L, Dominguez-Muñoz JE, Deprez PH, Falconi M, del Chiaro M, Crippa S, Laukkarinen J. Identification of patients with branch-duct intraductal papillary mucinous neoplasm and very low risk of cancer: multicentre study. Br J Surg 2022; 109:617-622. [PMID: 35511697 PMCID: PMC10364743 DOI: 10.1093/bjs/znac103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/05/2021] [Accepted: 03/15/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Different surveillance strategies for patients with low-risk branch-duct (BD) intraductal papillary neoplasm (IPMN) have been described. The aim of this study was to describe the natural history of low-risk BD-IPMN, and to identify risk factors for the development of worrisome features (WF)/high-risk stigmata (HRS) and of pancreatic malignancies. METHODS This was a multicentre retrospective study of patients with BD-IPMN who were under active surveillance between January 2006 and December 2015. Patients were eligible if they had a low-risk lesion and had a minimum follow-up of 24 months. Outcomes were development of WF/HRS or cytologically/histologically confirmed malignant IPMN. RESULTS Of 837 patients included, 168 (20 per cent) developed WF/HRS. At the end of the observation time, 132 patients (79 per cent) with WF/HRS were still under surveillance without progression to pancreatic cancer. Factors associated with the development of WF or HRS in multivariable analysis included localized nodules (versus diffuse: hazard ratio (HR) 0.43, 95 per cent c.i. 0.26 to 0.68), cyst size 15-19 mm (versus less than 15 mm: HR 1.88, 1.23 to 2.87) or at least 20 mm (versus less than 15 mm: HR 3.25, 2.30 to 4.60), main pancreatic duct size over 3 mm (versus 3 mm or less: HR 2.17, 1.41 to 3.34), and symptoms at diagnosis (versus no symptoms: HR 2.29, 1.52 to 3.45). Surveillance in an endoscopy-oriented centre was also associated with increased detection of WF or HRS (versus radiology-oriented: HR 2.46, 1.74 to 3.47). CONCLUSION Conservative management of patients with low-risk BD-IPMN is safe and feasible.
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Affiliation(s)
- Domenico Tamburrino
- Pancreatic Surgery Unit, Vita-Salute University, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Nicolò de Pretis
- Department of Gastroenterology, Pancreas Institute, University of Verona, Verona, Italy
| | - Enrique Pérez-Cuadrado-Robles
- Department of Hepato-Gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Department of Gastroenterology, Hôpital Européen Georges-Pompidou, Paris, France
| | - Laura Uribarri-Gonzalez
- Department of Gastroenterology, Complejo Hospitalario de Navarra, Pamplona, Spain
- Department of Gastroenterology, Hospital Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Zeeshan Ateeb
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Universitetsjukhuset i Huddinge, Huddinge, Sweden
| | - Giulio Belfiori
- Pancreatic Surgery Unit, Vita-Salute University, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Patrick Maisonneuve
- Division of Epidemiology and Biostatistics, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Gabriele Capurso
- Digestive and Liver Disease Unit, Sant’Andrea Hospital, Rome, Italy
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Vanella
- Digestive and Liver Disease Unit, Sant’Andrea Hospital, Rome, Italy
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Chiara Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Yrjo Vaalavuo
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Luca Frulloni
- Department of Gastroenterology, Pancreas Institute, University of Verona, Verona, Italy
| | - J. Enrique Dominguez-Muñoz
- Department of Gastroenterology, Hospital Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Pierre H. Deprez
- Department of Hepato-Gastroenterology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Massimo Falconi
- Pancreatic Surgery Unit, Vita-Salute University, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Marco del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, Colorado, USA
| | - Stefano Crippa
- Pancreatic Surgery Unit, Vita-Salute University, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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14
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Abstract
Andrew Canakis.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Linda S Lee
- Division of Gastroenterology Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.
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15
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Pancreatic cystic lesions. Differential diagnosis and treatment strategy. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2022; 87:188-197. [DOI: 10.1016/j.rgmxen.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 11/05/2021] [Indexed: 11/20/2022]
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16
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Valente R, Crippa S, Arnelo U, Vanella G, Zerboni G, Zarantonello L, Fogliati A, Arcidiacono PG, Vujasinovic M, Lohr JM, Falconi M, Capurso G, Del Chiaro M. The use of ace inhibitors influences the risk of progression of BD-IPMNs under follow-up. Pancreatology 2022; 22:516-524. [PMID: 35431111 DOI: 10.1016/j.pan.2022.03.020] [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: 10/24/2021] [Revised: 03/13/2022] [Accepted: 03/28/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chemoprevention's ability to slow down or prevent the progression of BD-IPMNs is extremely appealing. Aspirin (ASA), Ace Inhibitors/Angiotensin Receptor Blockers (ACEIs/ARBs) and Statins (STATs) are frequently prescribed drugs with a possible beneficial effect on different cancer types. Their effect on IPMNs is largely unknown. AIM To evaluate the association between the use of ASA, ACEIs/ARBs and STATs and the risk of progression of BD-IPMNs in follow-up. MATERIALS AND METHODS multicenter, retrospective cohort study on patients with presumed BD-IPMNs without relative or absolute indication for surgery. Pharmacological exposures and risk factors were collected. We identified clinically relevant progression (occurrence of radiological absolute or relative indication for surgery) and any progression (occurrence of clinically relevant progression OR any dimension increase OR the occurrence of new cysts). RESULTS Overall 594 patients were included. ACEIs were associated with a lower occurrence of any progression (HR = 0.70; 95% CI 0.49-0.98, p = 0.04) and clinically relevant progression, HR = 0.42 (95% CI 0.20-0.88; p = 0.02). No significant effect was shown for factors associated with the occurrence of pancreas cancer such as smoking, alcohol consumption and 1st degree family history of pancreas cancer. Among pharmacological exposures, no convincing effect was shown for the chronic use of ASA, ARB and STAT. CONCLUSIONS ACEIs might have an effect in slowing the progression of BD-IPMNs. ASA, STAT and ARBs show no convincing effect on the progression of BD-IPMNs. Further, prospective, and long-term multicenter studies are needed to verify such association and to define the potential underlying mechanisms.
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Affiliation(s)
- Roberto Valente
- Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden; Department of Surgery and Perioperative Sciences, Surgery, Umeå University Hospital, Umeå, Sweden; Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy; Department of Surgical Oncology, Anschutz Medical Campus, University of Colorado, Denver, USA
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, IRCCS, Milan, Italy
| | - Urban Arnelo
- Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden; Department of Surgery and Perioperative Sciences, Surgery, Umeå University Hospital, Umeå, Sweden
| | - Giuseppe Vanella
- Pancreatobiliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, IRCCS, Milan, Italy; Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Giulia Zerboni
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | | | - Alessandro Fogliati
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, IRCCS, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, IRCCS, Milan, Italy
| | - Miroslav Vujasinovic
- Department for Upper Abdominal Diseases, Karolinska University Hospital and Department of Medicine Huddinge, Karolinska Institute, Sweden
| | | | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, IRCCS, Milan, Italy
| | - Gabriele Capurso
- Pancreatobiliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, IRCCS, Milan, Italy; Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy.
| | - Marco Del Chiaro
- Department of Surgical Oncology, Anschutz Medical Campus, University of Colorado, Denver, USA
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17
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Overbeek KA, van Leeuwen N, Tacelli M, Anwar MS, Yousaf MN, Chhoda A, Arcidiacono PG, Gonda TA, Wallace MB, Capurso G, Farrell JJ, Cahen DL, Bruno MJ. International external validation of a stratification tool to identify branch-duct intraductal papillary mucinous neoplasms at lowest risk of progression. United European Gastroenterol J 2022; 10:169-178. [PMID: 35199484 PMCID: PMC8911544 DOI: 10.1002/ueg2.12207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/20/2022] [Indexed: 12/28/2022] Open
Abstract
Background Identifying branch‐duct intraductal papillary mucinous neoplasms (BD‐IPMNs) at lowest risk of progression may allow for a reduced intensity of surveillance. Objective We aimed to externally validate the previously developed Dutch‐American Risk stratification Tool (DART‐1; https://rtools.mayo.edu/DART/), which identifies cysts at low risk of developing worrisome features (WFs) or high‐risk stigmata (HRS). Methods Three prospective cohorts of individuals under surveillance for BD‐IPMNs were combined, independent from the original development cohort. We assessed the performance (discrimination and calibration) of DART‐1, a multivariable Cox‐proportional logistic regression model with five predictors for the development of WFs or HRS. Results Of 832 individuals (mean age 77 years, SD 11.5) under surveillance for a median of 40 months (IQR 44), 163 (20%) developed WFs or HRS. DART‐1's discriminative ability (C‐statistic 0.68) was similar to that in the development cohort (0.64–0.72) and showed moderate calibration. DART‐1 adequately estimated the risk for patients in the middle risk quintile, and slightly underestimated it in the lowest quintiles. Their range of predicted versus observed 3‐year risk was 0%–0% versus 0%–3.7% for Q1; 0.3%–0.4% versus 3%–11% for Q2; and 2.6%–3% versus 2.4%–9.8% for Q3. The development of WFs or HRS was associated with pancreatic cancer (p < 0.001). Vice versa, in absence of WFs or HRS, the risk of malignancy was low (0.3%). Conclusions The performance of DART‐1 to predict the development of WFs or HRS in BD‐IPMN was validated in an external international cohort, with a discriminative ability equal as in the development cohort. Risk estimations were most accurate for patients with BD‐IPMNs in the middle risk quintile and slightly underestimated in the lowest quintiles.
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Affiliation(s)
- Kasper A Overbeek
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Nikki van Leeuwen
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Matteo Tacelli
- Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Muhammad S Anwar
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Muhammad N Yousaf
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ankit Chhoda
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Paolo Giorgio Arcidiacono
- Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Tamas A Gonda
- Department of Medicine, NYU Langone, New York, New York, USA
| | - Michael B Wallace
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Gabriele Capurso
- Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute IRCCS, San Raffaele Scientific Institute IRCCS, Milan, Italy.,Digestive and Liver Disease Unit, S Andrea Hospital, Rome, Italy
| | - James J Farrell
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Djuna L Cahen
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
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18
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Das KK, Mullady DK. Main Pancreatic Duct Dilation in IPMN: When (and Where) to Get "Worried"? Clin Gastroenterol Hepatol 2022; 20:272-275. [PMID: 33581356 DOI: 10.1016/j.cgh.2021.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Koushik K Das
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel K Mullady
- Division of Gastroenterology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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19
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Crippa S, Aleotti F, Longo E, Belfiori G, Partelli S, Tamburrino D, Di Salvo F, De Cobelli F, Romano L, Arcidiacono PG, Petrone MC, Zamboni G, Lena MS, Doglioni C, Falconi M. Main Duct Thresholds for Malignancy Are Different in Intraductal Papillary Mucinous Neoplasms of the Pancreatic Head and Body-Tail. Clin Gastroenterol Hepatol 2022; 20:390-399.e7. [PMID: 33385536 DOI: 10.1016/j.cgh.2020.12.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 12/22/2020] [Accepted: 12/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The risk of malignancy is uncertain for intraductal papillary mucinous neoplasms (IPMNs) with main pancreatic duct (MPD) of 5-9 mm. No study has correlated MPD size and malignancy considering the anatomic site of the gland (head versus body-tail). Our aim was to analyze the significance of MPD in pancreatic head/body-tail as a predictor of malignancy in main-duct/mixed IPMNs. METHODS Retrospective analysis of resected patients between 2009-2018 was performed. Malignancy was defined as high-grade dysplasia and invasive carcinoma. MPD diameter was measured with magnetic resonance imaging. Receiver operating characteristic curve (ROC) analysis was utilized to identify optimal MPD cut-off for malignancy. Independent predictors of malignancy were searched. RESULTS Malignancy was detected in 74% of 312 identified patients. 213 patients (68.3%) had IPMNs of the pancreatic head and 99 (31.7%) of the body-tail. ROC analysis identified 9 and 7 mm as the optimal MPD cut-offs for malignancy in IPMNs of head and body-tail of the pancreas, respectively. Multivariate analysis confirmed that MPD ≥9 mm (pancreatic head) and ≥7 mm (body-tail) were independent predictors of malignancy along with macroscopic solid components, positive cytology and elevated CA 19-9. The risk of malignancy was low for IPMNs with MPD ≤8 mm (pancreatic head) or ≤6 mm (pancreatic body-tail) unless high-risk stigmata or multiple worrisome features were present. CONCLUSIONS Different thresholds of MPD dilation are associated with malignancy in IPMNs of the head and body-tail of the pancreas. The risk of malignancy for IPMNs with MPD ≤8 mm (pancreatic head) or ≤6 mm (pancreatic body-tail) lacking high-risk stigmata or multiple worrisome features is low.
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Affiliation(s)
- Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan; Vita-Salute San Raffaele University, Milan
| | - Francesca Aleotti
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan; Vita-Salute San Raffaele University, Milan
| | - Enrico Longo
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan; Vita-Salute San Raffaele University, Milan
| | - Giulio Belfiori
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan; Vita-Salute San Raffaele University, Milan
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan; Vita-Salute San Raffaele University, Milan
| | - Domenico Tamburrino
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan
| | - Francesca Di Salvo
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan
| | - Francesco De Cobelli
- Vita-Salute San Raffaele University, Milan; Department of Radiology, IRCCS San Raffaele Scientific Institute, Milan
| | - Luigi Romano
- Department of Radiology, IRCCS Sacro Cuore-Don Calabria Hospital, Negrar (VR)
| | - Paolo Giorgio Arcidiacono
- Vita-Salute San Raffaele University, Milan; Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan
| | - Maria Chiara Petrone
- Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan
| | - Giuseppe Zamboni
- Department of Pathology, IRCCS Sacro Cuore-Don Calabria Hospital, Negrar (VR)
| | - Marco Schiavo Lena
- Department of Pathology, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Claudio Doglioni
- Vita-Salute San Raffaele University, Milan; Department of Pathology, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan; Vita-Salute San Raffaele University, Milan.
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20
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Johansson K, Kaprio T, Nieminen H, Lehtimäki TE, Lantto E, Haglund C, Seppänen H. A retrospective study of intraductal papillary neoplasia of the pancreas (IPMN) under surveillance. Scand J Surg 2022; 111:14574969221076792. [PMID: 35333109 DOI: 10.1177/14574969221076792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVE The growing number of identified intraductal papillary mucinous neoplasm (IPMN) patients places greater pressure on healthcare systems. Only a minority of patients have IPMN-related symptoms. Thus, more precise surveillance is required. METHODS In this retrospective single-center cross-sectional study, patients with an active diagnosis of branch duct IPMN (BD-IPMN) and >6 months of surveillance were classified as follows: presence/absence of worrisome features (WF) or high-risk stigmata (HRS), newly developed WF/HRS, under/over 15 mm cyst, growing/not growing <15 mm cyst, and elevated serum carbohydrate antigen 19-9 (CA 19-9). RESULTS In all, 377 patients with BD-IPMN were followed for a median of 5.4 years, 28% with WF at diagnosis, and 14% who developed WF/HRS during surveillance. Half had a <15 mm primary cyst, 40% of which did not grow during surveillance. CA 19-9 was elevated in 12%. None of the patients with normal CA 19-9 levels developed cancer or high-grade dysplasia (HGD). CONCLUSIONS No carcinomas or HGDs appeared with normal CA 19-9 levels. Patients with <15 mm cysts that do not grow and have no WF/HRS could undergo imaging less frequently.
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Affiliation(s)
- Katarina Johansson
- Department of Radiology HUS Diagnostic Center University of Helsinki and Helsinki University Hospital P.O. Box 340, HUS 00029 Helsinki Finland
| | - Tuomas Kaprio
- Department of Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland Research Programs Unit, Translational Cancer Medicine, University of Helsinki, Helsinki, Finland
| | - Heini Nieminen
- Department of Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tiina E Lehtimäki
- Department of Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Eila Lantto
- Department of Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Caj Haglund
- Department of Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hanna Seppänen
- Department of Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland Research Programs Unit, Translational Cancer Medicine, University of Helsinki, Helsinki, Finland
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21
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Faccioli N, Santi E, Foti G, D’Onofrio M. Cost-effectiveness analysis of including contrast-enhanced ultrasound in management of pancreatic cystic neoplasms. LA RADIOLOGIA MEDICA 2022; 127:349-359. [PMID: 35230618 PMCID: PMC8989810 DOI: 10.1007/s11547-022-01459-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 01/21/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Pancreatic cystic neoplasms (PCN) management consists of non-invasive imaging studies (CT, MRI), with a high resource burden. We aimed to determine the cost-effectiveness of including contrast-enhanced ultrasound (CEUS) in the management of PCN without risk features. MATERIALS AND METHODS By using a decision-tree model in a hypothetical cohort of patients, we compared management strategy including CEUS with the latest Fukuoka consensus, European and Italian guidelines. Our strategy for BD-IPMN/MCN < 1 cm includes 1 CEUS annually. For those between 1 and 2 cm, it includes CEUS 4 times/year during the first year, then 3 times/year for 4 years and then annually. For those between 2 and 3 cm, it comprises MRI twice/year during the first one, then alternating 2 CEUS and 1 MRI yearly. RESULTS CEUS surveillance is the dominant strategy in all scenarios. CEUS surveillance average cost is 1,984.72 €, mean QALY 11.79 and mean ICER 181.99 €. If willingness to pay is 30,000 €, 45% of patients undergone CEUS surveillance of BDIPMN/MCN < 1 cm would be within budget. CONCLUSION Guidelines strategies are very effective, but costs are relatively high from a policy perspective. CEUS surveillance may be a cost-effective strategy yielding a nearly high QALYs, an acceptable ICER, and a lower cost.
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Affiliation(s)
- Niccolo’ Faccioli
- Present Address: Department of Radiology, G.B. Rossi Hospital, Università di Verona, Piazzale L.A.Scuro 10, 37134 Verona, Italy
| | - Elena Santi
- Present Address: Department of Radiology, G.B. Rossi Hospital, Università di Verona, Piazzale L.A.Scuro 10, 37134 Verona, Italy
| | - Giovanni Foti
- IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Mirko D’Onofrio
- Present Address: Department of Radiology, G.B. Rossi Hospital, Università di Verona, Piazzale L.A.Scuro 10, 37134 Verona, Italy
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22
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Bratanic A, Bozic D, Mestrovic A, Martinovic D, Kumric M, Ticinovic Kurir T, Bozic J. Role of endoscopic ultrasound in anticancer therapy: Current evidence and future perspectives. World J Gastrointest Oncol 2021; 13:1863-1879. [PMID: 35070030 PMCID: PMC8713319 DOI: 10.4251/wjgo.v13.i12.1863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/17/2021] [Accepted: 08/27/2021] [Indexed: 02/06/2023] Open
Abstract
The digestive system is one of the most common sites of malignancies in humans. Since gastrointestinal tumors represent a massive global health burden both in terms of morbidity and health care expenditures, scientists continuously develop novel diagnostic and therapeutic methods to ameliorate the detrimental effects of this group of diseases. Apart from the well-established role of the endoscopic ultrasound (EUS) in the diagnostic course of gastrointestinal and hepatobiliary malignancies, we have recently become acquainted with a vast array of its therapeutic possibilities. A multitude of previously established, evidence-based methods that might now be guided by the EUS emerged: Radiofrequency ablation, brachytherapy, fine needle injection, celiac plexus neurolysis, and endoscopic submucosal dissection. In this review we endeavored to provide a comprehensive overview of the role of these methods in different malignancies of the digestive system, primarily in the treatment and symptom control in pancreatic cancer, and additionally in the management of hepatic, gastrointestinal tumors, and pancreatic cysts.
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Affiliation(s)
- Andre Bratanic
- Department of Gastroenterology and Hepatology, University Hospital of Split, Split 21000, Croatia
| | - Dorotea Bozic
- Department of Gastroenterology and Hepatology, University Hospital of Split, Split 21000, Croatia
| | - Antonio Mestrovic
- Department of Gastroenterology and Hepatology, University Hospital of Split, Split 21000, Croatia
| | - Dinko Martinovic
- Department of Pathophysiology, University of Split School of Medicine, Split 21000, Croatia
| | - Marko Kumric
- Department of Pathophysiology, University of Split School of Medicine, Split 21000, Croatia
| | - Tina Ticinovic Kurir
- Department of Pathophysiology, University of Split School of Medicine, Split 21000, Croatia
- Department of Endocrinology, University Hospital of Split, Split 21000, Croatia
| | - Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, Split 21000, Croatia
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23
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Miller FH, Lopes Vendrami C, Recht HS, Wood CG, Mittal P, Keswani RN, Gabriel H, Borhani AA, Nikolaidis P, Hammond NA. Pancreatic Cystic Lesions and Malignancy: Assessment, Guidelines, and the Field Defect. Radiographics 2021; 42:87-105. [PMID: 34855543 DOI: 10.1148/rg.210056] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The widespread use of high-spatial-resolution cross-sectional imaging has led to an increase in detection of incidental pancreatic cystic lesions. These lesions are a diverse group, ranging from indolent and premalignant lesions to invasive cancers. The diagnosis of several of these lesions can be suggested on the basis of their imaging appearance, while many other lesions require follow-up imaging and/or aspiration. The smaller cystic lesions, often branch-duct intraductal papillary mucinous neoplasms, have overlapping imaging characteristics that make diagnostic assessment of the natural history and malignancy risk confusing. Expert panels have developed societal guidelines, based on a consensus, for surveillance of these lesions. However, these guidelines are often inconsistent and are constantly evolving as additional scientific data are accumulated. Identification of features associated with increased risk of malignancy is important for proper management. The concept of field defect, whereby pancreatic adenocarcinoma develops at a site different from the site of the pancreatic cyst, adds to the complexity of screening guidelines. As a result of the differences in guidelines, key stakeholders (eg, radiologists, gastroenterologists, and surgeons) must review and come to a consensus regarding which guideline, or combination of guidelines, to follow at their individual institutions. Standardized reporting and macros are helpful for ensuring the uniformity of interpretations. Radiologists play a critical role in the detection and characterization of pancreatic cystic lesions, in the follow-up recommendations for these lesions, and in the detection of associated cancer. An invited commentary by Zaheer is available online. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Frank H Miller
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Camila Lopes Vendrami
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Hannah S Recht
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Cecil G Wood
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Pardeep Mittal
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Rajesh N Keswani
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Helena Gabriel
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Amir A Borhani
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Paul Nikolaidis
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
| | - Nancy A Hammond
- From the Departments of Radiology (F.H.M., C.L.V., H.S.R., C.G.W., H.G., A.A.B., P.N., N.A.H.) and Gastroenterology (R.N.K.), Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, 676 N St. Clair Street, Suite 800, Chicago, IL 60611; and Department of Radiology, Medical College of Georgia, Augusta, Ga (P.M.)
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24
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Schweber AB, Agarunov E, Brooks C, Hur C, Gonda TA. Prevalence, Incidence, and Risk of Progression of Asymptomatic Pancreatic Cysts in Large Sample Real-world Data. Pancreas 2021; 50:1287-1292. [PMID: 34860813 DOI: 10.1097/mpa.0000000000001918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Using large-sample, real-world administrative claims data, we evaluated the prevalence of putatively asymptomatic pancreatic cysts, the historical growth in their incident diagnosis, and their risk of malignant progression. METHODS Data were sourced from IBM MarketScan administrative claims databases of more than 200 million patients. Period prevalence was assessed using 700,000 individuals without conditions that predispose to pancreatic cyst. The standardized cumulative incidence was compared with the cross-sectional abdominal imaging rate from 2010-2017. The risk of progression to pancreatic cancer for 14,279 newly diagnosed patients with a cyst was estimated using Kaplan-Meier analysis. RESULTS Standardized prevalence increased exponentially with age and was 1.84% (95% confidence interval, 1.80%-1.87%) for patients older than 45. Standardized incidence nearly doubled from 2010-2017 (6.3 to 11.4 per 10,000), whereas the imaging rate changed from only 8.0% to 9.4%. The cumulative risk of pancreatic cancer at 7 years was 3.0% (95% confidence interval, 2.4%-3.5%), increasing linearly (R2 = 0.991) with an annual progression risk of 0.47%. CONCLUSIONS Using large-sample data, we show a significant burden of asymptomatic pancreatic cysts, with an annual risk of progression to cancer of 0.47% for 7 years. Rapid growth in cyst diagnosis over the last decade far outpaced increases in the imaging rate.
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Affiliation(s)
- Adam B Schweber
- From the Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center
| | - Emil Agarunov
- Division of Gastroenterology and Hepatology, New York University, New York, NY
| | - Christian Brooks
- Larner College of Medicine, University of Vermont, Burlington, VT
| | - Chin Hur
- From the Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center
| | - Tamas A Gonda
- From the Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Irving Medical Center
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25
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Buerlein RCD, Shami VM. Management of pancreatic cysts and guidelines: what the gastroenterologist needs to know. Ther Adv Gastrointest Endosc 2021; 14:26317745211045769. [PMID: 34589706 PMCID: PMC8474323 DOI: 10.1177/26317745211045769] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/25/2021] [Indexed: 12/15/2022] Open
Abstract
The prevalence of pancreatic cysts has increased significantly over the last
decade, partly secondary to increased quality and frequency of cross-sectional
imaging. While the majority never progress to cancer, a small number will and
need to be followed. The management of pancreatic cysts can be both confusing
and intimidating due to the multiple guidelines with varying recommendations.
Despite the differences in the specifics of the guidelines, they all agree on
several high-risk features that should get the attention of any clinician when
assessing a pancreatic cyst: presence of a mural nodule or solid component,
dilation of the main pancreatic duct (or presence of main duct intraductal
papillary mucinous neoplasm), pancreatic cyst size ⩾3–4 cm, or positive cytology
on pancreatic cyst fluid aspiration. Other important criteria to consider
include rapid cyst growth (⩾5 mm/year), elevated serum carbohydrate antigen 19-9
levels, new-onset diabetes mellitus, or acute pancreatitis thought to be related
to the cystic lesion.
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Affiliation(s)
| | - Vanessa M Shami
- University of Virginia Digestive Health, 1215 Lee Street, Charlottesville, VA 22903, USA
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26
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Surci N, Marchegiani G, Andrianello S, Pollini T, Mühlbacher J, Jomrich G, Richwien P, Tamandl D, Schindl M, Bassi C, Salvia R, Sahora K. The faith of non-surveilled pancreatic cysts: a bicentric retrospective study. Eur J Surg Oncol 2021; 48:89-94. [PMID: 34148825 DOI: 10.1016/j.ejso.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/06/2021] [Accepted: 06/02/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Incidental discovery of pancreatic cystic neoplasms (PCLs) is a common and steadily increasing occurrence. The aim of this study was to investigate a cohort of patients presenting with incidentally detected PCLs which were not included in a surveillance protocol, and to compare their risk of malignant evolution with that of systematically surveilled lesions. MATERIALS AND METHODS A population of PCLs which did not receive surveillance over a period >10 years (population A) was selected at the Medical University of Vienna. A group of "low risk" branch duct intraductal papillary mucinous neoplasm ≤15 mm in size upon diagnosis undergoing a regular follow-up of at least 5 years at the University of Verona was selected as control (population B). The incidence of pancreatic cancer (PC), cumulative risk of PC and disease-specific survival were compared. RESULTS Overall, 376 patients with non-surveilled PCLs were included in study group A and compared to 299 patients in group B. This comparison resulted in similar incidence rates of PC (1.6% vs 1.7%, p = 0.938), a strong similarity in terms of disease-specific mortality rates (1.3% vs 0.3%, p = 0.171) and the 5- and 10-year cumulative risk of PC (≅ 1% and 2%, p = 0.589) and DSS (≅ 100% and 98%, p = 0.050). CONCLUSION The "price to pay" for a negligence-based policy in the population of non-surveilled PCLs was reasonable, and the incidence of PC was comparable to that reported for a population of low-risk cysts enrolled to a standardized surveillance protocol.
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Affiliation(s)
- N Surci
- Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria; Department of General and Pancreatic Surgery, Pancreas Institute, University and Hospital Trust of Verona, "GB Rossi" Hospital, Verona, Italy
| | - G Marchegiani
- Department of General and Pancreatic Surgery, Pancreas Institute, University and Hospital Trust of Verona, "GB Rossi" Hospital, Verona, Italy.
| | - S Andrianello
- Department of General and Pancreatic Surgery, Pancreas Institute, University and Hospital Trust of Verona, "GB Rossi" Hospital, Verona, Italy
| | - T Pollini
- Department of General and Pancreatic Surgery, Pancreas Institute, University and Hospital Trust of Verona, "GB Rossi" Hospital, Verona, Italy
| | - J Mühlbacher
- Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - G Jomrich
- Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - P Richwien
- Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - D Tamandl
- Department of Radiology, Medical University of Vienna, General Hospital, Vienna, Austria
| | - M Schindl
- Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - C Bassi
- Department of General and Pancreatic Surgery, Pancreas Institute, University and Hospital Trust of Verona, "GB Rossi" Hospital, Verona, Italy
| | - R Salvia
- Department of General and Pancreatic Surgery, Pancreas Institute, University and Hospital Trust of Verona, "GB Rossi" Hospital, Verona, Italy
| | - K Sahora
- Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
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27
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Balduzzi A, Marchegiani G, Pollini T, Biancotto M, Caravati A, Stigliani E, Burelli A, Bassi C, Salvia R. Systematic review and meta-analysis of observational studies on BD-IPMNS progression to malignancy. Pancreatology 2021; 21:S1424-3903(21)00148-4. [PMID: 33994068 DOI: 10.1016/j.pan.2021.04.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/14/2021] [Accepted: 04/28/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The vast majority of presumed branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) of the pancreas are referred to a surveillance program due to the relatively low risk of malignancy. We aim to evaluate all available data from observational studies focused on the risks of BD-IPMN progression and malignancy to provide vital insights into its management in clinical practice. METHODS A comprehensive search was conducted at PubMed, Cochrane, Web of Science and Embase for observational studies published before January 1st, 2020. The progression of BD-IPMN was defined as the development of worrisome features (WFs) or high-risk stigmata (HRS) during surveillance. Overall malignancy was defined as all malignancies, such as malignant IPMN, concomitant pancreatic ductal adenocarcinoma (PDAC) and other malignancies, including BD-IPMN with high-grade sec. Baltimore consensus 2015 or BD-IPMN with high-grade dysplasia (carcinoma in situ) sec. WHO 2010. A meta-analysis was performed to investigate the presence of a mural nodule as a possible predictor of malignancy. RESULTS Twenty-four studies were included, with a total of 8941 patients with a presumed BD-IPMN. The progression rate was 20.2%, and 11.8% underwent surgery, 29.5% of whom showed malignancy at the final pathology. Of those, 78% had malignant IPMNs, and 22% had concomitant pancreatic cancer. Overall, 0.5% had distant metastasis. The meta-analysis showed that the risk of malignancy in the presence of a mural nodule >5 mm had a RR of 5.457 (95% CI 1.404-21.353), while a nonenhancing mural nodule or an enhancing mural nodule < 5 mm had a RR of 5.286 (95% CI 1.805-15.481) of harboring malignancy. CONCLUSION Most presumed BD-IPMNs entering surveillance do not become malignant. Of those submitted to surgery, concomitant PDAC adds to the overall risk of detecting malignancy.
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Affiliation(s)
- A Balduzzi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - G Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy.
| | - T Pollini
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - M Biancotto
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - A Caravati
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - E Stigliani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - A Burelli
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - C Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - R Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
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28
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Wu YA, Oba A, Beaty L, Colborn KL, Rodriguez Franco S, Harnke B, Meguid C, Negrini D, Valente R, Ahrendt S, Schulick RD, Del Chiaro M. Ductal Dilatation of ≥5 mm in Intraductal Papillary Mucinous Neoplasm Should Trigger the Consideration for Pancreatectomy: A Meta-Analysis and Systematic Review of Resected Cases. Cancers (Basel) 2021; 13:cancers13092031. [PMID: 33922344 PMCID: PMC8122854 DOI: 10.3390/cancers13092031] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Intraductal papillary mucinous neoplasms (IPMN) are common but difficult to manage since accurate tools for diagnosing malignancy are unavailable. This study evaluates the diagnostic value of main pancreatic duct (MPD) diameter for detecting IPMN malignancy, using a meta-analysis of published data. The result suggests that malignancy is highly prevalent in IPMN with ductal dilatation of >5 mm. Abstract Intraductal papillary mucinous neoplasms (IPMN) are common but difficult to manage since accurate tools for diagnosing malignancy are unavailable. This study tests the diagnostic value of the main pancreatic duct (MPD) diameter for detecting IPMN malignancy using a meta-analysis of published data of resected IPMNs. Collected from a comprehensive literature search, the articles included in this analysis must report malignancy cases (high-grade dysplasia (HGD) and invasive carcinoma (IC)) and MPD diameter so that two MPD cut-offs could be created. The sensitivity, specificity, and odds ratios of the two cutoffs for predicting malignancy were calculated. A review of 1493 articles yielded 20 retrospective studies with 3982 resected cases. A cutoff of ≥5 mm is more sensitive than the ≥10 mm cutoff and has pooled sensitivity of 72.20% and 75.60% for classification of HGD and IC, respectively. Both MPD cutoffs of ≥5 mm and ≥10 mm were associated with malignancy (OR = 4.36 (95% CI: 2.82, 6.75) vs. OR = 3.18 (95% CI: 2.25, 4.49), respectively). The odds of HGD and IC for patients with MPD ≥5 mm were 5.66 (95% CI: 3.02, 10.62) and 7.40 (95% CI: 4.95, 11.06), respectively. OR of HGD and IC for MPD ≥10 mm cutoff were 4.36 (95% CI: 3.20, 5.93) and 4.75 (95% CI: 2.39, 9.45), respectively. IPMN with MPD of >5 mm could very likely be malignant. In selected IPMN patients, pancreatectomy should be considered when MPD is >5 mm.
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Affiliation(s)
- Y.H. Andrew Wu
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
| | - Atsushi Oba
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan
| | - Laurel Beaty
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Kathryn L. Colborn
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
- Surgical Outcomes and Applied Research Program, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Salvador Rodriguez Franco
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- The Heart Institute, Children’s Hospital Colorado, Aurora, CO 80045, USA
| | - Ben Harnke
- Strauss Health Sciences Library, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA;
| | - Cheryl Meguid
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
| | - Daniel Negrini
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Anesthesiology, Federal University of the State of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Roberto Valente
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- Department of Surgery and Perioperative Sciences, Umeå University Hospital, 907 37 Umeå, Sweden
| | - Steven Ahrendt
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- University of Colorado Cancer Center, Aurora, CO 80045, USA
| | - Richard D. Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- University of Colorado Cancer Center, Aurora, CO 80045, USA
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (Y.H.A.W.); (A.O.); (L.B.); (K.L.C.); (S.R.F.); (C.M.); (D.N.); (R.V.); (S.A.); (R.D.S.)
- University of Colorado Cancer Center, Aurora, CO 80045, USA
- Correspondence:
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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.
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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
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30
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Fukuda J, Ikezawa K, Nakao M, Okagaki S, Ashida R, Ioka T, Takada R, Yamai T, Fukutake N, Uehara H, Nagata S, Takahashi H, Tabuchi T, Tanaka S, Ohkawa K, Katayama K. Predictive Factors for Pancreatic Cancer and Its Early Detection Using Special Pancreatic Ultrasonography in High-Risk Individuals. Cancers (Basel) 2021; 13:502. [PMID: 33525645 PMCID: PMC7865866 DOI: 10.3390/cancers13030502] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/21/2021] [Accepted: 01/25/2021] [Indexed: 02/07/2023] Open
Abstract
Because pancreatic cancer has a dismal prognosis, a strategy for early diagnosis is required. This study aimed to identify predictive factors of neoplastic progression in patients at high risk for pancreatic cancer and examined the efficiency of surveillance using transabdominal special ultrasonography focusing on the pancreas (special pancreatic US). Patients with slight main pancreatic duct (MPD) dilatation (≥2.5 mm) and/or pancreatic cysts (≥5 mm) were enrolled in a prospective surveillance study with special pancreatic US in a Japanese cancer referral center. A total of 498 patients undergoing surveillance for ≥3 years were included. During the median follow-up of 5.9 years, neoplastic progression developed in 11 patients (2.2%), including 9 patients who underwent pancreatectomy. Eight patients (72.7%) were diagnosed with stage 0/I disease, with an overall survival duration of 8.8 years. Findings of both MPD dilatation and pancreatic cysts at initial surveillance, MPD growth (≥0.2 mm/year) and cyst growth (≥2 mm/year) during surveillance were identified as independent risk factors for neoplastic progression. In summary, surveillance with special pancreatic US for high-risk individuals contributed to earlier detection of neoplastic progression, leading to a favorable prognosis. During surveillance, attention should be paid to MPD growth as well as to cyst growth.
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Affiliation(s)
- Junko Fukuda
- Department of Cancer Survey and Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (J.F.); (M.N.); (S.O.); (R.A.); (T.I.); (S.T.); (K.K.)
| | - Kenji Ikezawa
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (R.T.); (T.Y.); (N.F.); (H.U.); (K.O.)
| | - Miho Nakao
- Department of Cancer Survey and Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (J.F.); (M.N.); (S.O.); (R.A.); (T.I.); (S.T.); (K.K.)
| | - Suetsumi Okagaki
- Department of Cancer Survey and Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (J.F.); (M.N.); (S.O.); (R.A.); (T.I.); (S.T.); (K.K.)
| | - Reiko Ashida
- Department of Cancer Survey and Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (J.F.); (M.N.); (S.O.); (R.A.); (T.I.); (S.T.); (K.K.)
| | - Tatsuya Ioka
- Department of Cancer Survey and Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (J.F.); (M.N.); (S.O.); (R.A.); (T.I.); (S.T.); (K.K.)
| | - Ryoji Takada
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (R.T.); (T.Y.); (N.F.); (H.U.); (K.O.)
| | - Takuo Yamai
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (R.T.); (T.Y.); (N.F.); (H.U.); (K.O.)
| | - Nobuyasu Fukutake
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (R.T.); (T.Y.); (N.F.); (H.U.); (K.O.)
| | - Hiroyuki Uehara
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (R.T.); (T.Y.); (N.F.); (H.U.); (K.O.)
| | - Shigenori Nagata
- Department of Diagnostic Pathology and Cytology, Osaka International Cancer Institute, Osaka 541-8567, Japan;
| | - Hidenori Takahashi
- Department of Surgery, Osaka International Cancer Institute, Osaka 541-8567, Japan;
| | - Takahiro Tabuchi
- Cancer Control Center, Osaka International Cancer Institute, Osaka 541-8567, Japan;
| | - Sachiko Tanaka
- Department of Cancer Survey and Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (J.F.); (M.N.); (S.O.); (R.A.); (T.I.); (S.T.); (K.K.)
| | - Kazuyoshi Ohkawa
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (R.T.); (T.Y.); (N.F.); (H.U.); (K.O.)
| | - Kazuhiro Katayama
- Department of Cancer Survey and Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (J.F.); (M.N.); (S.O.); (R.A.); (T.I.); (S.T.); (K.K.)
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka 541-8567, Japan; (R.T.); (T.Y.); (N.F.); (H.U.); (K.O.)
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31
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Lee BS, Nguyen AK, Tekeste TF, Chang K, Girgis A, Adeyemo M, Hanna MS, Yao JF, Kwok KK, Giap AQ, Hunt GC, Chaya CT, Kao KT, Attam R, Ko A, Pio JR, Tovar S, Lim BS. Long-term follow-up of branch-duct intraductal papillary mucinous neoplasms with No change in first 5 Years of diagnosis. Pancreatology 2021; 21:144-154. [PMID: 33309223 DOI: 10.1016/j.pan.2020.10.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 09/01/2020] [Accepted: 10/16/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Discontinuation of branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) surveillance after 5 years of no change remains controversial. Long-term outcomes of BD-IPMN without significant changes in the first 5 years were evaluated. METHODS We performed a multi-center retrospective analysis of patients with BD-IPMN diagnosis from 2005 to 2011 (follow-up until 2017). Significant changes were defined as pancreatic cancer (PC), pancreatectomy, high-risk stigmata (HRS), worrisome features (WF) and worrisome EUS features (WEUS). RESULTS Of 982 patients who had no significant changes, 5 (0.5%), 7 (0.7%), 99 (10.1%), 4 (0.4%) patients developed PC, HRS, WF, WEUS, respectively, post-5 years. PC and HRS/WF/WEUS incidences at 12 years were 1.0% and 29.0%, respectively. Patients that developed HRS/WF/WEUS had larger cyst size in first 5 years compared to those that did not [16 (12-23) vs. 12 (9-17) mm, p = 0.0001], cyst size of >15 mm having higher cumulative incidence of HRS/WF/WEUS. PC mortality was 0.8%; all-cause mortality was 32%. Incidence of mortality due to PC was higher in HRS/WF/WEUS group, p < 0.0001. The mortality rate at 12 years for ACCI (age-adjusted Charlson Comorbidity Index) of ≤3, 4-6, and ≥7 were 3.5%, 19.9%, and 57.6% (p < 0.0001), respectively. CONCLUSIONS Incidence of PC in patients with BD-IPMN without significant changes in first 5 years of diagnosis remains low at 1.0%. Incidence of HRS/WF/WEUS was higher at 29.0%. PC-related mortality was higher in HRS/WF/WEUS group. These risks should be weighed against patients' overall mortality (utilizing scoring systems such as ACCI) when making surveillance decision of BD-IPMN beyond 5 years.
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Affiliation(s)
- Brian S Lee
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, CA, USA
| | - Andrew K Nguyen
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, CA, USA
| | - Timnit F Tekeste
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, CA, USA
| | - Karen Chang
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, CA, USA
| | - Agathon Girgis
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, CA, USA
| | - Mopelola Adeyemo
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, CA, USA
| | - Maryam S Hanna
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, CA, USA
| | - Janis F Yao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Karl K Kwok
- Department of Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Andrew Q Giap
- Department of Gastroenterology, Kaiser Permanente Orange County Medical Center, Anaheim, CA, USA
| | - Gordon C Hunt
- Department of Gastroenterology, Kaiser Permanente San Diego Medical Center, San Diego, CA, USA
| | - Charles T Chaya
- Department of Gastroenterology, Kaiser Permanente Riverside Medical Center, Riverside, CA, USA
| | - Kevin T Kao
- Department of Gastroenterology, Kaiser Permanente Downey Medical Center, Downey, CA, USA
| | - Rajeev Attam
- Department of Gastroenterology, Kaiser Permanente Downey Medical Center, Downey, CA, USA
| | - Albert Ko
- Department of Surgery, Kaiser Permanente Riverside Medical Center, Riverside, CA, USA
| | - Jose R Pio
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Stephanie Tovar
- Southern California Permanente Medical Group, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Brian S Lim
- Department of Internal Medicine, University of California, Riverside School of Medicine, Riverside, CA, USA; Department of Gastroenterology, Kaiser Permanente Riverside Medical Center, Riverside, CA, USA.
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32
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Main Duct Dilatation Is the Best Predictor of High-grade Dysplasia or Invasion in Intraductal Papillary Mucinous Neoplasms of the Pancreas. Ann Surg 2020; 272:1118-1124. [PMID: 30672797 DOI: 10.1097/sla.0000000000003174] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The purpose of this study is to determine preoperative factors that are predictive of malignancy in patients undergoing pancreatic resection for intraductal papillary mucinous neoplasms (IPMN). SUMMARY BACKGROUND DATA IPMN of the pancreas may be precursor lesions to pancreatic cancer (PC) and represent a target for early diagnosis or prevention. While there has been much effort to define preoperative risk factors for malignant pathology, guidelines are ever-changing and controversy remains surrounding which patients would benefit most from resection. METHODS We performed a retrospective analysis of 901 consecutive patients obtained from two tertiary referral centers who underwent pancreatic resection for histologically proven IPMN between 2004 and 2017. Collected data included patient demographic characteristics, preoperative symptoms, radiological findings, and laboratory data. RESULTS Main pancreatic duct (MPD) dilatation was the only variable that was significantly associated with increased probability of malignancy (defined high-dysplasia or invasion) on both univariate and multivariate analysis. Even middle-range MPD dilatation from 5 mm to 9.9 mm (n = 286) was associated with increased odds of HG-IPMN (OR = 2.74; 95% CI = 1.80-4.16) and invasion (OR = 4.42; 95% CI = 2.55-7.66). MPD dilatation >10 mm (n = 150) had even greater odds of HG-IPMN (OR = 6.57; 95% CI = 3.94-10.98) and invasion (OR = 15.07; 95% CI = 8.21-27.65). A cutoff of 5 to 7 mm MPD diameter was determined to be the best predictor to discriminate between malignant and benign lesions. CONCLUSIONS In agreement with current IPMN management guidelines, we found MPD dilatation, even low levels from 5 mm to 9.9 mm, to be the single best predictor of HG-IPMN or invasion, highlighting the critical role that MPD plays in the selection of surgical candidates.
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33
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Kovacevic B, Hansen MC, Kristensen TS, Karstensen JG, Klausen P, Storkholm J, Hansen CP, Vilmann P. Diagnostic performance of current guidelines and postoperative outcome following surgical treatment of cystic pancreatic lesions - a 10-year single center experience. Scand J Gastroenterol 2020; 55:1447-1453. [PMID: 33147090 DOI: 10.1080/00365521.2020.1841283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Pancreatic cystic lesions (PCLs) are diagnostically challenging and there are currently several different guidelines. The aim of this study was to compare diagnostic performance of the most widely utilized International Association of Pancreatology (IAP) guidelines and the recent evidence-based European guidelines and to report on postoperative outcomes following surgical treatment of PCLs. METHODS This is a retrospective single-center study of patients undergoing surgery due to a PCL between 2010 and 2019. Primary outcome was a comparison of diagnostic performance between IAP and European guidelines, measured in area under the receiver operating characteristic curve (AUC). Other outcomes included diagnostic performance of different risk features, 30-day postoperative mortality and major morbidity, final diagnosis, and overall survival. RESULTS We identified 137 patients, three of whom did not undergo curative surgery due to metastatic disease. Overall, there was no difference in the performance of the two guidelines with AUC values ranging from 0.572-0.610 and 0.607-0.621 for IAP and European guidelines respectively. Postoperative 30-day mortality and major morbidity were 0% (95% CI 0.0-2.7%) and 37.3% (95% CI 29.1-46.1%), respectively. More than half of the resected lesions (52.6%) were low-grade dysplastic or non-neoplastic. CONCLUSIONS Overall, the IAP and the European guidelines performed equally, although European guidelines had a slightly higher mean specificity. Pancreatic surgery is associated with high major morbidity, and there is a need for new diagnostic tools and strategies in order to decrease the amount of overtreatment in patients with PCL.
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Affiliation(s)
- Bojan Kovacevic
- Gastro Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | | | | | - John Gásdal Karstensen
- Gastro Unit, Pancreatitis Centre East, Hvidovre Hospital, Hvidovre, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Pia Klausen
- Gastro Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark
| | - Jan Storkholm
- Department of Surgery, Rigshospitalet, Copenhagen, Denmark
| | | | - Peter Vilmann
- Gastro Unit, Division of Endoscopy, Herlev Hospital, Herlev, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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Capurso G, Crippa S, Vanella G, Traini M, Zerboni G, Zaccari P, Belfiori G, Gentiluomo M, Pessarelli T, Petrone MC, Campa D, Falconi M, Arcidiacono PG. Factors Associated With the Risk of Progression of Low-Risk Branch-Duct Intraductal Papillary Mucinous Neoplasms. JAMA Netw Open 2020; 3:e2022933. [PMID: 33252689 PMCID: PMC7705592 DOI: 10.1001/jamanetworkopen.2020.22933] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) are common pancreatic preneoplastic lesions, but their surveillance is not personalized. OBJECTIVE To investigate patient- and cyst-related factors associated with progression into worrisome features (WFs) or high-risk stigmata (HRS) categories of BD-IPMNs. DESIGN, SETTING, AND PARTICIPANTS Cyst- and patient-related factors of consecutive BD-IPMNs without WFs or HRS in 540 patients diagnosed from 2009 to 2018 with at least 12 months' surveillance until February 28, 2020, were registered in a 2-center ambispective cohort study in Italy. In a subgroup, the ABO blood group was studied for the first time in this setting. EXPOSURE Cyst-related and patients-related factors and ABO blood group. MAIN OUTCOMES AND MEASURES The study outcome was the appearance of WFs or HRS according to the 2017 International Association of Pancreatology guidelines. Survival probability was calculated using Kaplan-Meier curve and risk factors identified by Cox proportional hazards regression. ABO blood group was inferred through genotypes with DNA extraction. RESULTS Of 540 patients with BD-IPMNs (median age, 66 years [interquartile range, 58.5-72.0 years]; 337 women [62.4%]) undergoing surveillance for a median of 51.5 months (interquartile range, 28-84 months) for 2758 person-years, 130 patients (24.1%) experienced progression. Probability of progression was 3.7% at 1 year, 23.4% at 5 years, and 43.3% at 10 years; 15 patients (2.8%) underwent surgery, 7 patients (1.3%) had malignant histologic findings, and 3 patients (0.56%) died of pancreatic-associated disease. Initial cyst size greater than 15 mm (hazard ratio [HR], 2.05; 95% CI, 1.44-2.91), body mass index greater than 26.4 (HR, 1.72; 95% CI, 1.19-2.50), and heavy smoking (HR, 1.81; 95% CI, 1.14-2.86) were significant independent factors associated with progression risk. The AA blood genotype was also associated with progression risk (HR, 3.49; 95% CI, 1.04-11.71) compared with the OO genotype in the investigated subgroup. CONCLUSIONS AND RELEVANCE This analysis of factors associated with progression of BD-IPMNs according to recent guidelines suggests that cyst size alone is not a reliable factor for estimation of progression risk; however, along with other readily available data, size is helpful for planning personalized surveillance of BD-IPMNs.
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Affiliation(s)
- Gabriele Capurso
- Pancreato-biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
- Digestive and Liver Disease Unit, S Andrea Hospital, Rome, Italy
| | - Stefano Crippa
- Pancreatic Surgery Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
- Università Vita-Salute, Milan, Italy
| | - Giuseppe Vanella
- Pancreato-biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
- Digestive and Liver Disease Unit, S Andrea Hospital, Rome, Italy
| | - Mariaemilia Traini
- Pancreato-biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Giulia Zerboni
- Digestive and Liver Disease Unit, S Andrea Hospital, Rome, Italy
| | - Piera Zaccari
- Pancreato-biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Giulio Belfiori
- Pancreatic Surgery Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
- Università Vita-Salute, Milan, Italy
| | | | - Tommaso Pessarelli
- Pancreatic Surgery Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Maria Chiara Petrone
- Pancreato-biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Daniele Campa
- Department of Biology, University of Pisa, Pisa, Italy
| | - Massimo Falconi
- Pancreatic Surgery Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
- Università Vita-Salute, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-biliary Endoscopy and Endoscopic Ultrasound, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
- Università Vita-Salute, Milan, Italy
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35
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Ciprani D, Weniger M, Qadan M, Hank T, Horick NK, Harrison JM, Marchegiani G, Andrianello S, Pandharipande PV, Ferrone CR, Lillemoe KD, Warshaw AL, Bassi C, Salvia R, Fernández-Del Castillo C. Risk of malignancy in small pancreatic cysts decreases over time. Pancreatology 2020; 20:1213-1217. [PMID: 32819844 PMCID: PMC8168401 DOI: 10.1016/j.pan.2020.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic cysts <15 mm without worrisome features have practically no risk of malignancy at the time of diagnosis but this can change over time. Optimal duration of follow-up is a matter of debate. We evaluated predictors of malignancy and attempted to identify a time to safely discontinue surveillance. METHODS Bi-centric study utilizing prospectively collected databases of patients with pancreatic cysts measuring <15 mm and without worrisome features who underwent surveillance at the Massachusetts General Hospital (1988-2017) and at the University of Verona Hospital Trust (2000-2016). The risk of malignant transformation was assessed using the Kaplan-Meier method and parametric survival models, and predictors of malignancy were evaluated using Cox regression. RESULTS 806 patients were identified. Median follow-up was 58 months (6-347). Over time, 58 (7.2%) cysts were resected and of those, 11 had high grade dysplasia (HGD) or invasive cancer. Three additional patients had unresectable cancer for a total rate of malignancy of 1.7%. Predictors of development of malignancy included an increase in size ≥2.5 mm/year (HR = 29.54, 95% CI: 9.39-92.91, P < 0.001) and the development of worrisome features (HR = 9.17, 95% CI: 2.99-28.10, P = 0.001). Comparison of parametric survival models suggested that the risk of malignancy decreased after three years of surveillance and was lower than 0.2% after five years. CONCLUSIONS Pancreatic cysts <15 mm at the time of diagnosis have a very low risk of malignant transformation. Our findings indicate the risk decreases over time. Size increase of ≥2.5 mm/year is the strongest predictor of malignancy.
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Affiliation(s)
- D Ciprani
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - M Weniger
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - T Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - N K Horick
- Biostatistics Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - J M Harrison
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - G Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - S Andrianello
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - P V Pandharipande
- Department of Radiology, Institute for Technology Assessment, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - C R Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - K D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - A L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - C Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - R Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - C Fernández-Del Castillo
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Pollini T, Andrianello S, Caravati A, Perri G, Malleo G, Paiella S, Marchegiani G, Salvia R. The management of intraductal papillary mucinous neoplasms of the pancreas. MINERVA CHIR 2020; 74:414-421. [PMID: 31795628 DOI: 10.23736/s0026-4733.19.08145-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are one of the most common preneoplastic entities among pancreatic cystic neoplasms (PCN). Their incidence is increasing due to an extensive use of cross-sectional imaging, but management still remains controversial. Among IPMNs, the main duct (MD-IPMN) and mixed (MT-IPMN) types harbor a high risk of malignant degeneration requiring resection in most of cases. The branch duct type (BD-IPMN), on the other side, can be safely surveilled as surgical resection is limited to selected cases deemed at high risk of malignant progression according to specific clinical and radiological features. An accurate diagnosis and a correct assessment of malignant potential are often hard to achieve, and clinical management still relies on the experience of the gastroenterologist/surgeon that is called to choose between a major pancreatic resection burdened by high morbidity and mortality rates and a life-long surveillance. The purpose of this report is to summarize the available evidence supporting the current practice for the management of IPMN and to offer a useful practical guide from first observation to postoperative follow-up.
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Affiliation(s)
- Tommaso Pollini
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy -
| | - Stefano Andrianello
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Andrea Caravati
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Management of Incidental Pancreatic Cystic Lesions: Integrating Novel Diagnostic and Prognostic Factors With Current Clinical Guidelines. J Clin Gastroenterol 2020; 54:415-427. [PMID: 32011401 DOI: 10.1097/mcg.0000000000001310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Owing to increased detection rates, the diagnosis and management of incidental pancreatic cysts has become a common predicament. Up to 13% of patients undergoing cross-sectional imaging studies for other indications are found to have pancreatic cystic lesions. Although most cystic lesions are benign, the malignant potential of several types of pancreatic cysts makes accurate classification vital to directing therapy. To this end, advances in the last decade led to better characterization of pancreatic cyst morphology and hence enhanced the ability to predict underlying histopathology, and biological behavior. Although accurate classification remains a challenge, the utilization of complementary diagnostic tools is the optimal approach to dictate management. The following review includes a description of pancreatic cysts, a critical review of current and emerging diagnostic techniques and a review of recent guidelines in the management of incidental pancreatic cysts.
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Park HW, Lee JS, Park SY, Kim TH, Lee JY, Koo JE, Bae SE, Choe J, Chang HS, Park DH, Bae I, Park S. Progression of pancreatic cystic lesions without any risk features is associated with initial cyst size and obesity. J Gastroenterol Hepatol 2020; 35:877-884. [PMID: 31758719 DOI: 10.1111/jgh.14940] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 11/07/2019] [Accepted: 11/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM The clinical significance of incidental pancreatic cystic lesions (PCLs) remains unclear in those that are not accompanied by worrisome features or high-risk stigmata. We aimed to investigate the natural course of PCLs without any risk features and examine the clinical factors associated with their progression. METHODS We conducted a retrospective cohort study of 427 patients with PCLs, which were incidentally detected by computed tomography between January 2003 and December 2012. Progression of PCLs without any risk features and the clinical factors associated with their progression were investigated. The length of time to significant growth was also evaluated. RESULTS Ninety-four (22.0%) of the 427 patients had asymptomatic PCLs that showed significant growth after a median surveillance period of 5.3 years; approximately 27.7% of the patients showed significant size changes in the first 5 years, while the remaining 72.3% showed significant changes after 5 years. The cumulative rate of patients with significant growth was associated with initial cyst size and high body mass index. In the growth group, additional treatments were required for 12 patients, one of whom developed malignancy. Four patients in the stable group underwent additional treatment and showed no malignant change. CONCLUSIONS One-fifth of the asymptomatic PCLs significantly increased in size after a long-term follow-up period, which was associated with initial cyst size and obesity. The size of PCLs mostly increased after 5 years; although the malignancy risk of PCLs was low, it was still a concern.
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Affiliation(s)
- Hye Won Park
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Soo Lee
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seo Young Park
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Hyup Kim
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Young Lee
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ja Eun Koo
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suh Eun Bae
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jaewon Choe
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Sook Chang
- Division of Gastroenterology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Inyoung Bae
- Division of Radiology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sungwon Park
- Division of Radiology, Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Risk Factors for Pancreatic Cancer and the Necessity of Long-Term Surveillance in Patients With Pancreatic Cystic Lesions. Pancreas 2020; 49:552-560. [PMID: 32282769 DOI: 10.1097/mpa.0000000000001521] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Pancreatic cystic lesions (PCLs) are a risk factor for pancreatic cancer (PC). Which PCLs should be surveilled and necessity of long-term observation are still controversial. METHODS From January 2000 to March 2016, we enrolled 1137 patients with PCLs observed for 1 year. We defined PCLs with cyst size of greater than 30 mm, main pancreatic duct (MPD) of greater than 5 mm or mural nodule as high-risk group, and others as low-risk group (LRG). Kaplan-Meier method and Cox proportional hazard model were applied to assess incidence and risk factors of PC. RESULTS In 107 high-risk group and 1030 LRG patients, mean observation period was 4.3 years and 5.0 years, respectively, and 5-year PC incidence was 12.0% and 2.8%, respectively. In LRG, MPD of greater than 3 mm, diabetes mellitus, and presumed branch-duct intraductal papillary mucinous neoplasia (BD-IPMN), defined as PCLs fulfilling any of multilocular formation, multiplicity, or MPD communication, were independent risk factors for PC. In 450 LRG observed for 5 years, 10-year PC incidence was higher in PCLs with our identified risk factors. There was no PC occurrence in PCLs not presumed BD-IPMN after 5-year observation. CONCLUSIONS Continuous surveillance is needed after 5-year observation, especially in LRG with our identified risk factors. For discontinuing surveillance, PCLs not presumed BD-IPMN at fifth year could be candidates.
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Caravati A, Andrianello S, Pollini T, Biancotto M, Balduzzi A, Malleo G, Salvia R, Marchegiani G. Branch Duct Intraductal Papillary Mucinous Neoplasms: Recommendations for Follow-Up and Surgery. Scand J Surg 2020; 109:34-41. [PMID: 32009571 DOI: 10.1177/1457496919900414] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Pancreatic cysts are increasingly diagnosed, mainly during abdominal imaging performed for other reasons. Between pancreatic cystic neoplasm, intraductal papillary mucinous neoplasms are the most common pre-malignant entities. Intraductal papillary mucinous neoplasms involving side branches overall harbor a low risk of malignancy, and in the recent past, a progressively more conservative approach has been consolidated. Purpose of this report is to summarize the evidence supporting the current practice for the management of branch duct intraductal papillary mucinous neoplasm and to offer a useful practical guide from first observation to post-operative follow-up. MATERIALS AND METHODS Review of the most important scientific literature on intraductal papillary mucinous neoplasms was made. In this review article, we also report the experience of a high volume center in managing Pancreatic cystic neoplasms. RESULTS The correct management during surveillance still is a matter of debate, since many guidelines have been published suggesting different clinical approaches. Recently, follow-up discontinuation has also been proposed in selected cases. CONCLUSION Despite significant improvements made by the increase of evidence, selecting surgical candidates because of an increased risk of malignant progression remains an unsolved issue and a hot topic for pancreatologists.
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Affiliation(s)
- A Caravati
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - S Andrianello
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - T Pollini
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - M Biancotto
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - A Balduzzi
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - G Malleo
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - R Salvia
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - G Marchegiani
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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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.
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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
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Farrell JJ. Does Pancreatic Cyst Stability Justify Stopping Intraductal Papillary Mucinous Neoplasm Surveillance? Gastroenterology 2020; 158:44-46. [PMID: 31738923 DOI: 10.1053/j.gastro.2019.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Indexed: 12/16/2022]
Affiliation(s)
- James J Farrell
- Yale Center for Pancreatic Disease, Center for Advanced Endoscopy, Yale School of Medicine, New Haven, Connecticut.
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Crippa S, Arcidiacono PG, De Cobelli F, Falconi M. Review of the diagnosis and management of intraductal papillary mucinous neoplasms. United European Gastroenterol J 2019; 8:249-255. [PMID: 32213017 DOI: 10.1177/2050640619894767] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Intraductal papillary mucinous neoplasms are common lesions with the potential of harbouring/developing a pancreatic cancer. An accurate evaluation of intraductal papillary mucinous neoplasms with high-resolution imaging techniques and endoscopic ultrasound is mandatory in order to identify patients worthy either of surgical treatment or surveillance. In this review, the diagnosis and management of patients with intraductal papillary mucinous neoplasms are discussed with a specific focus on current guidelines. Areas of uncertainty are also discussed, as there are controversies related to the optimal indications for surgery, surveillance protocols and surveillance discontinuation.
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Affiliation(s)
- Stefano Crippa
- Division of Pancreatic Surgery, Vita e Salute University, Milan, Italy
| | - Paolo G Arcidiacono
- Division of Pancreato-Biliary Endoscopy and EUS, Vita e Salute University, Milan, Italy
| | | | - Massimo Falconi
- Division of Pancreatic Surgery, Vita e Salute University, Milan, Italy
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van Huijgevoort NCM, Del Chiaro M, Wolfgang CL, van Hooft JE, Besselink MG. Diagnosis and management of pancreatic cystic neoplasms: current evidence and guidelines. Nat Rev Gastroenterol Hepatol 2019; 16:676-689. [PMID: 31527862 DOI: 10.1038/s41575-019-0195-x] [Citation(s) in RCA: 123] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2019] [Indexed: 12/11/2022]
Abstract
Pancreatic cystic neoplasms (PCN) are a heterogeneous group of pancreatic cysts that include intraductal papillary mucinous neoplasms, mucinous cystic neoplasms, serous cystic neoplasms and other rare cystic lesions, all with different biological behaviours and variable risk of progression to malignancy. As more pancreatic cysts are incidentally discovered on routine cross-sectional imaging, optimal surveillance for patients with PCN is becoming an increasingly common clinical problem, highlighting the need to balance cancer prevention with the risk of (surgical) overtreatment. This Review summarizes the latest developments in the diagnosis and management of PCN, including the quality of available evidence. Also discussed are the most important differences between the PCN guidelines from the American Gastroenterological Association, the International Association of Pancreatology and the European Study Group on Cystic Tumours of the Pancreas, including diagnostic and follow-up strategies and indications for surgery. Finally, new developments in the management of patients with PCN are addressed.
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Affiliation(s)
- Nadine C M van Huijgevoort
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marco Del Chiaro
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christopher L Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
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Overbeek KA, Alblas M, Gausman V, Kandel P, Schweber AB, Brooks C, Van Riet PA, Wallace MB, Gonda TA, Cahen DL, Bruno MJ. Development of a stratification tool to identify pancreatic intraductal papillary mucinous neoplasms at lowest risk of progression. Aliment Pharmacol Ther 2019; 50:789-799. [PMID: 31429105 PMCID: PMC6772152 DOI: 10.1111/apt.15440] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/11/2019] [Accepted: 07/06/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Because most pancreatic intraductal papillary mucinous neoplasms (IPMNs) will never become malignant, currently advocated long-term surveillance is low-yield for most individuals. AIM To develop a score chart identifying IPMNs at lowest risk of developing worrisome features or high-risk stigmata. METHODS We combined prospectively maintained pancreatic cyst surveillance databases of three academic institutions. Patients were included if they had a presumed side-branch IPMN, without worrisome features or high-risk stigmata at baseline (as defined by the 2012 international Fukuoka guidelines), and were followed ≥ 12 months. The endpoint was development of one or more worrisome features or high-risk stigmata during follow-up. We created a multivariable prediction model using Cox-proportional logistic regression analysis and performed an internal-external validation. RESULTS 875 patients were included. After a mean follow-up of 50 months (range 12-157), 116 (13%) patients developed worrisome features or high-risk stigmata. The final model included cyst size (HR 1.12, 95% CI 1.09-1.15), cyst multifocality (HR 1.49, 95% CI 1.01-2.18), ever having smoked (HR 1.40, 95% CI 0.95-2.04), history of acute pancreatitis (HR 2.07, 95% CI 1.21-3.55), and history of extrapancreatic malignancy (HR 1.34, 95% CI 0.91-1.97). After validation, the model had good discriminative ability (C-statistic 0.72 in the Mayo cohort, 0.71 in the Columbia cohort, 0.64 in the Erasmus cohort). CONCLUSION In presumed side branch IPMNs without worrisome features or high-risk stigmata at baseline, the Dutch-American Risk stratification Tool (DART-1) successfully identifies pancreatic lesions at low risk of developing worrisome features or high-risk stigmata.
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Affiliation(s)
- Kasper A. Overbeek
- Department of Gastroenterology & HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Maaike Alblas
- Department of Public HealthErasmus University Medical CenterRotterdamThe Netherlands
| | - Valerie Gausman
- Department of MedicineNYU – Langone Medical CenterNew YorkUSA
| | - Pujan Kandel
- Department of Gastroenterology and HepatologyMayo ClinicJacksonvilleUSA
| | - Adam B. Schweber
- Division of Digestive and Liver Diseases, Department of MedicineColumbia University Medical CenterNew YorkUSA
| | - Christian Brooks
- Division of Digestive and Liver Diseases, Department of MedicineColumbia University Medical CenterNew YorkUSA
| | - Priscilla A. Van Riet
- Department of Gastroenterology & HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | | | - Tamas A. Gonda
- Division of Digestive and Liver Diseases, Department of MedicineColumbia University Medical CenterNew YorkUSA
| | - Djuna L. Cahen
- Department of Gastroenterology & HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology & HepatologyErasmus University Medical CenterRotterdamThe Netherlands
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Teoh AYB, Seo DW, Brugge W, Dewitt J, Kongkam P, Linghu E, Moyer MT, Ryu JK, Ho KY. Position statement on EUS-guided ablation of pancreatic cystic neoplasms from an international expert panel. Endosc Int Open 2019; 7:E1064-E1077. [PMID: 31475223 PMCID: PMC6715424 DOI: 10.1055/a-0959-5870] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/11/2019] [Indexed: 02/08/2023] Open
Abstract
Background and aim Recently, several guidelines with divergent recommendations on management of pancreatic cystic neoplasm have been published but the role of endoscopic ultrasound (EUS)-guided pancreatic cyst ablation has not been thoroughly addressed. The aim of the current paper is to explore the issues surrounding EUS-guided pancreatic cyst ablation by generating a list of clinical questions and providing answers based on best scientific evidence available. Methods An expert panel in EUS-guided pancreatic cyst ablation was recruited from members of the Asian EUS group and an international expert panel. A list of clinical questions was created and each question allocated to one member to generate a statement in response. The statements were then discussed in three Internet conference meetings between October 2016 and October 2017. The statements were changed until consensus was obtained. Afterwards, the complete set of statements was sent to all the panelist to vote on strength of the statements, classification of the statement sand grading of the evidence. Results Twenty-three statements on EUS-guided drainage of pancreatic cyst ablation were formulated. The statements addressed indications for the procedures, technical aspects, pre-procedure and post-procedure management, management of complications, and competency and training in the procedures. Conclusion The current set of statements on EUS-guided pancreatic cyst ablation are the first to be published by any endoscopic society. Clinicians interested in developing the technique should reference these statements and future studies should address the key issues raised in the document.
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Affiliation(s)
- Anthony Yuen-Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong,Corresponding author Prof. Anthony Yuen Bun Teoh Department of SurgeryThe Chinese University of Hong KongPrince of Wales HospitalShatin, New TerritoriesHong Kong SARChina+852-2637-7974
| | - Dong Wan Seo
- Department of Gastroenterology, Asan Medical Centre, Seoul, Korea
| | - William Brugge
- Pancreas Biliary Center, Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - John Dewitt
- Division of Gastroenterology, Department of Medicine, Indiana University Hospital, Indianapolis, Indiana, United States
| | - Pradermchai Kongkam
- Pancreas Research Unit and Gastrointestinal Endoscopy Excellent Center, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Enqiang Linghu
- Department of Gastroenterology, Chinese PLA General Hospital, Beijing, China
| | - Matthew T. Moyer
- Division of GI-Hepatology and Penn State University Cancer Institute, Penn State Hershey Medical Center, Hershey, Pennsylvania, United States
| | - Ji Kon Ryu
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Khek Yu Ho
- Department of Medicine, National University of Singapore, Singapore
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Kang JS, Park T, Han Y, Lee S, Lim H, Kim H, Kim SH, Kwon W, Kim SW, Jang JY. Clinical validation of the 2017 international consensus guidelines on intraductal papillary mucinous neoplasm of the pancreas. Ann Surg Treat Res 2019; 97:58-64. [PMID: 31388508 PMCID: PMC6669133 DOI: 10.4174/astr.2019.97.2.58] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 05/03/2019] [Accepted: 06/26/2019] [Indexed: 12/24/2022] Open
Abstract
Purpose The 2017 international consensus guidelines (ICG) for intraductal papillary mucinous neoplasm (IPMN) of the pancreas were recently released. Important changes included the addition of worrisome features such as elevated serum CA 19-9 and rapid cyst growth (>5 mm over 2 years). We aimed to clinically validate the 2017 ICG and compare the diagnostic performance between the 2017 and 2012 ICG. Methods This was a retrospective cohort study. During January 2000–January 2017, patients who underwent complete surgical resection and had pathologic confirmation of branch-duct or mixed-type IPMN were included. To evaluate diagnostic performance, the areas under the receiver operating curves (AUCs) were evaluated. Results A total of 448 patients were included. The presence of mural nodule (hazard ratio [HR], 9.12; 95% confidence interval [CI], 4.60–18.09; P = 0.001), main pancreatic duct dilatation (>5 mm) (HR, 5.32; 95% CI, 2.67–10.60; P = 0.001), thickened cystic wall (HR, 3.40; 95% CI, 1.51–7.63; P = 0.003), and elevated CA 19-9 level (>37 unit/mL) (HR, 5.25; 95% CI, 2.05–13.42; P = 0.001) were significantly associated with malignant IPMN. Malignant lesions showed a cyst growth rate >5 mm over 2 years more frequently than benign lesions (60.9% vs. 29.7%, P = 0.012). The AUC was higher for the 2017 ICG than the 2012 ICG (0.784 vs. 0.746). Conclusion The new 2017 ICG for IPMN is clinically valid, with a superior diagnostic performance to the 2012 ICG. The inclusion of elevated serum CA 19-9 level and cyst growth rate to the 2017 ICG is appropriate.
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Affiliation(s)
- Jae Seung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Taesung Park
- Department of Statistics and Interdisciplinary Program in Biostatistics, Seoul National University, Seoul, Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Seungyeon Lee
- Department of Mathematics and Statistics, Sejong University, Sejong, Korea
| | - Heeju Lim
- Department of Mathematics and Statistics, Sejong University, Sejong, Korea
| | - Hyeongseok Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Se Hyung Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sun-Whe Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Zerboni G, Signoretti M, Crippa S, Falconi M, Arcidiacono PG, Capurso G. Systematic review and meta-analysis: Prevalence of incidentally detected pancreatic cystic lesions in asymptomatic individuals. Pancreatology 2019; 19:2-9. [PMID: 30503370 DOI: 10.1016/j.pan.2018.11.014] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/18/2018] [Accepted: 11/27/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Pancreatic cystic lesions (PCLs) are frequent incidental findings. As most PCLs require costly diagnostic evaluation and active surveillance, it is important to clarify their prevalence in asymptomatic individuals. We therefore aimed at performing a systematic review and meta-analysis to determine it. METHODS a systematic search was conducted and studies meeting inclusion criteria were included. The prevalence of PCLs was pooled across studies. A random effect model was used with assessment of heterogeneity. RESULTS 17 studies, with 48,860 patients, were included. Only 3 were prospective; 5 studies were conducted in the US, 7 in Europe, 4 in Asia and 1 in Brazil. The pooled prevalence of PCLs was 8% (95% CI 4-14) with considerable heterogeneity (I2 = 99.5%). This prevalence was higher in studies of higher quality, examining older subjects, smaller cohorts, and employing MRCP (24.8% vs 2.7% with CT-scan). The pooled rate of PCLs was four times higher in studies conducted in the US than in Asia (12.6% vs 3.1%). 7 studies reported the prevalence of mucinous lesions, with a pooled rate of 4.3% (95% CI 2-10; I2 = 99.2%), but of 0.7% only for worrisome features or high risk stigmata. CONCLUSION The rate of incidentally detected PCLs is of 8%. Mucinous lesions are the most common incidentally detected PCLs, although they rarely present with potential indication for surgery. The observed different rates in the US and other geographic Areas suggest that different protocols might be necessary to help balancing costs and effectiveness of follow-up investigations in asymptomatic subjects.
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Affiliation(s)
- Giulia Zerboni
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Marianna Signoretti
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Stefano Crippa
- Pancreatic Surgery Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; Vita Salute San Raffaele University, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; Vita Salute San Raffaele University, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- PancreatoBiliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Gabriele Capurso
- PancreatoBiliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy.
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Growth in Branch Duct IPMN Undergoing Surveillance: Unsafe at Any Speed? Clin Gastroenterol Hepatol 2018; 16:1401-1403. [PMID: 29775796 DOI: 10.1016/j.cgh.2018.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/04/2018] [Indexed: 02/07/2023]
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Andrianello S, Falconi M, Salvia R, Crippa S, Marchegiani G. Surveillance of Cystic Lesions of the Pancreas: Whom and How to Survey? Visc Med 2018; 34:202-205. [PMID: 30140686 DOI: 10.1159/000489240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The sudden prevalence increase of pancreatic cystic neoplasms (PCN) related to the use of cross-sectional imaging has raised several concerns. Even if there is a tangible risk of progression towards pancreatic cancer (PC), surgical resection cannot be offered to all patients due to the high risk of morbidity and mortality. Available guidelines are useful tools to identify patients at higher risk for harboring cancer thanks to their sensitivity. Because of their low specificity, however, such a risk is often overestimated. Recent evidence deriving from large observational series of surveilled patients suggests that the overall risk of PC is low. A large proportion of patients affected by PCN can be safely observed over time. Several follow-up schedules have been proposed in guidelines but none of them proved to be the most cost-effective. Moreover, it must still be demonstrated that any surveillance protocol can be associated with a reduction in PC-related mortality. By now, with most studies reporting a lifelong risk of malignancy, the only evidence-based recommendation regarding surveillance is that follow-up should never be discontinued as repeated observations are crucial for PC risk stratification.
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Affiliation(s)
- Stefano Andrianello
- Pancreatic Surgery Unit of the Department of Surgery, Verona University Hospital, Verona, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy
| | - Roberto Salvia
- Pancreatic Surgery Unit of the Department of Surgery, Verona University Hospital, Verona, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy
| | - Giovanni Marchegiani
- Pancreatic Surgery Unit of the Department of Surgery, Verona University Hospital, Verona, Italy
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