Diagnosis and management of pancreatic cystic neoplasms: current evidence and guidelines

Application of artificial intelligence in pancreas endoscopic ultrasound imaging- A systematic review

The pancreas is a vital organ in digestive system which has significant health implications. It is imperative to evaluate and identify malignant pancreatic lesions promptly in light of the high mortality rate linked to such malignancies. Endoscopic Ultrasound (EUS) is a non-invasive precise technique to detect pancreas disorders, but it is highly operator dependent. Artificial intelligence (AI), including traditional machine learning (ML) and deep learning (DL) techniques can play a pivotal role to enhancing the performance of EUS regardless of operator. AI performs a critical function in the detection, classification, and segmentation of medical images. The utilization of AI-assisted systems has improved the accuracy and productivity of pancreatic analysis, including the detection of diverse pancreatic disorders (e.g., pancreatitis, masses, and cysts) as well as landmarks and parenchyma. This systematic review examines the rapidly developing domain of AI-assisted system in EUS of the pancreas. Its objective is to present a thorough study of the present research status and developments in this area. This paper explores the significant challenges of AI-assisted system in pancreas EUS imaging, highlights the potential of AI techniques in addressing these challenges, and suggests the scope for future research in domain of AI-assisted EUS systems.

Should All Pancreatic Cystic Lesions with Worrisome or High-Risk Features Be Resected? A Clinical and Radiological Machine Learning Model May Help to Answer

RATIONALE AND OBJECTIVES

According to current guidelines, pancreatic cystic lesions (PCLs) with worrisome or high-risk features may have overtreatment. The purpose of this study was to build a clinical and radiological based machine-learning (ML) model to identify malignant PCLs for surgery among preoperative PCLs with worrisome or high-risk features.

MATERIALS AND METHODS

Clinical and radiological details of 317 pathologically confirmed PCLs with worrisome or high-risk features were retrospectively analyzed and applied to ML models including Support Vector Machine, Logistic Regression (LR), Decision Tree, Bernoulli NB, Gaussian NB, K Nearest Neighbors and Linear Discriminant Analysis. The diagnostic ability for malignancy of the optimal model with the highest diagnostic AUC in the cross-validation procedure was further evaluated in internal (n = 77) and external (n = 50) testing cohorts, and was compared to two published guidelines in internal mucinous cyst cohort.

RESULTS

Ten clinical and radiological feature-based LR model was the optimal model with the highest AUC (0.951) in the cross-validation procedure. In the internal testing cohort, LR model reached an AUC, accuracy, sensitivity, and specificity of 0.927, 0.909, 0.914, and 0.905; in the external testing cohort, LR model reached 0.948, 0.900, 0.963, and 0.826. When compared to the European guidelines and the ACG guidelines, LR model demonstrated significantly better accuracy and specificity in identifying malignancy, while maintaining the same high sensitivity.

CONCLUSION

Clinical- and radiological-based LR model can accurately identify malignant PCLs in patients with worrisome or high-risk features, possessing diagnostic performance better than the European guidelines as well as ACG guidelines.

Glucose and lactate levels are lower in EUS-aspirated cyst fluid of mucinous vs non-mucinous pancreatic cystic lesions

BACKGROUND

Distinguishing mucinous (M) pancreatic cystic neoplasms (PCNs) from non-mucinous (NM) is challenging but crucial. Low intracystic glucose level has shown diagnostic tool promise, however further investigation is needed to understand metabolic processes.

AIMS

To compare the diagnostic accuracy of intracystic glucose and CEA levels in a large cohort and explore lactate levels as potential marker.

METHODS

PCNs≥15 mm which underwent EUS-fine needle aspiration were prospectively enrolled. Glucose, CEA and lactate levels were measured. Diagnostic accuracy for M-PCN diagnosis was evaluated using surgical/cytology reports or multidisciplinary evaluations.

RESULTS

169 PCNs were included (64 % M-PCNs). Median intracystic glucose was significantly lower in M-PCNs (1 mg/dL) compared to NM-PCNs (101 mg/dL); mean intracystic CEA was significantly higher in M-PCNs (152.5 ng/mL) compared to NM-PCNs (0.3 ng/mL). ROC curve analysis revealed best glucose cut-off ≤58 mg/dL (accuracy 93.5 %) and CEA cut-off >2.5 ng/mL (accuracy 90.5 %) for M-PCNs. Intracystic lactates were significantly lower in M-PCNs correlating directly with glucose. Single glucose dosage evidenced best diagnostic accuracy respect markers combination.

CONCLUSION

Intracystic glucose demonstrated high diagnostic utility for M-PCNs differentiation, surpassing CEA. Lactate levels correlated with glucose, suggesting their uptake by M-PCNs cells. These findings contribute to a better metabolic landscape understanding glucose use as diagnostic marker.

Gastrointestinal cancer precursor risk and mortality in pancreatic intraductal papillary mucinous neoplasms: a nationwide cohort study

BACKGROUND AND AIMS

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a precursor of pancreatic cancer. While earlier research has shown a high prevalence of synchronous/metachronous extrapancreatic tumors in IPMN patients, these studies have often been small with retrospective data collection. The aim of the study was to examine absolute and relative risks of non-pancreatic gastrointestinal (GI) cancer precursors and mortality in histologically confirmed IPMN.

METHODS

Through the nationwide ESPRESSO histopathology cohort, we retrieved data on IPMN between 1965 and 2016. Each index case was matched to ≤5 general population controls. Through Cox regression, we estimated hazard ratios (HRs) for future GI cancer precursors and death.

RESULTS

A total of 117 patients with IPMN and 539 age- and sex-matched controls were included. Over a median of 2.1 years of follow up, we confirmed two (1.7%) incident GI cancer precursors in IPMN vs. four (0.7%) in controls, corresponding to an HR of 1.89 (95%CI = 0.34-10.55). By contrast, IPMN patients were at increased risk of death (HR 3.61 (95%CI = 1.79-7.27)). The most common cause of death in IPMN was pancreatic cancer (n = 14; 45.2% of all deaths).

CONCLUSIONS

We found no association between IPMN and other GI cancer precursors. This argues against comprehensive routine surveillance for other GI cancer precursors in IPMN patients. Mortality was increased in IPMN with pancreatic cancer being the most common cause of death, indicating the need for lifelong follow up in all resected and non-resected patients with IPMN. However, results should be confirmed in larger cohorts.

Revolutionizing the Pancreatic Tumor Diagnosis: Emerging Trends in Imaging Technologies: A Systematic Review

Background and Objectives: The pancreas, ensconced within the abdominal cavity, requires a plethora of sophisticated imaging modalities for its comprehensive evaluation, with ultrasonography serving as a primary investigative technique. A myriad of pancreatic pathologies, encompassing pancreatic neoplasia and a spectrum of inflammatory diseases, are detectable through these imaging strategies. Nevertheless, the intricate anatomical confluence and the pancreas's deep-seated topography render the visualization and accurate diagnosis of its pathologies a formidable endeavor. The objective of our paper is to review the best diagnostic imagistic tools for the pancreas. Materials and Methods: we have gathered several articles using Prisma guidelines to determine the best imagistic methods. The imperative of pancreatic scanning transcends its diagnostic utility, proving to be a pivotal element in a multitude of clinical specialties, notably surgical oncology. Within this domain, multidetector computed tomography (MDCT) of the pancreas holds the distinction of being the paramount imaging modality, endorsed for its unrivaled capacity to delineate the staging and progression of pancreatic carcinoma. In synergy with MDCT, there has been a notable advent of avant-garde imaging techniques in recent years. These advanced methodologies, including ultrasonography, endoscopic ultrasonography, contrast-enhanced ultrasonography, and magnetic resonance imaging (MRI) conjoined with magnetic resonance cholangiopancreatography (MRCP), have broadened the horizon of tumor characterization, offering unparalleled depth and precision in oncological assessment. Other emerging diagnostic techniques, such as elastography, also hold a lot of potential and promise for the future of pancreatic imaging. Fine needle aspiration (FNA) is a quick, minimally invasive procedure to evaluate lumps using a thin needle to extract tissue for analysis. It is less invasive than surgical biopsies and usually performed as an outpatient with quick recovery. Its accuracy depends on sample quality, and the risks include minimal bleeding or discomfort. Results, guiding further treatment, are typically available within a week. Elastography is a non-invasive medical imaging technique that maps the elastic properties and stiffness of soft tissue. This method, often used in conjunction with ultrasound or MRI, helps differentiate between hard and soft areas in tissue, providing valuable diagnostic information. It is particularly useful for assessing liver fibrosis, thyroid nodules, breast lumps, and musculoskeletal conditions. The technique is painless and involves applying gentle pressure to the area being examined. The resulting images show tissue stiffness, indicating potential abnormalities. Elastography is advantageous for its ability to detect diseases in early stages and monitor treatment effectiveness. The procedure is quick, safe, and requires no special preparation, with results typically available immediately. Results: The assembled and gathered data shows the efficacy of various techniques in discerning the nature and extent of neoplastic lesions within the pancreas. Conclusions: The most common imaging modalities currently used in diagnosing pancreatic neoplasms are multidetector computed tomography (MDCT), endoscopic ultrasound (EUS), and magnetic resonance imaging (MRI), alongside new technologies, such as elastography.

Pancreatic Cysts Greater Than 1 cm Are Associated With an Increased Risk for Developing Pancreatic Cancer in Individuals From Pancreatic-Cancer Prone Kindreds Undergoing Surveillance

BACKGROUND

The International Cancer of the Pancreas Screening Consortium recommended annual imaging for individuals at increased risk for developing a pancreatic ductal adenocarcinoma (PDAC) who did not have concerning pancreatic findings or a cyst <3 cm without worrisome features. We aimed to determine if 3-cm cyst size accurately predicted advanced precursor lesions in high-risk individuals undergoing surveillance.

METHODS

Imaging for high-risk individuals (HRIs) undergoing PDAC surveillance from 2007 to 2021 was reviewed and pancreatic abnormalities were recorded including dominant cyst size and number of cysts. Subjects were excluded if they had the following: (1) no follow-up imaging after baseline, (2) solid lesion at baseline, or (3) development of solid lesion without having cyst on prior imaging.

RESULTS

Five of the 77 HRIs found to have a cystic lesion on surveillance developed a PDAC: 3 with cystic lesion >1 cm as compared with only 2 of 67 HRIs with cystic lesions <1 cm (P < 0.05). None of these cysts developed worrisome findings and 4/5 PDACs did not arise from visualized cystic precursor lesion.

CONCLUSIONS

Patients with a cyst ≥1 cm were at increased risk for developing PDAC compared with patients with cyst <1 cm. Pancreatic ductal adenocarcinoma usually did not arise from a recognized cystic lesion.

Using a customized GPT to provide guideline-based recommendations for management of pancreatic cystic lesions

Background and study aims Rising prevalence of pancreatic cysts and inconsistent management guidelines necessitate innovative approaches. New features of large language models (LLMs), namely custom GPT creation, provided by ChatGPT can be utilized to integrate multiple guidelines and settle inconsistencies. Methods A custom GPT was developed to provide guideline-based management advice for pancreatic cysts. Sixty clinical scenarios were evaluated by both the custom GPT and gastroenterology experts. A consensus was reached between experts and review of guidelines and the accuracy of recommendations provided by the custom GPT was evaluated and compared with experts. Results The custom GPT aligned with expert recommendations in 87% of scenarios. Initial expert recommendations were correct in 97% and 87% of cases, respectively. No significant difference was observed between the accuracy of custom GPT and the experts. Agreement analysis using Cohen's and Fleiss' Kappa coefficients indicated consistency among experts and the custom GPT. Conclusions This proof-of-concept study shows the custom GPT's potential to provide accurate, guideline-based recommendations for pancreatic cyst management, comparable to expert opinions. The study highlights the role of advanced features of LLMs in enhancing clinical decision-making in fields with significant practice variability.

The Role of Intraoperative Pancreatoscopy in the Surgical Management of Intraductal Papillary Mucinous Neoplasms: A Scoping Review

OBJECTIVES

Most patients with intraductal papillary mucinous neoplasms (IPMNs) are diagnosed with a solitary lesion; however, the presence of skip lesions, not appreciable on imaging, has been described. Postoperatively, these missed lesions can continue to grow and potentially become cancerous. Intraoperative pancreatoscopy (IOP) may facilitate detection of such skip lesions in the remnant gland. The aim of this scoping review was to appraise the evidence on the role of IOP in the surgical management of IPMNs.

MATERIALS AND METHODS

Studies reporting on the use of IOP during IPMN surgery were identified through searches of the PubMed, Embase, and Scopus databases. Data extracted included IOP findings, surgical plan modifications, and patient outcomes. The primary outcome of interest was the utility of IOP in surgical decision making.

RESULTS

Ten studies reporting on the use of IOP for IPMNs were identified, representing 147 patients. A total of 46 skip lesions were identified by IOP. Overall, surgical plans were altered in 37% of patients who underwent IOP. No IOP-related complications were reported.

CONCLUSIONS

The current literature suggests a potential role of integration of IOP into the management of patients with IPMNs. This tool is safe and feasible and can result in changes in surgical decision making.

Analytical Validation of Loss of Heterozygosity and Mutation Detection in Pancreatic Fine-Needle Aspirates by Capillary Electrophoresis and Sanger Sequencing

Pancreatic cystic disease, including duct dilation, represents precursor states towards the development of pancreatic cancer, a form of malignancy with relatively low incidence but high mortality. While most of these cysts (>85%) are benign, the remainder can progress over time, leading to malignant transformation, invasion, and metastasis. Cytologic diagnosis is challenging, limited by the paucity or complete absence of cells representative of cystic lesions and fibrosis. Molecular analysis of fluids collected from endoscopic-guided fine-needle aspiration of pancreatic cysts and dilated duct lesions can be used to evaluate the risk of progression to malignancy. The basis for the enhanced diagnostic utility of molecular approaches is the ability to interrogate cell-free nucleic acid of the cyst/duct and/or extracellular fluid. The allelic imbalances at tumor suppressor loci and the selective oncogenic drivers are used clinically to help differentiate benign stable pancreatic cysts from those progressing toward high-grade dysplasia. Methods are discussed and used to determine the efficacy for diagnostic implementation. Here, we report the analytical validation of methods to detect causally associated molecular changes integral to the pathogenesis of pancreatic cancer from pancreatic cyst fluids.

Radiomics advances in the evaluation of pancreatic cystic neoplasms

With the development of medical imaging, the detection rate of pancreatic cystic neoplasms (PCNs) has increased greatly. Serous cystic neoplasm, solid pseudopapillary neoplasm, intraductal papillary mucinous neoplasm and mucinous cystic neoplasm are the main subtypes of PCN, and their treatment options vary greatly due to the different biological behaviours of the tumours. Different from conventional qualitative imaging evaluation, radiomics is a promising noninvasive approach for the diagnosis, classification, and risk stratification of diseases involving high-throughput extraction of medical image features. We present a review of radiomics in the diagnosis of serous cystic neoplasm and mucinous cystic neoplasm, risk classification of intraductal papillary mucinous neoplasm and prediction of solid pseudopapillary neoplasm invasiveness compared to conventional imaging diagnosis. Radiomics is a promising tool in the field of medical imaging, providing a noninvasive, high-performance model for preoperative diagnosis and risk stratification of PCNs and improving prospects regarding management of these diseases. Further studies are warranted to investigate MRI image radiomics in connection with PCNs to improve the diagnosis and treatment strategies in the management of PCN patients.

Pancreatic serous cystic neoplasms with spontaneous hemorrhage in a young woman: A case report

INTRODUCTION

Pancreatic serous cystic neoplasm (SCN) is usually benign and is often managed using imaging surveillance if asymptomatic. It has a higher incidence in females but is rare in younger age groups. Acute hemorrhagic complications associated with SCN are infrequent. Whether asymptomatic SCN can cause acute hemorrhage, especially in women of childbearing age, is not well-established.

PRESENTATION OF CASE

A 30-year-old Japanese female, who was six months postpartum and under surveillance for asymptomatic pancreatic SCN, presented to the emergency department with gradually worsening left lateral abdominal pain. Regular ultrasound revealed no change in SCN size; however, no imaging surveillance had been conducted over the past two years. She had pain in the entire abdomen, which intensified around the navel and elicited guarding. Abdominal contrast-enhanced computed tomography revealed a cystic mass in the pancreatic tail with a contrast blush within the cyst and an adjacent retroperitoneal hematoma. Endovascular embolization was performed to control the hemorrhage. The patient had an uneventful medical recovery and was discharged five days after embolization. Five months after discharge, she underwent laparoscopic distal pancreatectomy and splenectomy as an elective surgery and was discharged uneventfully.

DISCUSSION

Even with periodic imaging surveillance, pancreatic SCN can suddenly cause spontaneous hemorrhage. Clinicians should be aware that pancreatic SCN can potentially cause life-threatening complications, including spontaneous hemorrhage.

CONCLUSION

We report a case of an unexpected complication with spontaneous hemorrhage in a young woman who was under imaging surveillance for pancreatic SCN. The patient was successfully treated with angioembolization and planned laparoscopic surgery.

The Deception of Pancreas Cyst Surveillance: A Case Study

Pancreatic cysts are a growing pandemic around the world. Intrapapillary mucinous neoplasms are the most common type of pancreatic cysts and given their premalignant nature, guidelines recommend surveillance. This case study and discussion addresses the five existing guidelines published to help clinicians manage patients with intraductal papillary mucinous neoplasms and illustrates how, despite guidelines and close surveillance, intraductal papillary mucinous neoplasms can transform into pancreatic adenocarcinoma.

Intraductal papillary mucinous neoplasms of the pancreas: Uncommon imaging presentation, evolution and comparison of guidelines

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.

Quality of Pancreatic Cyst Clinical Practice Guidelines

BACKGROUND

There are various published clinical practice guidelines (CPGs) for the management of pancreatic cystic lesions. However, the quality of these guidelines has not been systematically appraised. This study aimed to evaluate the quality of CPGs published in the last 5 years for the management of pancreatic cysts.

METHODS

A systematic search of the PubMed database for eligible CPGs published between January 1, 2016 and November 17, 2021, using a sensitive filter. The quality of the CPGs was independently evaluated using the Appraisal of Guidelines for Research & Evaluation II instrument, with domain scores considered sufficient quality if >60% and good quality if >80%.

RESULTS

The search yielded 4 eligible CPGs out of 426 citations. The scores varied for different domains for each CPG, with the overall median score being 79% for scope and purpose, 26% for stakeholder involvement, 51% for rigor of development, 69% for clarity of presentation, 14% for applicability, and 75% for editorial independence.

CONCLUSIONS

The study revealed that the quality of the CPGs for pancreatic cyst management in adults remains moderate at best. Patient representatives were not involved in any of the CPG development process. There is a significant scope for improvement in methodological rigor and clarity of presentation.

Minimally invasive enucleation of pancreatic tumors: The main pancreatic duct is no longer a restricted area

Background

Tumors involving the main pancreatic duct (MPD) used to be a contraindication for enucleation.

Methods

Clinical data of consecutive patients with pancreatic tumors who received laparoscopic or robotic enucleation (LEN or REN) between January 2019 and December 2021 at Fudan University Shanghai Cancer Center were analyzed.

Results

Ninety-six patients were included in the analysis, with 55 in the LEN group and 41 in the REN group, and no conversion to laparotomy. Most tumors were located in the head of pancreas (71.9 %). The tumor diameter (3.1 vs. 1.9 cm) was larger, and more cystic tumors (92.7 % vs. 56.4 %) and more tumors involving the MPD (34.1 % vs. 3.6 %) were observed in the REN group. MPD support tube insertion was performed in 15 cases, with 11 in the REN group and 4 in the LEN group. The incidence of biochemical and grade B postoperative pancreatic fistula (POPF) was both 46.9 %, and no grade C POPF occurred. Among the 45 patients with grade B POPF, 28 cases (62.2 %) were due to carrying drainage tube >3 weeks without additional treatment, and only 4 cases required invasive treatment. For patients with MPD support tube implantation (n = 15), support tube fall-offs were observed in 12 cases, 2 patients had MPD dilatation, and no MPD stricture, stone formation or pancreatic atrophy was observed during follow-up.

Conclusions

The incidence of POPF was high but still controllable without serious complications after minimally invasive enucleation. The MPD is no longer a restricted area, and the robotic system has advantages in handling complex enucleations.

Cyst fluid glycoproteins accurately distinguishing malignancies of pancreatic cystic neoplasm

Pancreatic cystic neoplasms (PCNs) are recognized as precursor lesions of pancreatic cancer, with a marked increase in prevalence. Early detection of malignant PCNs is crucial for improving prognosis; however, current diagnostic methods are insufficient for accurately identifying malignant PCNs. Here, we utilized mass spectrometry (MS)-based glycosite- and glycoform-specific glycoproteomics, combined with proteomics, to explore potential cyst fluid diagnostic biomarkers for PCN. The glycoproteomic and proteomic landscape of pancreatic cyst fluid samples from PCN patients was comprehensively investigated, and its characteristics during the malignant transformation of PCN were analyzed. Under the criteria of screening specific cyst fluid biomarkers for the diagnosis of PCN, a group of cyst fluid glycoprotein biomarkers was identified. Through parallel reaction monitoring (PRM)-based targeted glycoproteomic analysis, we validated these chosen glycoprotein biomarkers in a second cohort, ultimately confirming N-glycosylated PHKB (Asn-935, H5N2F0S0; Asn-935, H4N4F0S0; Asn-935, H5N4F0S0), CEACAM5 (Asn-197, H5N4F0S0) and ATP6V0A4 (Asn-367, H6N4F0S0) as promising diagnostic biomarkers for distinguishing malignant PCNs. These glycoprotein biomarkers exhibited robust performance, with an area under the curve ranging from 0.771 to 0.948. In conclusion, we successfully established and conducted MS-based glycoproteomic analysis to identify novel cyst fluid glycoprotein biomarkers for PCN. These findings hold significant clinical implications, providing valuable insights for PCN decision-making, and potentially offering therapeutic targets for PCN treatment.

Rare clinical entity of diffuse mucinous cystic neoplasm of the pancreas: A case report and review of the literature

INTRODUCTION

Mucinous cystic neoplasm is a rare premalignant tumor of the pancreas typically affects middle aged women. Mostly it affects the body and the tail of the pancreas and in very rare cases it may affect the head.

CASE PRESENTATION

A 56-year-old female patient, previously diagnosed with type 2 diabetes mellitus, and with an unremarkable medical and surgical history except for a laparoscopic cholecystectomy and multiple admissions due to colonic diverticular disease, which ultimately required a left hemicolectomy. Recently, the patient has been experiencing a gradual onset of symptoms, including persistent right upper quadrant and epigastric pain. This pain has been progressively worsening, characterized by a constricting sensation, radiating to the back. Additionally, the patient has reported a feverish sensation, yellowish discoloration of the skin over the past two months, itching, nausea, and a notable loss of appetite. Within the last two months, there has also been a significant weight loss of 10 kg. A thorough evaluation led to a diagnosis of diffuse mucinous cystic neoplasm, which involves the entire pancreas.

DISCUSSION

Due to its categorization as a premalignant abnormality, swift surgical action is imperative following diagnosis to minimize the possibility of evolving into a malignant state. This strategy is vital to secure the best possible results for the patient and to lower the likelihood of progression to more advanced malignant stages.

CONCLUSION

To our knowledge, this is one of the few reported cases of diffuse histology-proven MCN of the pancreas.

Clinical outcomes of minimally invasive duodenum-preserving pancreatic head resection

BACKGROUND

The procedure of total duodenum-preserving pancreatic head resection (DPPHRt) has been reported frequently, but rare in minimally invasive procedure, especially robotic-assisted operation. Here we share our experience and analyze the clinical outcomes of minimally invasive DPPHRt in the treatment of benign lesions or low-grade malignant tumors of the pancreatic head in this study.

MATERIALS AND METHODS

From October 2016 to January 2022, three patients received robot-assisted DPPHRt(RA-DPPHRt), and seventeen patients received laparoscopic DPPHRt(LDPPHRt). Data were retrospectively collected in terms of demographic characteristics (age, gender, body mass index, and pathological diagnosis), intraoperative variables (operative time, estimated blood loss), and post-operative variables (post-operative hospital stay, and complications).

RESULTS

All 20 patients received minimally invasive total duodenum-preserving pancreatic head resection successfully without conversion, including 8 males and 12 females. Pathological diagnosis suggested 1 case of serous cystadenoma (SCA), 4 cases of intraductal papillary mucinous neoplasm (IPMN) ,5 cases of mucinous cystic neoplasm (MCN), 4 cases of pancreatic neuroendocrine neoplasm (PNET), 2 cases of chronic pancreatitis (CP),4 case of solid pseudopapillary tumor (SPT). The average operation time was (285.35 ± 95.13 min), ranging from 95 to 420 min. The average estimate blood loss was (196.50 ± 174.45ml) ,ranging from 10 to 600ml.The average post-operative hospital stay was(20.90 ± 14.44days),ranging from 8 to 54 days. Postoperative complications occurred in 10 patients (50%). A total of 5 patients (20%) suffered grade B or C pancreatic fistula. Two patients (10%) suffered from biliary fistula. Two patients (10%) suffered from delayed gastric emptying. One patient (5%) suffered from abdominal bleeding. The 90-day mortality was 0. No patient was observed tumor recurrence and new-onset diabetes but one developed diarrhea.

CONCLUSION

RA-DPPHRt or LDPPHRt provided a minimally invasive approach with good organ-preservation for patients with benign and low-grade malignant pancreatic head tumor. It is only recommended to be performed in high-volume pancreatic centers by experienced pancreatic surgeons.

Real-Time Ultrasound-Computed Tomography Fusion with Volume Navigation to Assess Pancreatic Cystic Lesions

Transabdominal ultrasound is a promising imaging modality for pancreatic cystic lesions. This study aims to determine if transabdominal ultrasonography with CT fusion (TAUS-f) using volume navigation can be used to measure pancreatic cystic lesions (PCLs) compared to CT alone. We evaluated 33 patients prospectively with known PCLs. The readers evaluated each PCL's size and imaging characteristics on TAUS-f and CT alone. These were compared to endoscopic ultrasonography reports. A total of 43 PCLs from 32 patients were evaluated. The detection rate by TAUS-f was 93%. Two of the three undetected PCLs were in the tail of the pancreas. Inter-reader variabilities for TAUS-f and CT were 0.005 cm and 0.03 cm, respectively. Subgroup analysis by size and location demonstrated that inter-modality variability between TAUS-f and CT was smallest for lesions < 1.5 cm with a size difference of -0.13 cm for each reader and smallest in the pancreatic head with a size difference of -0.16 cm and -0.17 cm for readers 1 and 2. We found that TAUS-f effectively evaluates PCLs compared to CT alone, thus suggesting that it should be considered part of the surveillance algorithm for a subset of patients.

Misdiagnosis of pancreatic tuberculosis as a pancreatic cystic neoplasm - A case report

Pancreatic tuberculosis is an extremely rare condition. Its non-specific clinical and radiological findings resemble pancreatic malignancy. Here, we report a case of pancreatic tuberculosis that presented with abdominal pain and dyspeptic symptoms for 2 months and was misdiagnosed as a pancreatic cystic neoplasm. Abdominal magnetic resonance imaging showed a well-demarcated exophytic lesion with multiple T2 high signals small cystic areas in the anterior superior part of the head of the pancreas measuring 23 × 20 × 28 mm. This patient has undergone laparotomy and excision of the pancreatic mass. Histological examination revealed granulomatous inflammation of a lymph node with caseation, which was pathognomonic of tuberculosis. She was treated for tuberculosis for 6 months and has become symptom free. The diagnosis of pancreatic tuberculosis could be misleading and should be considered when dealing with pancreatic masses in countries with high incidence.

A Review of Current Practices and Future Trends in Body Fluid Testing

BACKGROUND

Body fluid testing in the clinical chemistry laboratory is a cornerstone in the diagnostic workup of pathological effusions. Laboratorians may not be aware of the preanalytical workflows used in the collection of body fluids though the value is evident whenever processes change or issues arise. The analytical validation requirements can vary depending on the regulations dictated by the laboratories' jurisdiction and accreditor requirements. Much of analytical validation hinges on how useful testing is to clinical care. Usefulness of testing varies with how well established and incorporated the tests and interpretation are in practice guidelines.

CONTENT

Body fluid collections are depicted and described so clinical laboratorians have a basic appreciation of what specimens are submitted to the laboratory for testing. A review of validation requirements by major laboratory accreditation entities is presented. A review of the usefulness and proposed decision limits for common body fluid chemistry analytes is presented. Body fluid tests that show promise and those that are losing (or lost long ago) value are also reviewed.

SUMMARY

The total testing process from collection to result interpretation can be complicated and easily overlooked by the clinical laboratory. This review aims to improve the understanding and awareness of collections, validation, result interpretation, and provide an update on recent trends.

Low-Pass Genomic Sequencing Reveals Novel Subtypes of Pancreatic Cystic Neoplasms

BACKGROUND

Over the years, the detection rate of pancreatic cystic neoplasms (PCNs) has significantly increased; however, the differential diagnosis and identification of high-risk PCNs remain challenging. We sought to investigate whether chromosomal instability (CIN) features in cell-free DNA in the cystic fluid of PCNs could help to identify high-risk PCNs.

METHODS

Pancreatic cystic fluid samples from 102 patients with PCNs were intraoperatively collected for detection of CIN using an ultrasensitive chromosomal aneuploidy detector. Clinical and imaging data were retrospectively collected, and statistical analysis was performed to assess the potential role of CIN in clinical practice.

RESULTS

CIN was investigated in a total of 100 patients. Sixteen of 26 serous cystic cystadenomas (SCAs) harbored deletions of chr3p and/or chr6p, whereas low rates of CIN were detected in mucinous cystic neoplasms. Most malignant PCNs presented with more than one type of CIN; amplification of chr1q and chr8q found in nine and seven of 11 malignant PCNs (81.8% and 63.6%), respectively, could aid in distinguishing high-risk IPMNs from low-risk ones, with a higher sensitivity than imaging. A combination of the mural nodule imaging feature and amplification of chr1q and chr8q achieved a sensitivity of 70.0% and a specificity of 82.4% in identifying high-risk IPMNs.

CONCLUSIONS

Our work revealed the distinct CIN signature of different types of PCNs. Deletions of chr3p and chr6p defined a subtype of SCAs. Gains of chr1q and chr8q were associated with insidious malignant PCNs and helped identify high-risk IPMNs.

Clinical characteristics and survival prediction of surgical patients with invasive pancreatic cystic neoplasm: a large retrospective study over two decades

PURPOSES

Invasive pancreatic cystic neoplasms (iPCNs) are an uncommon and biologically heterogeneous group of malignant neoplasms. We aimed to investigate the clinicopathological characteristics of iPCN patients and to develop nomograms for individual survival prediction after radical surgery.

METHODS

Data of patients diagnosed with iPCN and pancreatic ductal adenocarcinoma (PDAC) between 2000 and 2018 from the SEER database were retrieved. The differences in clinical outcomes were evaluated using the Kaplan-Meier analysis. Nomograms were proposed based on the Cox regression model and internally validated by C-index, area under the curve (AUC) value, and calibration plot.

RESULTS

A total of 7777 iPCN patients and 154,336 PDAC patients were enrolled. Most neoplasms were advanced, with 63.1% at stage IV. The 3-year overall survival (OS) and cancer-specific survival (CSS) rates in surgical patients were as follows: 45.7% and 50.1% for invasive intraductal papillary mucinous neoplasm (IPMN), 54.8% and 59.3% for invasive mucinous cystic neoplasm (MCN), 97.8% and 98.2% for invasive solid pseudopapillary neoplasm (SPN), 88.9% and 88.9% for invasive serous cystic neoplasm (SCN), and 27.3% and 30.5% for PDAC. Subgroup analyses showed no clinical benefit from chemotherapy or radiotherapy in lymph node-negative iPCN patients who underwent surgery. The following variables associated with OS and CSS were identified: age, race, chemotherapy, radiotherapy, histologic type, pathological grade, regional nodes examined, and T, N, and M stage. The nomograms had good discrimination and calibration by internal validation, with an AUC value of 0.800 for 3-year OS and 0.814 for 3-year CSS.

CONCLUSION

Our study showed that the prognosis of iPCN patients was significantly better than PDAC patients. The proposed nomograms demonstrated substantially better discrimination and calibration.

Intraductal papillary neoplasm of the bile duct: review of updated clinicopathological and imaging characteristics

BACKGROUND

Intraductal papillary neoplasm of the bile duct (IPNB) is a relatively rare disease and is known as one of the premalignant lesions in the biliary tract. The concept of IPNB has changed through numerous studies and is still evolving. As a lesser studied clinical entity compared with its pancreatic counterpart, intraductal papillary mucinous neoplasm, IPNB has been described in many similar terms, including biliary papillomatosis, biliary intraductal papillary-mucinous neoplasm, and papillary cholangiocarcinoma. This is based on the diversity of histopathological spectrum of IPNB.

METHODS

This review investigated previous studies including original articles, case studies, and expert opinions. Recently, two types of IPNB (types 1 and 2) have been proposed and validated based on the content first established in the WHO 2010 criteria.

RESULTS

This review provides a comprehensive analysis of existing literature, summarizing the clinical, radiological, morphological, and pathological characteristics of IPNB.

CONCLUSION

Given the ongoing ambiguity and controversies surrounding IPNB, future research, including large population-based studies and molecular investigations, is essential to enhance understanding of this disease.

Prediction of malignant intraductal papillary mucinous neoplasm: A nomogram based on clinical information and radiological outcomes

OBJECTIVE

Clinical practitioners face a significant challenge in maintaining a healthy balance between overtreatment and missed diagnosis in the management of intraductal papillary mucinous neoplasm (IPMN). The current study aimed to identify significant risk factors of malignant IPMN from a series of clinical and radiological parameters that are widely available and noninvasive and develop a method to individually predict the risk of malignant IPMN to improve its management.

METHODS

We retrospectively investigated 168 patients who were pathologically diagnosed with IPMN after individualized pancreatic resection between June, 2012 and December, 2020. Independent predictors determined using both univariate and multivariate analyses to construct a predictive model. The discriminatory power of the nomogram was assessed using the area under the receiver operating characteristic curve (AUC). Decision curve analysis was performed to demonstrate the clinical usefulness of the nomogram. Internal cross validation was performed to assess the validity of the predictive model.

RESULTS

In the multivariate analysis, five significant independent risk factors were identified: increased serum CA19-9 level, low prognostic nutritional index (PNI), cyst size, enhancing mural nodule, and main pancreatic duct diameter. The nomogram based on the parameters mentioned above had outstanding performance in distinguishing malignancy, with an AUC of 0.907 (95% confidence interval: 0.859-0.956, p < 0.05), which remained 0.875 after internal cross-validation, and showed good clinical usefulness.

CONCLUSION

A novel nomogram for predicting malignant IPMN first introducing PNI was developed, which may aid in improving IPMN management. Nevertheless, external validation is required to confirm its efficacy.

Pancreatic Cyst Fluid Analysis

Pancreatic cyst fluid analysis can help diagnose pancreatic cyst type and the risk of high-grade dysplasia and cancer. Recent evidence from molecular analysis of cyst fluid has revolutionized the field with multiple markers showing promise in accurate diagnosis and prognostication of pancreatic cysts. The availability of multi-analyte panels has great potential for more accurate prediction of cancer.

Are All Cysts Created Equal?: Pancreatic Cystic Neoplasms in Patients with Familial or Genetic Risk Factors for Pancreatic Cancer

Pancreatic cystic lesions (PCLs) have become more prevalent over time, particularly in asymptomatic individuals. Current screening guidelines for incidental PCLs offer a unified approach to surveillance and management, predicated on "worrisome features." Although PCLs are common in the general population, their prevalence may be higher in high-risk individuals (HRI, unaffected patients with specific familial and/or genetic risk factors). As more PCLs are diagnosed and more HRI identified, it is important to promote research that bridges data gaps and introduces nuance to risk assessment tools, ensuring tailoring of guidelines to the needs of HRI with varying pancreatic cancer risk factors.

Burden of New Pancreatic Cyst Diagnosis

Pancreatic cysts are an increasingly identified entity with significant health care implications. Although some cysts present with concurrent symptoms that often require operative intervention, the advent of improved cross-sectional imaging has heralded an era of increased incidentally detected pancreatic cysts. Although the rate of malignant progression in pancreatic cysts remains low, the poor prognosis of pancreatic malignancy has driven recommendations for ongoing surveillance. A uniform consensus has not been reached on the management and surveillance of pancreatic cysts leading clinicians to grapple with the burden of how best to approach pancreatic cysts from a health, psychosocial, and cost perspective.

Clinical Outcomes of Intraductal Papillary Mucinous Neoplasms With Dilatation of the Main Pancreatic Duct

BACKGROUND & AIMS

Dilatation of the main pancreatic duct (MPD) has been a surgical indication for intraductal papillary mucinous neoplasms (IPMNs). Few studies have investigated long-term outcomes of IPMNs with MPD dilatation.

METHODS

Among 3610 patients diagnosed with pancreatic cysts between 1994 and 2021, we identified 2829 IPMN patients, including 282 patients with MPD ≥5 mm, and examined short-term (≤6 months) and long-term risks of pancreatic carcinoma. Utilizing competing risks proportional hazards models, we estimated subdistribution hazard ratios for incidence of pancreatic carcinoma with adjustment for potential confounders.

RESULTS

In analyses of short-term outcomes of the 282 patients with MPD dilatation, 72 (26%) patients were diagnosed with pancreatic carcinoma based on surgical or nonsurgical exploration. During long-term follow-up of 168 patients, we documented 24 (14%) patients diagnosed with pancreatic carcinoma (18 with IPMN-derived carcinoma and 6 with concomitant ductal adenocarcinoma). The patients with the MPD = 5-9.9 mm had cumulative incidence rates of pancreatic carcinoma diagnosis of 8.1% (95% confidence interval [CI], 4.3%-13.5%) and 10.0% (95% CI, 5.5%-15.9%) at 2 and 5 years, respectively; and the patients with the MPD ≥10 mm had the corresponding rates of 16.0% (95% CI, 3.6-36.5%) and 33.3% (95% CI, 10.3%-58.8%). The multivariable subdistribution hazard ratios were 2.78 (95% CI, 1.57-4.90) and 7.00 (95% CI, 2.58-19.0) for the MPD = 5-9.9 mm and ≥10 mm (vs <5 mm), respectively.

CONCLUSIONS

IPMNs with MPD dilatation at baseline were associated with higher prevalence and incidence of pancreatic carcinoma compared with IPMNs with no MPD dilatation.

Real-Life Management of Pancreatic Cysts: Simplified Review of Current Guidelines

Pancreatic cysts are becoming a popular diagnostic tool due to the increased availability of high-quality cross-sectional imaging. Pancreatic cystic lesions constitute closed, liquid-containing cavities, which are either neoplastic or non-neoplastic. While serous lesions often follow a benign course, mucinous lesions can hide carcinoma and, therefore, require different management. Moreover, all cysts should be considered mucinous until proven otherwise, thus limiting the errors in managing these entities. Due to the need for high contrast soft tissue imaging, magnetic resonance imaging represents an elective, non-invasive diagnostic tool. Endoscopic ultrasound (EUS) has started gaining more prominence with regard to the proper diagnosis and management of pancreatic cysts, offering quality information with minimal risks. Enabling both the acquisition of endoscopic images of the papilla and the endosonographic high-quality evaluation of septae, mural nodules along with the vascular patterns of the lesion contribute to a definitive diagnosis. Moreover, the possibility of obtaining cytological or histological samples could become mandatory in the foreseeable future, allowing for more precise molecular testing. Future research should focus on detecting methods to quickly diagnose high-grade dysplasia or early cancer for patients with pancreatic cysts, thus allowing time for appropriate treatment and avoiding surgical overtreatment or over surveillance in selected cases.

Pre-emptive resection for intraductal papillary mucinous neoplasia - Long-term outcome is similar between non-invasive and early invasive lesions in a tertiary single center

BACKGROUND

Pre-emptive resection for intraductal papillary mucinous neoplasm (IPMN) aims to reduce the risk before invasive transformation has taken place. Pancreatic resections are highly associated with major morbidity and mortality. Long-term overall survival (OS) after resection for invasive IPMN (inv-IPMN) in early stages is favorable. Comparison of long-term OS for resected non-invasive IPMN and early staged inv-IPMN is poorly delineated. This study aims to compare outcomes for resected non-invasive IPMN and T1-staged inv-IPMN.

METHODS

All patients ≥18 years of age resected for IPMN up to stage T1 at Karolinska University Hospital between 2008 and 2020 were included. Two-year OS were compared between groups by chi-squared test, and 5-year OS was estimated using Kaplan-Meier method. Covariates associated with death was assessed in multivariable Cox regression model.

RESULTS

We included 284 patients, 264 (93%) non-invasive IPMN and 20 (7%) T1-staged inv-IPMN. Dysplasia of low grade (LGD) and high grade, i.e., tumor in situ (Tis) were present in 190 (67%) and 75 (26%) patients respectively. The 2-year OS for the entire cohort was 96%, and there were no differences between non-invasive and inv-IPMN (96% vs 92%, p = 0.203), nor between IPMN with LGD and Tis-T1b-staged IPMN (96% vs 95%, p = 0.734).

CONCLUSION

Two thirds of the specimen from pre-emptive resections were of LGD and did not involve superior OS than in situ or early cancer. Due to high complication burden, efforts should be made to avoid resection when LGD is probable and rather identify more accurate predictors for surgery.

Intraoperative Pancreatoscopy During Robotic Pancreatoduodenectomy and Robotic Distal Pancreatectomy for Intraductal Papillary Mucinous Neoplasm with Involvement of the Main Pancreatic Duct

Background

Intraductal papillary mucinous neoplasm (IPMN) with involvement of the main pancreatic duct usually requires surgical resection. Consensus is lacking whether to partially or completely resect the pancreatic portion with a dilated main pancreatic duct. Intraoperative pancreatoscopy may be useful to determine the extent of IPMN to tailor surgical resection and was recently studied in a large prospective international study. IPMN is increasingly utilized using a robotic approach. Studies describing the technical approach to intraoperative pancreatoscopy in robotic pancreatoduodenectomy and robotic distal pancreatectomy are lacking.

Methods

During robotic pancreatoduodenectomy, pancreatoscopy is performed once the pancreas neck is transected. The scope is advanced via a laparoscopic port into the left and right-sided pancreatic duct, guided by robotic graspers. During robotic distal pancreatectomy, pancreatoscopy is performed before complete parenchymal transection. The scope is advanced through an anterior ductotomy to examine the duct and guide the pancreatic transection line. Tips and tricks how to perform the procedure efficiently without complications are detailed.

Results

In total, 28 robot-assisted pancreatoscopies were performed during robotic pancreatoduodenectomy and robotic distal pancreatectomy. No intraoperative complications resulting from the intraoperative pancreatoscopy were noted. In the 2 described procedures, the added time required to perform the pancreatoscopy was 6 and 17 minutes, respectively. Both patients recovered without complication and were discharged on postoperative day 5 for the robotic pancreatoduodenectomy and day 6 for the robotic distal pancreatectomy.

Conclusions

Intraoperative pancreatoscopy can be safely performed during both robotic pancreatoduodenectomy and robotic distal pancreatectomy for IPMN with the involvement of the main pancreatic duct. An international prospective study has recently been completed with this technique.

Malignancy risk factors and prognostic variables of pancreatic mucinous cystic neoplasms in Chinese patients

BACKGROUND

Pancreatic mucinous cystic neoplasms (MCNs) represent one of the precursor lesions of pancreatic ductal adenocarcinoma, and their detection has been facilitated by advances in preoperative imaging. Due primarily to the rarity of MCNs, however, there is limited knowledge regarding the prognostic variables and high-risk factors for malignant transformation. A more comprehensive and nuanced approach is necessary to fill this gap and provide a basis for improved treatment decisions and patient outcomes.

AIM

To investigate the high-risk factors associated with malignant MCNs and to explore the prognostic factors of MCN with associated invasive carcinoma (MCN-AIC).

METHODS

All cases of resected MCNs from a single high-volume institution between January 2012 and January 2022 were retrospectively reviewed. Only cases with ovarian-type stroma verified by progesterone receptor staining were included. Preoperative features, histological findings and postoperative course were documented. Multivariate logistic regression was employed to investigate variables related to malignancy. Survival analysis was performed using the Kaplan-Meier curve, and the prognostic factors were assessed to evaluate the postoperative course of patients with MCN-AIC.

RESULTS

Among the 48 patients, 36 had benign MCNs, and 12 had malignant MCNs (1 high-grade atypical hyperplasia and 11 MCN-AIC). Age, tumour size, presence of solid components or mural nodules and pancreatic duct dilatation were identified as independent risk factors associated with malignancy. The follow-up period ranged from 12 mo to 120 mo, with a median overall survival of 58.2 mo. Only three patients with MCN-AIC died, and the 5-year survival rate was 70.1%. All 11 cases of MCN-AIC were stage I, and extracapsular invasion was identified as a prognostic factor for poorer outcomes.

CONCLUSION

The risk factors independently associated with malignant transformation of MCNs included age, tumour size, presence of solid components or mural nodules, and pancreatic duct dilatation. Our study also revealed that encapsulated invasion was a favourable prognostic factor in MCN-AIC patients.

CYSTIC PANCREATIC LESIONS: IMAGING VERSUS ANATOMOPATHOLOGICAL FINDINGS-HOW TO IMPROVE DIAGNOSTIC ACCURACY?

BACKGROUND

Pancreatic cystic lesions are a group of pancreatic neoplasms with different behavior and risk of malignancy. Imaging diagnosis and differentiation of these lesions remain a challenge.

AIMS

The aim of this study was to evaluate the agreement between computed tomography and/or magnetic resonance imaging and post-operative pathologic diagnoses of Pancreatic cystic lesions in a University Hospital of São Paulo State.

METHODS

A total of 39 patients with surgically diagnosed Pancreatic cystic lesions were enrolled, as a study cohort from 2009 to 2019. Preoperative radiological and final pathological diagnosis was correlated to measure computed tomography and/or magnetic resonance imaging diagnostic. Pancreatic adenocarcinoma, choledochal pancreatic cyst, mucinous cystadenoma, serous cystadenoma, intraductal papillary mucinous neoplasms, and pancreatic pseudocyst were classified as neoplastic cysts.

RESULTS

It was noted that 27 patients (69.23%) had preoperative computed tomography and magnetic resonance imaging, 11 patients (28.20%) had preoperative computed tomography only, and 1 patient had preoperative magnetic resonance imaging only. The values for diagnoses made only with computed tomography (p=0.47) and from the combination of computed tomography+magnetic resonance imaging (p=0.50) did also point to moderate agreement with the anatomopathological findings. The values pointed to a fair agreement for the diagnosis of mucinous cystadenoma (p=0.3), moderate agreement for intraductal papillary mucinous neoplasms (p= 0.41), good agreement for serous cystadenoma (p=0.79), and excellent agreement for choledochal pancreatic cyst (p=1), pancreatic pseudocyst (p=0.84), and Frantz tumor (p=1) (p<0.05).

CONCLUSIONS

The findings of computed tomography and/or magnetic resonance imaging have an equivalent diagnostic agreement with an anatomopathological diagnosis for differentiating benign from malignant Pancreatic cystic lesions and in suggesting a specific diagnosis. There is no statistical difference between the use of computed tomography alone and computed tomography+magnetic resonance imaging in the improvement of diagnostic accuracy.

Endoscopic Ultrasound (EUS) Guided Elastography

Endoscopic ultrasound (EUS) is an essential technique for the management of several diseases. Over the years, new technologies have been developed to improve and overcome certain limitations related to EUS-guided tissue acquisition. Among these new methods, EUS-guided elastography, which is a real-time method for the evaluation of tissue stiffness, has arisen as one of the most widely recognized and available. At present, there are available two different systems to perform an elastographic evaluation: strain elastography and shear wave elastography. Strain elastography is based on the knowledge that certain diseases lead to a change in tissue hardness while shear wave elastography monitored shear-wave propagation and measures its velocity. EUS-guided elastography has shown in several studies high accuracy in differentiating benign from malignant lesions from many different locations, mostly in the pancreas and lymph nodes. Therefore, nowadays, there are well-established indications for this technology, mainly for supporting the management of pancreatic diseases (diagnosis of chronic pancreatitis and differential diagnosis of solid pancreatic tumors) and characterization of different diseases. However, there are more data on new potential indications for the near future. In this review, we will present the theoretical bases of this technology and we will discuss the scientific evidence to support its use.

Performance and Safety of EUS Ablation Techniques for Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis

BACKGROUND

Pancreatic cystic lesions (PCL) represent an increasingly diagnosed condition with significant burden to patients' lives and medical resources. Endoscopic ultrasound (EUS) ablation techniques have been utilized to treat focal pancreatic lesions. This systematic review with meta-analysis aims to assess the efficacy of EUS ablation on PCL in terms of complete or partial response and safety.

METHODS

A systematic search in Medline, Cochrane and Scopus databases was performed in April 2023 for studies assessing the performance of the various EUS ablation techniques. The primary outcome was complete cyst resolution, defined as cyst disappearance in follow-up imaging. Secondary outcomes included partial resolution (reduction in PCL size), and adverse events rate. A subgroup analysis was planned to evaluate the impact of the available ablation techniques (ethanol, ethanol/paclitaxel, radiofrequency ablation (RFA), and lauromacrogol) on the results. Meta-analyses using a random effects model were conducted and the results were reported as percentages with 95% confidence intervals (95%CI).

RESULTS

Fifteen studies (840 patients) were eligible for analysis. Complete cyst resolution after EUS ablation was achieved in 44% of cases (95%CI: 31-57; 352/767; I² = 93.7%), and the respective partial response rate was 30% (95%CI: 20-39; 206/767; I² = 86.1%). Adverse events were recorded in 14% (95%CI: 8-20; 164/840; I² = 87.2%) of cases, rated as mild in 10% (95%CI: 5-15; 128/840; I² = 86.7%), and severe in 4% (95%CI: 3-5; 36/840; I² = 0%). The subgroup analysis for the primary outcome revealed rates of 70% (95%CI: 64-76; I² = 42.3%) for ethanol/paclitaxel, 44% (95%CI: 33-54; I²= 0%) for lauromacrogol, 32% (95%CI: 27-36; I² = 88.4%) for ethanol, and 13% (95%CI: 4-22; I² = 95.8%) for RFA. Considering adverse events, the ethanol-based subgroup rated the highest percentage (16%; 95%CI: 13-20; I² = 91.0%).

CONCLUSION

EUS ablation of pancreatic cysts provides acceptable rates of complete resolution and a low incidence of severe adverse events, with chemoablative agents yielding higher performance rates.

Short-term clinical outcomes of laparoscopic duodenum-preserving pancreatic head resection for the management of pancreatic-head cystic neoplasms

BACKGROUND

In this study, we aimed to investigate the short-term clinical outcomes of laparoscopic duodenum-preserving pancreatic-head resection (LDPPHR) for the management of pancreatic-head cystic neoplasms.

METHODS

This retrospective study included 60 patients who were treated with pancreatic-head cystic neoplasms at the Shandong Provincial Hospital Affiliated to Shandong First Medical University from December 2019 to July 2022.

RESULTS

No significant difference was found between the two groups in terms of the baseline and pathological characteristics of patients (P > 0.05). The postoperative exhaust time was shorter in the LDPPHR group compared with the laparoscopic pancreaticoduodenectomy (LPD) group (2 (2 and 4) vs. 4 (3 and 5) days; P = 0.003). No significant difference was found between the two groups in terms of operative time, estimated blood loss, intraoperative transfusion, hemoglobin levels on the first postoperative day, total bilirubin before discharge, direct bilirubin before discharge, postoperative hospital stay, postoperative pancreatic fistula, bile leakage, hemorrhage, peritoneal effusion, abdominal infection, delayed gastric emptying, interventional embolization hemostasis, reoperation, and 30-day readmission (P > 0.05). No conversion and 90-day mortality were found in the two groups. The LDPPHR group showed a higher 3-month postoperative PNI, 6-month postoperative TG and 6-month postoperative BMI than the LPD group (P < 0.05).

CONCLUSIONS

Compared with LPD, LDPPHR can decrease the postoperative exhaust time of patients, improve the short-term postoperative nutritional status, and does not decrease the safety of the perioperative period.

Approach to Cystic Lesions of the Pancreas: Review of Literature

Pancreatic cystic lesions (PCL) have a wide range of demographical, clinical, morphological and histological characteristics. The distinction between these lesions is of paramount importance due to the risk of malignancy in specific categories of PCL. Considering the malignant potential for pancreatic cystic neoplasm (PCN) lesions, guidelines have been made to balance unnecessary treatment and manage the progression to malignancy. Various surgical procedures can be done for PCN depending on the location and size of the cyst; pancreatoduodenectomy is done for PCN located in the head of the uncinate process, whereas distal pancreatectomy is done for PCN in the body or tail. In the neck and proximal body of the pancreas, less extensive resections such as central pancreatectomy can be performed. Active surveillance of PCN is typically offered to asymptomatic PCNs of subtype intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN) without any concerning features. In recent years, numerous guidelines have been created to augment PCN diagnosis, classification and management. Despite this, the management of PCNs remains complex. Thus, discussions with multidisciplinary teams involving surgeons, gastroenterologists, pathologists, and radiologists are required to ensure optimum care for the patient.

Prevalence and progression of intraductal papillary mucinous neoplasms of the pancreas in solid organ transplant recipients: A systematic review

Solid organ transplantation (SOT) recipients are known to carry an increased risk of malignancy because of long-term immunosuppression. However, the progression of intraductal papillary mucinous neoplasm of the pancreas (IPMN) in this population remains unclear. We performed a systematic review by searching PubMed, Embase, Scopus, and Google Scholar. All studies containing IPMNs in solid organ transplantation recipients were screened. We included 11 studies in our final analysis, totaling 274 patients with IPMNs of the 8213 SOT recipients. The prevalence from 8 studies was 4.7% (95% CI 2.4%-7.7%) in a random-effects model with median study periods of 24 to 220 months. The median rate for all progressions from 10 studies was 20% (range, 0%-88%) within 13 to 41 months of the median follow-up time. By utilizing the results of 3 case-control studies, the relative risk from a random-effects model for progression (worrisome features and high-risk stigmata) of IPMNs was 0.39 (95% CI 0.12-1.31). No adenocarcinoma derived from IPMN was reported in the included studies. Overall, this study indicates that the progression of pretransplant IPMN does not increase drastically compared with the general nontransplant population. However, considering the limited literature, further studies are required for confirmation.

"Evolving Trends in Pancreatic Cystic Tumors: A 3-Decade Single-Center Experience With 1290 Resections"

OBJECTIVE

The aim of this study was to describe our institutional experience with resected cystic tumors of the pancreas with emphasis on changes in clinical presentation and accuracy of preoperative diagnosis.

SUMMARY BACKGROUND DATA

Incidental discovery of pancreatic cystic lesions has increased and has led to a rise in pancreatic resections. It is important to analyze surgical outcomes from these procedures, and the prevalence of malignancy, pre-malignancy and resections for purely benign lesions, some of which may be unintended.

METHODS

Retrospective review of a prospective database spanning 3 decades. Presence of symptoms, incidental discovery, diagnostic studies, type of surgery, postoperative outcomes, and concordance between presumptive diagnosis and final histopathology were recorded.

RESULTS

A total of 1290 patients were identified, 62% female with mean age of 60 years. Fifty-seven percent of tumors were incidentally discovered. Ninety-day operative mortality was 0.9% and major morbidity 14.4%. There were 23 different diagnosis, but IPMN, MCN, and serous cystadenoma comprised 80% of cases. Concordance between preoperative and final histopathological diagnosis increased by decade from 45%, to 68%, and is presently 80%, rising in parallel with the use of endoscopic ultrasound, cytology, and molecular analysis. The addition of molecular analysis improved accuracy to 91%. Of misdiagnosed cases, half were purely benign and taken to surgery with the presumption of malignancy or premalignancy. The majority of these were serous cystadenomas.

CONCLUSIONS

Indications and diagnostic work-up of cystic tumors of the pancreas have changed over time. Surgical resection can be performed with very low mortality and acceptable morbidity and diagnostic accuracy is presently 80%. About 10% of patients are still undergoing surgery for purely benign lesions that were presumed to be malignant or premalignant. Further refinements in diagnostic tests are required to improve accuracy.

Comparison of Invasive Pancreatic Ductal Adenocarcinoma versus Intraductal Papillary Mucinous Neoplasm: A National Cancer Database Analysis

BACKGROUND

Current evidence on overall survival (OS) between invasive pancreatic ductal adenocarcinoma (PDAC) and intraductal papillary mucinous neoplasm (IPMN) is limited to single-center reports. We aimed to compare the characteristics, management, and OS of invasive PDAC vs. IPMN using a national United States (US) database.

METHODS

Invasive PDAC or IPMN adult (≥18 years) patients were identified in the National Cancer Database (2004-2016). OS was assessed with the Kaplan-Meier method and the stratified log-rank test.

RESULTS

We included 101,190 patients (100,834 PDAC, 356 IPMN). A higher proportion of PDAC vs. IPMN patients had clinical N1 (36.8% vs. 15.7%, p < 0.001) and M1 disease (41.2% vs. 5.9%, p < 0.001). A lower proportion of PDAC patients underwent surgery (25.5% vs. 80.3%, p < 0.001), but a higher proportion received chemotherapy (65.4% vs. 46.1%, p < 0.001) or radiation (25.3% vs. 20.5%, p = 0.04). A higher proportion of surgical patients with PDAC vs. IPMN underwent margin-positive resection (23.0% vs. 14.0%, p = 0.001). The median OS for PDAC vs. IPMN was 8.3 vs. 33.4 months. In the stratified analysis for N0M0 disease, the median OS for PDAC vs. IPMN was 12.8 vs. 43.3 months, for N1M0, it was 11.5 vs. 17.0 months, while for M1, it was 4.0 vs. 7.0 months. In both diagnoses, surgery yielded improved OS, while stratified analysis in the surgical cohort demonstrated similar findings.

CONCLUSIONS

Invasive PDAC is more aggressive than invasive IPMN, yet in the case of metastasis, OS is equally poor. Excellent long-term OS is achievable with surgical resection in highly selected cases, and efforts should focus on facilitating surgical treatment.

Pancreatic serous cystic neoplasm mimicking intraductal papillary mucinous neoplasm: Two case reports and literature review

RATIONALE

Serous cystic neoplasms (SCNs) are treated as benign lesions. It is widely known that SCN rarely have a connection with the main pancreatic duct (MPD), which helps differentiate them from other cystic lesions, such as intraductal papillary mucinous neoplasm (IPMN). However, very rare cases where the SCN appears connected to the MPD cause diagnostic confusion.

PATIENT CONCERNS

We present 2 patients with SCN (1 male, 54, and 1 female, 42). Both patients were asymptomatic, without abnormal laboratory results.

DIAGNOSIS

In both cases, abdominopelvic computed tomography and pancreatic magnetic resonance imaging scans revealed a multilobulated cystic lesion in communication with the MPD. Since the size of each patient's lesion was >3 cm and there was connectivity with the MPD, it was strongly suspected to be a branch duct-type IPMN with worrisome features rather than SCN and surgical intervention was considered.

INTERVENTIONS

Both neoplasms were misdiagnosed as IPMN due to appearing connected with the MPD on radiologic imaging. Surgery was performed.

OUTCOMES

A final diagnosis of microcystic serous cystadenoma of the pancreas without connectivity of MPD was confirmed in both patients.

LESSONS

An unnecessary surgery was performed due to atypical radiologic features in which the pancreatic duct seems to be connected to the pancreatic cystic lesion on magnetic resonance imaging, leading to misdiagnosis of SCN as IPMN. Particular attention should be paid to interpretation of clinicoradiologic findings of pancreatic cystic lesions, especially to the decision of surgical intervention. Also, awareness of presence of the atypical radiologic features of SCN may broaden the knowledge base of radiologists.

LESSONS

An unnecessary surgery was performed due to atypical radiologic features in which the pancreatic duct seems to be connected to the pancreatic cystic lesion on magnetic resonance imaging, leading to misdiagnosis of SCN as IPMN. Particular attention should be paid to interpretation of clinicoradiologic findings of pancreatic cystic lesions, especially to the decision of surgical intervention. Also, awareness of presence of the atypical radiologic features of SCN may broaden the knowledge base of radiologists.

Sulforaphane suppresses skin squamous cell carcinoma cells proliferation through miR-199a-5p/Sirt1/CD44ICD signaling pathway

BACKGROUND

The present study aimed to explore the impact of sulforaphane on the growth of sSCC cells, and the activation of miR-199a-5p/Sirt1 and CD44ICD signaling pathways.

METHODS

Cell viability, count, apoptosis, and invasion assays were performed in the sSCC cell line (SCC-13) in which miR-199a-5p was over-expressed or under-expressed. The expression levels of miR-199a-5p, Sirt1 and CD44ICD mRNA were measured by quantitative real-time polymerase chain reaction (qRT-PCR).

RESULTS

Sulforaphane significantly inhibited the cell growth and invasion of SCC-13 cells, and dramatically induced cell apoptosis. Additionally, sulforaphane also greatly increased miR-199a-5p expression and suppressed Sirt1 and CD44ICD mRNA levels. Moreover, miR-199a-5p overexpression considerably down-regulated the expressions of Sirt1 and CD44ICD mRNA, and promoted the ability of sulforaphane to represses cell growth and invasion, and to induce cell apoptosis. However, miR-199a-5p underexpression has the opposite effects.

CONCLUSIONS

Sulforaphane appears to inhibit sCC progression by impacting its growth and invasion ability, and regulates miR-199a-5p/Sirt1 and CD44ICD signaling pathways, and may be utilized to develop a curative approach for sSCC.

Comparative Performance of Endoscopic Ultrasound-Based Techniques in Patients With Pancreatic Cystic Lesions: A Network Meta-Analysis

INTRODUCTION

Evidence on the comparative diagnostic performance of endoscopic ultrasound (EUS)-based techniques for pancreatic cystic lesions (PCLs) is limited. This network meta-analysis comprehensively compared EUS-based techniques for PCL diagnosis.

METHODS

A comprehensive literature search was performed for all comparative studies assessing the accuracy of 2 or more modalities for PCL diagnosis. The primary outcome was the diagnostic efficacy for mucinous PCLs. Secondary outcomes were the diagnostic efficacy for malignant PCLs, diagnostic success rate, and adverse event rate. A network meta-analysis was conducted using the ANOVA model to assess the diagnostic accuracy of each index.

RESULTS

Forty studies comprising 3,641 patients were identified. The network ranking of the superiority index for EUS-guided needle-based confocal laser endomicroscopy (EUS-nCLE) and EUS-guided through-the-needle biopsy (EUS-TTNB) were significantly higher than other techniques for differentiating mucinous PCLs; besides, EUS-TTNB was also the optimal technique in identifying malignant PCLs. The evidence was inadequate for EUS-nCLE diagnosing malignant PCLs and contrast-enhanced harmonic EUS diagnosing both mucinous and malignant PCLs. Glucose showed a high sensitivity but low specificity, and molecular analysis (KRAS, GNAS, and KRAS + GNAS mutations) showed a high specificity but low sensitivity for diagnosing mucinous PCLs. Satisfactory results were not obtained during the evaluation of the efficiency of pancreatic cyst fluid (PCF) biomarkers in detecting malignant PCLs.

DISCUSSION

For centers with relevant expertise and facilities, EUS-TTNB and EUS-nCLE were better choices for the diagnosis of PCLs. Further studies are urgently required for further improving PCF biomarkers and validating the diagnostic performance of the index techniques.

Validation of combined carcinoembryonic antigen and glucose testing in pancreatic cyst fluid to differentiate mucinous from non-mucinous cysts

BACKGROUND

More accurate diagnosis of mucinous cysts will reduce the risk of unnecessary pancreatic surgery. Carcinoembryonic antigen (CEA) and glucose in pancreatic cyst fluid (PCF) can differentiate mucinous from non-mucinous pancreatic cystic neoplasms (PCN). The current study assessed the value of combined CEA and glucose testing in PCF.

METHODS

Cross-sectional validation study including prospectively collected PCF from patients undergoing endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) and pancreatic surgery. We performed laboratory measurements for CEA and glucose and measured glucose levels by a hand glucometer. Primary outcome was diagnostic accuracy evaluated by receiver operator curves (ROC), sensitivity, specificity, positive, and negative predictive value (PPV, NPV).

RESULTS

Overall, PCF was collected from 63 patients, including 33 (52%) with mucinous and 30 (48%) with non-mucinous PCN. Histopathology (n = 36; 57%), cytopathology (n = 2; 3%), or clinical and/or radiological diagnosis (n = 25; 40%) was used as reference standard. Combined CEA (cut-off ≥ 192 ng/ml) and laboratory glucose testing (cut-off ≤ 50 mg/dL) reached 92% specificity and 48% sensitivity, whereas either positive CEA (cut-off ≥ 20 ng/ml) or glucose testing (cut-off ≤ 50 mg/dL) showed 97% sensitivity and 50% specificity. Sensitivity and specificity were 80% and 68% for CEA ≥ 20 ng/mL versus 50% and 93% for CEA ≥ 192 ng/mL (the conventional cut-off level). Laboratory and glucometer glucose both reached 100% sensitivity and 60% and 45% specificity, respectively. None of the biomarkers and cut-offs reached a PPV exceeding 90%, whereas both glucose measurements had a NPV of 100% (i.e., high glucose excludes a mucinous cyst).

CONCLUSION

Combined CEA and glucose testing in PCF reached high specificity and sensitivity for differentiating mucinous from non-mucinous PCN. Glucose testing, whether alone or combined with the new CEA cut-off (≥ 20 ng/mL), reached > 95% sensitivity for mucinous cysts, whereas only glucose reached a NPV > 95%.

Surgical treatment for pancreatic cystic lesions-implications from the multi-center and prospective German StuDoQ|Pancreas registry

PURPOSE

The detection of pancreatic cystic lesions (PCL) causes uncertainty for physicians and patients, and international guidelines are based on low evidence. The extent and perioperative risk of resections of PCL in Germany needs comparison with these guidelines to highlight controversies and derive recommendations.

METHODS

Clinical data of 1137 patients who underwent surgery for PCL between 2014 and 2019 were retrieved from the German StuDoQ|Pancreas registry. Relevant features for preoperative evaluation and predictive factors for adverse outcomes were statistically identified.

RESULTS

Patients with intraductal papillary mucinous neoplasms (IPMN) represented the largest PCL subgroup (N = 689; 60.6%) while other entities (mucinous cystic neoplasms (MCN), serous cystic neoplasms (SCN), neuroendocrine tumors, pseudocysts) were less frequently resected. Symptoms of pancreatitis were associated with IPMN (OR, 1.8; P = 0.012) and pseudocysts (OR, 4.78; P < 0.001), but likewise lowered the likelihood of MCN (OR, 0.49; P = 0.046) and SCN (OR, 0.15, P = 0.002). A total of 639 (57.2%) patients received endoscopic ultrasound before resection, as recommended by guidelines. Malignancy was histologically confirmed in 137 patients (12.0%), while jaundice (OR, 5.1; P < 0.001) and weight loss (OR, 2.0; P = 0.002) were independent predictors. Most resections were performed by open surgery (N = 847, 74.5%), while distal lesions were in majority treated using minimally invasive approaches (P < 0.001). Severe morbidity was 28.4% (N = 323) and 30d mortality was 2.6% (N = 29). Increased age (P = 0.004), higher BMI (P = 0.002), liver cirrhosis (P < 0.001), and esophageal varices (P = 0.002) were independent risk factors for 30d mortality.

CONCLUSION

With respect to unclear findings frequently present in PCL, diagnostic means recommended in guidelines should always be considered in the preoperative phase. The therapy of PCL should be decided upon in the light of patient-specific factors, and the surgical strategy needs to be adapted accordingly.

Limitations and prospects in the management of IPMN: a retrospective, single-center observational study

BACKGROUND

With increasing use and enhanced accuracy of cross-sectional imaging, the diagnosis of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas has increased over the last few decades. The extent to which malignant transformation occurs remains unclear, making the management of IPMNs controversial. The aim of this study was to evaluate the progression rate and outcome of follow-up in patients with IPMNs.

METHODS

A database of all patients diagnosed with IPMN at the Cantonal Hospital HFR Fribourg, Switzerland, between January 2006 and December 2019 with a follow-up of at least 6 months was analyzed retrospectively. Descriptive statistics were performed on patient demographics, IPMN characteristics, and follow-up data.

RESULTS

A total of 56 patients were included in this study. Ten patients underwent primary surgery, 46 were enrolled in a surveillance program.21.7% (n = 5) of patients under surveillance presented with worrisome features of IPMN; progression rates were significantly higher in these patients (p = 0.043). Most progression occurred in the early follow-up period. Five patients underwent surgery due to progression, of which 2 presented high-grade dysplasia and 2 malignancy on postoperative histology.

CONCLUSIONS

The limited predictive value of current guidelines may lead to surgical overtreatment, and the decision to proceed with surgical resection should be made with caution. Further prospective analyses and the development of novel biomarkers are needed to better understand the natural history of IPMN and improve diagnostic precision.

Gastrointestinal malignancies in pregnancy

Gastrointestinal malignancies, though uncommon in pregnancy, present several unique challenges with regards to diagnosis, staging, and treatment. Imaging the pregnant patient with a suspected or confirmed GI malignancy requires modifications to the radiologic modality of choice and protocol in order to minimize harm to the fetus, ensure accuracy in diagnosis and staging and guide treatment decisions. In this review article, we discuss the imaging approach to the pregnant patient with GI cancer, including safe radiologic modalities and modifications to imaging protocols. We also review the most common GI cancers encountered in pregnancy, including colorectal, pancreatic, gastric, and small bowel tumors, with emphasis to imaging findings, staging, and treatment considerations.

Risk Assessment and Pancreatic Cancer: Diagnostic Management and Artificial Intelligence

Pancreatic cancer (PC) is one of the deadliest cancers, and it is responsible for a number of deaths almost equal to its incidence. The high mortality rate is correlated with several explanations; the main one is the late disease stage at which the majority of patients are diagnosed. Since surgical resection has been recognised as the only curative treatment, a PC diagnosis at the initial stage is believed the main tool to improve survival. Therefore, patient stratification according to familial and genetic risk and the creation of screening protocol by using minimally invasive diagnostic tools would be appropriate. Pancreatic cystic neoplasms (PCNs) are subsets of lesions which deserve special management to avoid overtreatment. The current PC screening programs are based on the annual employment of magnetic resonance imaging with cholangiopancreatography sequences (MR/MRCP) and/or endoscopic ultrasonography (EUS). For patients unfit for MRI, computed tomography (CT) could be proposed, although CT results in lower detection rates, compared to MRI, for small lesions. The actual major limit is the incapacity to detect and characterize the pancreatic intraepithelial neoplasia (PanIN) by EUS and MR/MRCP. The possibility of utilizing artificial intelligence models to evaluate higher-risk patients could favour the diagnosis of these entities, although more data are needed to support the real utility of these applications in the field of screening. For these motives, it would be appropriate to realize screening programs in research settings.