Pancreatic incidentalomas: Investigation and management

Early features of pancreatic cancer on magnetic resonance imaging (MRI): a case-control study

PURPOSE

Magnetic resonance imaging has been recommended as a primary imaging modality among high-risk individuals undergoing screening for pancreatic cancer. We aimed to delineate potential precursor lesions for pancreatic cancer on MR imaging.

METHODS

We conducted a case-control study at Kaiser Permanente Southern California (2008-2018) among patients that developed pancreatic cancer who had pre-diagnostic MRI examinations obtained 2-36 months prior to cancer diagnosis (cases) matched 1:2 by age, gender, race/ethnicity, contrast status and year of scan (controls). Patients with history of acute/chronic pancreatitis or prior pancreatic surgery were excluded. Images underwent blind review with assessment of a priori defined series of parenchymal and ductal features. We performed logistic regression to assess the associations between individual factors and pancreatic cancer. We further assessed the interaction among features as well as performed a sensitivity analysis stratifying based on specific time-windows (2-3 months, 4-12 months, 13-36 months prior to cancer diagnosis).

RESULTS

We identified 141 cases (37.9% stage I-II, 2.1% III, 31.4% IV, 28.6% unknown) and 292 matched controls. A solid mass was noted in 24 (17%) of the pre-diagnostic MRI scans. Compared to controls, pre-diagnostic images from cancer cases more frequently exhibited the following ductal findings: main duct dilatation (51.4% vs 14.3%, OR [95% CI]: 7.75 [4.19-15.44], focal pancreatic duct stricture with distal (upstream) dilatation (43.6% vs 5.6%, OR 12.71 [6.02-30.89], irregularity (42.1% vs 6.0%, OR 9.73 [4.91-21.43]), focal pancreatic side branch dilation (13.6% vs1.6%, OR 11.57 [3.38-61.32]) as well as parenchymal features: atrophy (57.9% vs 27.4%, OR 46.4 [2.71-8.28], focal area of signal abnormality (39.3% vs 4.8%, OR 15.69 [6.72-44,78]), all p < 0.001).

CONCLUSION

In addition to potential missed lesions, we have identified a series of ductal and parenchymal features on MRI that are associated with increased odds of developing pancreatic cancer.

Role of artificial intelligence in the characterization of indeterminate pancreatic head mass and its usefulness in preoperative diagnosis

Artificial intelligence (AI) has been used in various fields of day-to-day life and its role in medicine is immense. Understanding of oncology has been improved with the introduction of AI which helps in diagnosis, treatment planning, management, prognosis, and follow-up. It also helps to identify high-risk groups who can be subjected to timely screening for early detection of malignant conditions. It is more important in pancreatic cancer as it is one of the major causes of cancer-related deaths worldwide and there are no specific early features (clinical and radiological) for diagnosis. With improvement in imaging modalities (computed tomography, magnetic resonance imaging, endoscopic ultrasound), most often clinicians were being challenged with lesions that were difficult to diagnose with human competence. AI has been used in various other branches of medicine to differentiate such indeterminate lesions including the thyroid gland, breast, lungs, liver, adrenal gland, kidney, etc. In the case of pancreatic cancer, the role of AI has been explored and is still ongoing. This review article will focus on how AI can be used to diagnose pancreatic cancer early or differentiate it from benign pancreatic lesions, therefore, management can be planned at an earlier stage.

Completion Pancreatectomy After Pancreatoduodenectomy: Who Needs It?

OBJECTIVE

The objective of this study was to identify the indications for and report the outcomes of completion pancreatectomy (CPLP) in the postoperative course after pancreatoduodenectomy (PD).

BACKGROUND

CPLP may be considered or even inevitable for damage control after PD.

METHODS

A prospectively maintained database of all patients undergoing PD between 2001 and 2019 was searched for patients who underwent CPLP in the postoperative course after PD. Baseline characteristics, perioperative details, and outcomes of CPLP patients were analyzed and specific indications for CPLP were identified.

RESULTS

A total of 3953 consecutive patients underwent PD during the observation period. CPLP was performed in 120 patients (3%) after a median of 10 days following PD. The main indications for CPLP included postpancreatectomy acute necrotizing pancreatitis [n=47 (39%)] and postoperative pancreatic fistula complicated by hemorrhage [n=41 (34%)] or associated with uncontrollable leakage of the pancreatoenteric anastomosis [n=23 (19%)]. The overall 90-day mortality rate of all 3953 patients was 3.5% and 37% for patients undergoing CPLP.

CONCLUSIONS

Our finding that only very few patients (3%) need CPLP suggests that conservative, interventional, and organ-preserving surgical measures are the mainstay of complication management after PD. Postpancreatectomy acute necrotizing pancreatitis, uncontrollable postoperative pancreatic fistula, and fistula-associated hemorrhage are highly dangerous and represent the main indications for CPLP after PD.

Pancreatic Incidentaloma

Pancreatic incidentalomas (PIs) represent a clinical entity increasingly recognized due to advances in and easier access to imaging techniques. By definition, PIs should be detected during abdominal imaging performed for indications other than a pancreatic disease. They range from small cysts to invasive cancer. The incidental diagnosis of pancreatic cancer can contribute to early diagnosis and treatment. On the other hand, inadequate management of PIs may result in overtreatment and unneeded morbidity. Therefore, there is a strong need to evaluate the nature and clinical features of individual PIs. In this review, we summarize the major characteristics related to PIs and present suggestions for their management.

Clinical features and prognostic impact of asymptomatic pancreatic cancer

Pancreatic ductal adenocarcinoma (PDAC) is highly lethal, and early diagnosis is challenging. Because patients who present with symptoms generally have advanced-stage diseases, analysis of asymptomatic PDAC provides invaluable information for developing strategies for early diagnosis. Here, we reviewed 577 patients with PDAC (372 diagnosed with symptoms [symptomatic group] and 205 without symptoms [asymptomatic group]) diagnosed at our institute. Among the 205 asymptomatic PDAC patients, 109 were detected during follow-up/work-up for other diseases, 61 because of new-onset or exacerbation of diabetes mellitus, and 35 in a medical check-up. Asymptomatic PDAC is characterized by smaller tumor size, earlier disease stage, and higher resectability than those of symptomatic PDAC. In 22.7% of asymptomatic cases, indirect findings, e.g., dilatation of the main pancreatic duct, triggered PDAC detection. Although pancreatic tumors were less frequently detected, overall abnormality detection rates on imaging studies were nearly 100% in asymptomatic PDAC. Asymptomatic PDAC had a better prognosis (median survival time, 881 days) than symptomatic PDAC (342 days, P < 0.001). In conclusion, diagnosis of PDAC in the asymptomatic stage is associated with early diagnosis and a better prognosis. Incidental detection of abnormal findings during the follow-up/work-up for other diseases provides important opportunities for early diagnosis of asymptomatic PDAC.