European evidence-based guidelines on pancreatic cystic neoplasms

Recent advances in dynamic single-molecule analysis platforms for diagnostics: Advantages over bulk assays and miniaturization approaches

Single-molecule science is a unique technique for unraveling molecular biophysical processes. Sensitivity to single molecules provides the capacity for the early diagnosis of low biomarker amounts. Furthermore, the miniaturization of instruments for portable diagnostic tools toward point-of-care testing (POCT) is a crucial development in this field. Herein, we discuss recent developments in single-molecule sensing platforms and their advantages for diagnostics over bulk measurements including molecular size measurements, interaction dynamics, and fast biomarker sensing and sequencing at low concentrations. We highlight the capabilities of dynamic optical and electrical sensing platforms for single-biomolecule and single-vesicle monitoring associated with neurodegenerative disorders, viral diseases, cancers, and more. Current approaches to instrument miniaturization have brought technology closer to portable diagnostics settings via smartphone-based devices, multifunctional portable microscopes, handheld electrical circuit devices, and remote single-molecule assays. Finally, we provide an overview of the clinical applications of single-molecule sensors in POCT assays. Altogether, single-molecule analyses platforms exhibit significant potential for the development of novel portable healthcare devices.

Rare pancreatic cystic neoplasms: A pictorial review

Since rare pancreatic cystic tumors may differ from common pancreatic cystic neoplasms in terms of treatment plan and prognosis, the differential diagnosis of these diseases is clinically relevant. Various imaging tests play an important role in the differential diagnosis of rare cystic pancreatic tumors, but accurately distinguishing these diseases solely on the basis of imaging findings is challenging. The purpose of this pictorial review is to present CT and in particular MR imaging features of rare pancreatic cystic tumors and discuss potential elements for differential diagnosis.

[Relevance of frozen section diagnostics in pancreatic surgery]

Frozen sections are performed in pancreatic surgery for three reasons: histopathological confirmation of previously unclear space-occupying lesions, determination of the extent of surgical resection in an operative exploration and for possible follow-up resections after previously carried out surgical resections. Overall, in the literature there are heterogeneous data with respect to an improvement in the prognosis of a secondary R0 resection by a repeat resection in comparison to a R1 resection. Nowadays, extended pancreatic resections including vascular resections are technically feasible and safe. Nevertheless, with respect to the precise radicality in the surgical procedure, all patient characteristics should be taken into consideration in addition to the histopathological diagnosis of the frozen sections.

Tumor immune microenvironment alterations associated with progression in human intraductal papillary mucinous neoplasms

Pancreatic ductal adenocarcinoma (PDAC) poses a significant challenge due to late-stage diagnoses. To improve patient outcomes, early intervention in precursor lesions such as intraductal papillary mucinous neoplasm (IPMN) is crucial. However, early intervention must be balanced against overtreatment of low-risk lesions that are unlikely to progress, underscoring the need to better understand molecular alterations in neoplastic cells and changes in the tumor microenvironment (TME) that drive the progression of IPMNs. In this study, we characterized alterations in the TME of IPMNs as they progressed to high-grade dysplasia, using immunohistochemistry to quantify immune cell density and activation status in more than 100 well-characterized human IPMN samples. Analyses revealed progression to a more immunosuppressive TME in high-grade IPMN compared with low-grade IPMN, characterized by elevated expression of immune checkpoint molecules (PD-L1, TIM3, VISTA), increased density of macrophages, and decreased density of cytotoxic T cells. Intriguingly, the alterations in macrophages were limited to focal regions of high-grade dysplasia, while T-cell alterations affected the entire IPMN. Additionally, elevated VISTA expression was associated with poorer clinical outcome after IPMN resection in an independent cohort. These findings provide important insights into the interplay between the immune microenvironment and IPMN progression, highlighting potential targets to modify the TME for cancer interception. © 2025 The Pathological Society of Great Britain and Ireland.

Clinical impact of epithelial types on postoperative outcomes for intraductal papillary mucinous neoplasms: a multicenter retrospective study

BACKGROUND

Intraductal papillary mucinous neoplasms (IPMNs) are classified into three epithelial types with distinct biological behaviors. However, their effects on the postoperative outcomes remain unclear.

METHODS

This multicenter retrospective study included 556 patients with IPMNs who underwent surgical resection. The epithelial types were categorized into the gastric (n = 323), intestinal (n = 160), and pancreatobiliary (n = 73) types. Their associations with the development of extrapancreatic lesions; remnant high-risk lesions (HRLs), including metachronous pancreatic ductal adenocarcinoma (PDAC); and disease-specific survival (DSS) were analyzed.

RESULTS

Fifty-one patients (9.2%) developed extrapancreatic lesions. The 10-year cumulative incidence rates for the gastric, intestinal, and pancreatobiliary types were 9.3%, 9.1%, and 32.0%, respectively (P < 0.001). Multivariate analysis identified invasive carcinoma, the gastric, and pancreatobiliary types as independent predictors. Among 516 patients who did not undergo total pancreatectomy, 40 (7.8%) and 13 (2.5%) developed HRLs and metachronous PDAC, respectively. The 10-year cumulative incidence rates of HRLs and metachronous PDAC for the gastric, intestinal, and pancreatobiliary types were 7.0%, 16.2%, and 37.2% and 1.8%, 3.7%, and 22.7%, respectively (P = 0.001 and P = 0.012). In multivariate analysis, the pancreatobiliary type was an independent predictor of metachronous PDAC. Five-year DSS rates for the gastric, intestinal, and pancreatobiliary types were 92.5%, 96.0%, and 76.1% (P < 0.001), respectively. Multivariate analysis identified invasive carcinoma, the gastric, and pancreatobiliary types as independent prognostic factors for DSS.

CONCLUSIONS

IPMN epithelial type can independently affect postoperative outcomes. In particular, the pancreatobiliary type has significant impact on the development of metachronous PDAC. Therefore, postoperative surveillance should be tailored according to the epithelial type.

Radiomics for Differentiating Pancreatic Mucinous Cystic Neoplasm from Serous Cystic Neoplasm: Systematic Review and Meta-Analysis

BACKGROUND

As pancreatic cystic neoplasms (PCN) differ in current standard of care, and these treatments can affect quality of life to varying degrees, a definitive preoperative diagnosis must be reliable. Current diagnostic approaches, specifically traditional cross-sectional imaging techniques, face certain limitations. But radiomics has been shown to have high diagnostic accuracy across a range of diseases. Objective to conduct a comprehensive review of the literature on the use of radiomics to differentiate Mucinous Cystic Neoplasm (MCN) from Serous Cystic Neoplasm (SCN).

METHODS

This study was comprehensively searched in Pubmed, Scopus and Web of Science databases for meta-analysis of studies that used radiomics to distinguish MCN from SCN. Risk of bias was assessed using the diagnostic accuracy study quality assessment method and combined with sensitivity, specificity, diagnostic odds ratio, and summary receiver operating characteristic (SROC)curve analysis.

RESULTS

A total of 884 patients from 8 studies were included in this analysis, including 365 MCN and 519 SCN. The Meta-analysis found that radiomics identified MCN and SCN with high sensitivity and specificity, with combined sensitivity and specificity of 0.84(0.82-0.87) and 0.82(0.79-0.84). The positive likelihood ratio (PLR) and the negative likelihood ratio (NLR) are 5.61(3.72, 8.47) and 0.14(0.09-0.26). In addition, the area under the SROC curve (AUC) was drawn at 0.93. No significant risk of publication bias was detected through the funnel plot analysis. The performances of feature extraction from the volume of interest (VOI) or Using AI classifier in the radiomics models were superior to those of protocols employing region of interest (ROI) or absence of AI classifier.

CONCLUSION

This meta-analysis demonstrates that radiomics exhibits high sensitivity and specificity in distinguishing between MCN and SCN, and has the potential to become a reliable diagnostic tool for their identification.

Microbiome, Metabolome, and Ionome Profiling of Cystic Fluids Reveals Heterogeneity in Pancreatic Cystic Neoplasms

Pancreatic cystic neoplasms (PCNs) carry variable malignant potential, requiring precise clinical management. However, the heterogeneity and progression of PCNs remain poorly understood. This study analyzed the microbiome, metabolome, and ionome profiles of cyst fluids from 188 patients, including 165 with PCNs and 23 with other cyst types, using PacBio full-length 16S/ITS sequencing, LC-MS/MS, and ICP-MS. Bioinformatic analyses were performed, and metabolic enzyme and endoplasmic reticulum (ER) stress-related gene expression were examined using the PAAD TCGA dataset. PCNs were classified into distinct histopathological subtypes, including mucinous cystic lesions (MCLs) and serous cystic lesions (SCLs). MCLs demonstrated lower microbial diversity compared to SCLs, indicating microbial instability. Streptococcus and Staphylococcus were identified as key taxa in intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs), respectively. MCLs exhibited metabolic shifts towards lipid metabolism, while IPMNs showed distinct metabolic profiles potentially reflecting inflammation-related metabolic reprogramming. Ionic diversity varied among subtypes, with MCLs showing reduced diversity and IPMNs presenting broader ionic profiles. Palmitic acid (PA), a metabolite linked to Streptococcus, may contribute to pro-inflammatory metabolic alterations in IPMN. Our preliminary experiments demonstrated that co-culturing Streptococcus orails (S. orails) with ASAN-PaCa cells promoted their proliferation, accompanied by an elevation of PA levels in the supernatant. This integrative microbiome-metabolome-ionome analysis highlights histopathological heterogeneity among PCNs. While mechanistic associations remain to be fully defined, mucinous lesions may be more susceptible to microbe-driven metabolic disruption, with Streptococcus-associated lipid alterations as a potential contributing factor.

Can Ultrasound be Used as an Alternative Tool for Pancreatic Cystic Disease Compared With MRI?

RATIONALE AND OBJECTIVES

To analyze the ultrasound features of pancreatic cystic lesions and to compare contrast-enhanced sonography (CEUS) with magnetic resonance imaging (MRI) to investigate the diagnostic value of CEUS for pancreatic cystic lesions.

MATERIALS AND METHODS

Patients with pancreatic cystic lesions who underwent CEUS examination and enhanced MRI from February 2022 to January 2023 at Peking Union Medical College Hospital were prospectively included. The diagnostic value of CEUS in the diagnosis of pancreatic cystic lesions was analyzed using postoperative histopathology as the gold standard and compared with enhanced MRI.

RESULTS

In total, 17 patients with pancreatic cystic lesions were included, the CEUS diagnostic accuracy was 76.47% (13/17), the enhanced MRI diagnostic accuracy was 64.71% (11/17), and the diagnostic results of CEUS were in moderate agreement with those of enhanced MRI (κ = 0.52). The CEUS features of all lesions were categorized into four types: Type I, unilocular cystic type, five cases; Type II, microcystic lesion type, four cases; Type III, macrocystic lesion type, two cases; and Type IV, lesion with an enhanced solid component, six cases. There were two cases of Type I and one case of Type II simple cysts. Pancreatic pseudocysts were Type I in one case. Of the pancreatic serous cystadenomas, three cases were Type II, two cases were Type III, and one case was Type IV. The case of pancreatic mucinous cystadenoma was Type I. For the intraductal papillary mucinous neoplasm, four cases were all Type IV. For solid pseudopapillary tumors of the pancreas, one case was classified as Type IV. One case of pancreatic neuroendocrine tumor was classified as Type I.

CONCLUSION

CEUS, as an economical, radiation-free, and effective imaging modality, can be an optional test for pancreatic cystic diseases and helps in their diagnosis and follow-up.

Comprehensive insights into pancreatic cancer treatment approaches and cutting-edge nanocarrier solutions: from pathology to nanomedicine

Pancreatic cancer is one of the most lethal malignancies worldwide. It is characterized by poor prognosis, high mortality, and recurrence rates. Various modifiable and non-modifiable risk factors are associated with pancreatic cancer incidence. Available treatments for pancreatic cancer include surgery, chemotherapy, radiotherapy, photodynamic therapy, supportive care, targeted therapy, and immunotherapy. However, the survival rates for PC are very low. Regrettably, despite efforts to enhance prognosis, the survival rate of pancreatic cancer remains relatively low. Therefore, it is essential to investigate new approaches to improve pancreatic cancer treatment. By synthesizing current knowledge and identifying existing gaps, this article provides a comprehensive overview of risk factors, pathology, conventional treatments, targeted therapies, and recent advancements in nanocarriers for its treatment, along with various clinical trials and patents that justify the safety and efficacy of innovative carriers for drug delivery systems. Ultimately, this review underscores the potential of these innovative formulations to improve outcomes and contribute significantly to the advancement of Pancreatic Cancer treatment. Together, these insights highlight nano-formulations as a promising frontier for effectively treating Pancreatic Cancer.

Impact of a dilated main pancreatic duct in the expected remnant pancreas on the incidence of clinically significant remnant pancreatic lesion after resection of noninvasive and microinvasive intraductal papillary mucinous neoplasms

BACKGROUND

Partial pancreatectomies for intraductal papillary mucinous neoplasms (IPMN) often leave a dilated main pancreatic duct (MPD). However, its impact on the development of remnant pancreatic lesions is unknown.

METHODS

Medical records of consecutive patients who underwent partial pancreatectomy for noninvasive or microinvasive IPMN with dilated MPD on preoperative imaging between April 2007 and March 2023 at two tertiary referral centers in Japan were retrospectively reviewed. A dilated remnant MPD (DRM) was defined as an MPD diameter of the expected remnant pancreas of ≥5 mm. The clinically significant remnant pancreatic lesion (CSRPL) was defined as a remnant pancreatic lesion which requires intervention.

RESULTS

A total of 172 patients (106 males and 66 females) were analyzed. Preoperatively, 132 patients (76.7 %) had mixed-type IPMN and 40 (23.1 %) had main duct IPMN. Among them, 16 patients (9.3 %) had CSRPL at 1569 days (median; range, 120-5503 days) after the initial surgery. In the preoperative imaging analysis, 104 patients (60.5 %) had DRM. The univariate analysis revealed that high-grade or micro-invasive pathology (p = 0.013) was significantly associated with CSRPL, whereas DRM was inversely associated with CSRPL (p = 0.021). The multivariate analysis revealed that the trends of DRM (p = 0.002) and high-grade/micro-invasive pathology (p = 0.003) remained significant.

CONCLUSIONS

Leaving a dilated MPD did not increase but instead inversely associated with the incidence of CSRPL after IPMN resection. It was suggested that preserving the pancreas, including the dilated MPD, is oncologically safe if the lesion of interest can be resected.

Pancreatic cancer

Pancreatic cancer is frequently a lethal disease with an aggressive tumour biology often presenting with non-specific symptoms. Median survival is approximately 4 months with a 5-year survival of 13%. Surveillance is recommended in individuals with familial pancreatic cancer, specific mutations, and high-risk intraductal papillary mucinous neoplasm, as they are at high risk of developing pancreatic cancer. Chemotherapy combined with surgical resection remains the cornerstone of treatment. However, only a small subset of patients are candidates for surgery. Multi-agent chemotherapy has improved survival in the palliative setting for patients with metastatic disease, as (neo)adjuvant and induction therapy have in patients with borderline resectable and locally advanced pancreatic. Given that pancreatic cancer is predicted to become the second leading cause of cancer-related death by 2030, novel therapies are urgently needed.

Multimodal Pancreatic Cancer Detection Using Methylated DNA Biomarkers in Pancreatic Juice and Plasma CA 19-9: A Prospective Multicenter Study

BACKGROUND AND AIMS

In previous studies, methylated DNA markers (MDMs) have been identified in pancreatic juice (PJ) for detecting pancreatic ductal adenocarcinoma (PDAC). In this prospective multicenter study, the sensitivity and specificity characteristics of this panel of PJ-MDMs was evaluated standalone and in combination with plasma carbohydrate antigen 19-9 (CA 19-9).

METHODS

Paired PJ and plasma were assayed from 88 biopsy-proven treatment-naïve PDAC cases and 134 controls (53 with normal pancreas, 23 with chronic pancreatitis [CP], 58 with intraductal papillary mucinous neoplasm). Bisulfite-converted DNA from buffered PJ was analyzed using long-probe quantitative amplified signal assay targeting 14 MDMs (NDRG4, BMP3, TBX15, C13orf18, PRKCB, CLEC11A, CD1D, ELMO1, IGF2BP1, RYR2, ADCY1, FER1L4, EMX1, and LRRC4) and a reference gene (methylated B3GALT6). Logistic regression was used to fit the previously identified 3-MDM PJ panel (FER1L4, C13orf18, and BMP3). Discrimination accuracy was summarized using area under the receiver-operating characteristic curve (AUROC) with corresponding 95% confidence interval (CI).

RESULTS

Methylated FER1L4 had the highest individual AUROC of 0.83 (95% CI, 0.78-0.89). The AUROC for the 3-MDM PJ + plasma CA 19-9 model (0.95; 95% CI, 0.92-0.98) was higher than both the 3-MDM PJ panel (0.87; 95% CI, 0.82-0.92)) and plasma CA 19-9 alone (0.91; 95% CI, 0.87-0.96) (P = .0002 and .0135, respectively). At a specificity of 88% (95% CI, 81%-93%), the sensitivity of this model was 89% (95% CI, 80%-94%) for all PDAC stages and 83% (95% CI, 64%-94%) for stage I/II PDAC.

CONCLUSIONS

A panel combining PJ-MDMs and plasma CA 19-9 discriminates PDAC from both healthy and disease control groups with high accuracy. This provides support for combining PJ and blood-based biomarkers for enhancing diagnostic sensitivity and successful early PDAC detection.

Differences in the Clinicopathologic and Radiological Characteristics of Patients With Microcystic and Macrocystic Serous Cystadenoma of the Pancreas

OBJECTIVES

The aims of the study were to elucidate the clinicopathological characteristics, imaging features, and surgical outcomes of patients with serous cystic neoplasms (SCNs) and to compare the features between microcystic (MiC) and macrocystic (MaC) SCNs.

MATERIALS AND METHODS

In this single-center retrospective study, information of patients with SCN between 2016 and 2022 at our institution was collected and analyzed.

RESULTS

A total of 105 patients with SCNs were identified, including 58 (55.2%) with MiC type and 47 (44.8%) with MaC type. Patient age and American Society of Anesthesiologists grade in the MiC group were significantly higher than those in the MaC group. The overall preoperative diagnostic accuracy was 7.6%, with no patients in the MaC group correctly diagnosed before surgery. In imaging examinations, almost all (97.1%) exhibited a lobulated pattern. Internal septation, honeycomb pattern, central scar, and calcification were common, with a significantly higher incidence in the MiC group. No in-hospital deaths occurred, and the incidence of major complications were comparable in both groups.

CONCLUSIONS

Although many patients presented with typical imaging features, accurate diagnosis of SCN remained difficult. Except for older age and higher American Society of Anesthesiologists grade in the MiC group, there were no significant differences in the clinicopathological characteristics between MiC and MaC SCN patients.

Current status of endoscopic ultrasound in the diagnosis of intraductal papillary mucinous neoplasms

The new Kyoto guidelines for the management of intraductal papillary mucinous neoplasm (IPMN) provide evidence-based recommendations for the diagnosis and treatment of IPMN. Endoscopic ultrasonography (EUS) is a diagnostic modality with a high spatial resolution that allows detailed observation and obtaining cyst fluid or tissue samples via EUS-guided fine needle aspiration (EUS-FNA). Currently, EUS is an indispensable examination method for the diagnosis of pancreatic diseases. On the other hand, there have been concerns that EUS imaging tends to be highly operator-dependent, and may lack objectivity. Previous guidelines have assigned EUS as an option for patients with worrisome features. However, recent reports indicate that the sensitivity of EUS for the diagnosis of mural nodules (MNs) is more than 90%, comparable or superior to that of contrast-enhanced computed tomography or magnetic resonance cholangiopancreatography. The specific advantages of EUS in the diagnosis of IPMN are: (1) high spatial resolution imaging for the diagnosis of MNs, (2) contrast-enhanced EUS for differentiation of intra-cystic MNs from mucous clots, and (3) pathological diagnosis using EUS-FNA and differential diagnosis of a pancreatic cystic tumor by cystic fluid analysis. In order to utilize EUS in the diagnosis of IPMN, endoscopists are required to have the skills to provide sufficiently objective imaging findings.

Central pancreatectomy: An uncommon but potentially optimal choice of pancreatic resection

Benign, premalignant or low-grade malignant pancreatic tumors are increasingly diagnosed owing to the widespread uptake of cross-sectional imaging. Surgical excision is a potential treatment option for these tumors. Pancreatoduodenectomy and distal pancreatectomy are the standard resections for tumors located in the pancreatic head-neck or body-tail, respectively, and not uncommonly sacrifice a significant amount of healthy pancreatic parenchyma. Central pancreatectomy (CP) is a parenchyma-sparing procedure, initially performed by Dagradi and Serio in 1982, in a patient with pancreatic neck insulinoma. Since then, an increasing number of cases are being performed worldwide, either via open or minimally invasive surgical access. Additionally, pancreatic enucleation is reserved for tumors < 3 cm, without involvement of the main pancreatic duct. CP remains an alternative approach in selected cases, albeit in the presence of some controversies, such as its use in early pancreatic ductal adenocarcinoma or metastatic deposits to the central aspect of the pancreas from other malignancies. In recent years, clarity is lacking as regards indications for CP, and despite accumulating evidence in favor of limited resections for suitable pancreatic tumors, no evidence-based consensus guidelines are yet available. Nevertheless, it appears that appropriate patient selection is of paramount importance to maximize the advantages of preservation of endocrine and exocrine pancreatic functions as well as to mitigate the risks of higher complication rates. In this comprehensive review, we explore the role of CP in the treatment of lesions located in the neck and proximal body of the pancreas.

Role of Endoscopy in Clinical Management of Intraductal Papillary Mucinous Neoplasms

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a well-recognized precursor of pancreatic carcinoma. Along with cross-sectional abdominal imaging tests, endoscopic examinations remain the cornerstone in the diagnosis of pancreatic cysts, early detection of IPMN-derived carcinomas, and risk stratification of patients with IPMNs for subsequent surveillance strategies. In particular, endoscopic ultrasound (EUS) facilitates the optimal patient management by providing high-resolution morphological information, and the contrast-enhanced harmonic mode may further enhance diagnostic accuracy. EUS-guided fine-needle aspiration for solid mass and/or cyst fluid is considered for pathological and molecular examinations for the diagnosis of pancreatic cysts and malignancy. Emerging evidence suggests the usefulness of through-the-needle biopsy and confocal laser microendoscopy in this setting. In addition to the undoubtful diagnostic utility, recent studies have demonstrated the potential effect of endoscopic interventions (i.e., ablation) on the control of IPMNs. Despite the increasing role of endoscopy in the clinical management of IPMNs, there remains a gap in our understanding of how to utilize endoscopy in the personalized care for patients with IPMNs (e.g., the optimal interval of EUS) and the prevention of deaths due to pancreatic carcinomas developing concomitantly with IPMNs. This review summarizes the current evidence on the role of endoscopy in both the diagnostic and therapeutic landscapes of clinical management of IPMNs and identifies key clinical unmet needs that should be addressed in future research. Combined with emerging technologies (e.g., artificial intelligence and high-throughput molecular profiling), endoscopy would offer more effective and tailored management strategies for patients with IPMNs.

Long-term clinical outcomes of pancreatic cystic lesions in liver transplant patients

BACKGROUND

Pancreatic cystic lesions (PCL) are often incidentally diagnosed in transplant patients, although long-term impact in this chronically immunosuppressed population remains unclear. This study examines long-term malignant potential and outcomes of PCL in orthotopic liver transplant (OLT) patients.

METHODS

A retrospective study of 1110 patients who underwent OLT from 2011 to 2017 at a tertiary referral center was performed. Demographic, imaging, and outcomes data were examined.

RESULTS

86 OLT patients with 148 PCL were identified. Median follow up after PCL identification was 7.6 years (IQR 5.7-9.7). Most cysts decreased in size (45%) or remained stable (30.2%). Only 24% of PCL increased in size, with average growth of 2.7 mm/year. Based on American College of Gastroenterology (ACG) 2018 guidelines, 20 patients (23%) developed high-risk imaging characteristics. Of 16 endoscopic ultrasounds (EUS) performed, 1 patient was diagnosed with pancreatic adenocarcinoma. There were no pancreas-specific causes of death and no survival differences in OLT patients with and without PCL on multivariate analysis.

CONCLUSION

There is a low incidence of malignant transformation of PCL in OLT patients and no survival disadvantage at long-term follow up despite immunosuppression. PCL in OLT patients should be managed under similar guidelines as immunocompetent patients.

The relationship of the microbiome, associated metabolites and the gut barrier with pancreatic cancer

Pancreatic cancers have high mortality and rising incidence rates which may be related to unhealthy western-type dietary and lifestyle patterns as well as increasing body weights and obesity rates. Recent data also suggest a role for the gut microbiome in the development of pancreatic cancer. Here, we review the experimental and observational evidence for the roles of the oral, gut and intratumoural microbiomes, impaired gut barrier function and exposure to inflammatory compounds as well as metabolic dysfunction as contributors to pancreatic disease with a focus on pancreatic ductal adenocarcinoma (PDAC) initiation and progression. We also highlight some emerging gut microbiome editing techniques currently being investigated in the context of pancreatic disease. Notably, while the gut microbiome is significantly altered in PDAC and its precursor diseases, its utility as a diagnostic and prognostic tool is hindered by a lack of reproducibility and the potential for reverse causality in case-control cohorts. Future research should emphasise longitudinal and mechanistic studies as well as integrating lifestyle exposure and multi-omics data to unravel complex host-microbiome interactions. This will allow for deeper aetiologic and mechanistic insights that can inform treatments and guide public health recommendations.

MULTI-REGION GENOMIC ANALYSIS OF HUMAN PANCREATIC MUCINOUS CYSTIC NEOPLASMS

Mucinous cystic neoplasms (MCNs) are precursors to invasive pancreatic cancer. Conflicting clinical management recommendations call for better molecular characterization to improve our understanding of their tumorigenesis and risk assessment. We sampled epithelial tissue from a total of 18 surgically resected MCNs and performed dedicated multi-region analysis of somatic genetic alterations by targeted next-generation sequencing of 25 driver genes. In addition, we performed whole exome sequencing and immunohistochemistry on selected samples to supplement our analyses. In total, 128 samples of epithelial MCN tissue were sequenced and analyzed, including samples from 13 small MCNs with low-grade dysplasia, one small MCN with high-grade dysplasia, and four large MCNs with high-grade dysplasia. Eight of 13 (61.5%) comprehensively sampled small low-grade MCNs lacked somatic driver gene mutations in all tissue blocks. These MCNs were lined by predominantly flat epithelium. In contrast, the majority of MCNs with driver gene mutations were predominantly lined by mucin-rich epithelium. No heterogeneity in KRAS mutations was seen across the sampled regions. Multi-region genetic analysis of four large MCNs with high-grade dysplasia provide insights into neoplastic progression, with shared somatic alterations suggesting that high-grade dysplasia arises from low-grade mucin-rich epithelium. These findings were supported by complementary whole exome sequencing studies in 26 MCN epithelium samples. The neoplastic epithelium in the majority of small MCNs does not harbor somatic mutations in pancreatic driver genes. The genetic findings from multi-region analysis on MCNs contrast previous investigations in other mucin-producing pancreatic cysts, indicating distinct mechanisms in early tumorigenesis. This calls for a more nuanced risk assessment in MCNs, requiring improved pre-operative assessment tools.

Spatial analysis of IPMNs defines a paradoxical KRT17-positive, low-grade epithelial population harboring malignant features

Background & Aims

Intraductal papillary mucinous neoplasms (IPMNs) are pancreatic cysts that represent one of the few radiologically identifiable precursors to pancreatic ductal adenocarcinoma (PDAC).Though the IPMN-bearing patient population represents a unique opportunity for early detection and interception, current guidelines provide insufficient accuracy in determining which patients should undergo resection versus surveillance, resulting in a sizable fraction of resected IPMNs only harboring low-grade dysplasia, suggesting that there may be overtreatment of this clinical entity.

Methods

To investigate the transcriptional changes that occur during IPMN progression, we performed spatial transcriptomics using the Nanostring GeoMx on patient samples containing the entire spectrum of IPMN disease including low-grade dysplasia, high-grade dysplasia, and IPMN-derived carcinoma. Single cell RNA sequencing was performed on side branch and main duct IPMN biospecimens.

Results

We identified a subpopulation of histologically low-grade IPMN epithelial cells that express malignant transcriptional features including KRT17 , S100A10 and CEACAM5 , markers that are enriched in PDAC. We validated and refined this high-risk gene signature by integrating our ST analysis with an external ST dataset containing a larger number of IPMN samples including non-tumor bearing IPMN (i.e. low-grade IPMN in isolation). We confirmed the presence of the KRT17+ population using immunofluorescence on a large cohort of patient tissues, revealing a widespread but patchy distribution of KRT17+ cells in histologically low-grade IPMN.

Conclusions

Our study demonstrates that KRT17 marks a distinct transcriptional signature in a subpopulation of epithelial cells within histologically low-grade IPMN. This population of cells likely represents a transitional state of histologically low-grade epithelial cells undergoing progression to a higher grade of dysplasia and thus may represent a higher risk of progression to carcinoma.

Graphical abstract

Lymphoepithelial cyst of the pancreatic tail: a rare entity with surgical and histopathological insights

Lymphoepithelial cysts (LECs) of the pancreas are rare, benign lesions often discovered incidentally during imaging for unrelated conditions. Their radiological features frequently overlap with those of other more common pancreatic cystic lesions, presenting a diagnostic challenge. In this report from a general surgical department on the Australia, we detail the assessment and management of a 54-year-old male with an enlarging pancreatic tail lesion initially thought to be a mucinous cystic neoplasm. Laparoscopic distal pancreatectomy and splenectomy was performed, and subsequent histopathological evaluation confirmed a benign LEC. This report reviews the literature base, clinical presentation, radiological findings, surgical approach, and pathological diagnosis of this rare condition. We emphasize the importance of a tailored approach to management and the role of surgery in definitive treatment.

The World Health Organization Reporting System for Pancreaticobiliary Cytopathology: Review and Comparison to the Papanicolaou Society of Cytopathology System

CONTEXT.—

The World Health Organization (WHO) Reporting System for Pancreaticobiliary Cytopathology (WHO System) is the product of a joint venture between the World Health Organization, the International Academy of Cytology, and the International Agency for Research on Cancer. The WHO System revises the Papanicolaou Society of Cytopathology System for Reporting Pancreaticobiliary Cytology (PSC System) and replaces the 6-tiered system with a 7-tiered system.

OBJECTIVE.—

To explain the WHO System and the differences with the PSC System.

DATA SOURCES.—

The WHO System and the PSC System of Reporting Pancreaticobiliary Cytopathology.

CONCLUSIONS.—

The diagnostic categories of the WHO System are "Insufficient/Inadequate/Nondiagnostic"; "Benign (Negative for Malignancy)"; "Atypical"; "Pancreaticobiliary Neoplasm, Low Risk/Low Grade (PaN-Low)"; "Pancreatic Neoplasm, High Risk/High Grade (PaN-High)"; "Suspicious for Malignancy"; and "Malignant." In the WHO System, the "benign" category includes both nonneoplastic and neoplastic lesions, so the "Neoplastic: Benign" category of the PSC system has been eliminated. Low-grade malignancies, pancreatic neuroendocrine tumors (PanNETs), and solid-pseudopapillary neoplasm (SPN) classified as "Neoplastic: Other" in the PSC System are classified as "Malignant" in the WHO System, leaving in the "Neoplasm" category intraductal lesions, which are divided into 2 new diagnostic categories: "Pancreaticobiliary Neoplasm (PaN)-Low Risk/Grade" and "PaN-High Risk/Grade." As with the PSC System, the WHO System advocates close correlation with imaging and encourages incorporation of ancillary testing into the final diagnosis, such as biochemical (carcinoembryonic antigen [CEA] and amylase) and molecular testing. The WHO System includes risk of malignancy per category, and reporting and diagnostic management options that recognize the variations in resources of low- and middle-income countries.

[Precancerous lesions of the pancreas, prophylactic surgery]

Pancreatic cancer is a serious pathology whose incidence is increasing. Advances in imaging have made it possible to fortuitously highlight more and more cystic pancreatic lesions, some of which have a malignant potential, leading to the consideration of prophylactic excision. The various known precancerous lesions of the pancreas as well as current management recommendations are here reviewed.

What Is the Latest in Pancreatic Cysts?

Pancreatic cysts are common incidental findings. The understanding of pancreatic cysts has evolved tremendously over the past few decades. Molecular diagnostic and endoscopic techniques have led to more precise characterization of cyst types and interventions to improve patient outcomes. This article outlines these recent innovations in pancreatic cyst diagnosis and management.

Machine Learning-Driven Radiomics Analysis for Distinguishing Mucinous and Non-Mucinous Pancreatic Cystic Lesions: A Multicentric Study

The increasing use of high-resolution cross-sectional imaging has significantly enhanced the detection of pancreatic cystic lesions (PCLs), including pseudocysts and neoplastic entities such as IPMN, MCN, and SCN. However, accurate categorization of PCLs remains a challenge. This study aims to improve PCL evaluation by developing and validating a radiomics-based software tool leveraging machine learning (ML) for lesion classification. The model categorizes PCLs into mucinous and non-mucinous types using a custom dataset of 261 CT examinations, with 156 images for training and 105 for external validation. Three experienced radiologists manually delineated the images, extracting 38 radiological and 214 radiomic features using the Pyradiomics module in Python 3.13.2. Feature selection was performed using Least Absolute Shrinkage and Selection Operator (LASSO) regression, followed by classification with an Adaptive Boosting (AdaBoost) model trained on the optimized feature set. The proposed model achieved an accuracy of 89.3% in the internal validation cohort and demonstrated robust performance in the external validation cohort, with 90.2% sensitivity, 80% specificity, and 88.2% overall accuracy. Comparative analysis with existing radiomics-based studies showed that the proposed model either outperforms or performs on par with the current state-of-the-art methods, particularly in external validation scenarios. These findings highlight the potential of radiomics-driven machine learning approaches in enhancing PCL diagnosis across diverse patient populations.

The 12-Year Experience of the Hungarian Pancreatic Study Group

The Hungarian Pancreatic Study Group (HPSG) was established with the aim of advancing pancreatology. Our summary outlines the methodologies, key results, and future directions of the HPSG. Methodological elements included, the formation of strategic national and international collaborations, the establishment of patient registries and biobanks, and a strong focus on education and guideline development. Key results encompassed, pioneering research on pancreatic ductal function and the role of cystic fibrosis transmembrane conductance regulator (CFTR) in inflammation, significant advancements in understanding acute and chronic pancreatitis, and the execution of numerous clinical trials to explore new therapeutic approaches. Despite challenges, such as securing funding and translating research into clinical practice, the HPSG's commitment to patient care and scientific innovation has been unwavering. The group aims to deepen research into pancreatic cancer and chronic pancreatitis, conduct more randomized controlled trials (RCTs), and expand its efforts internationally by involving global staff and patients. The authors hope that this summary inspires others to undertake similar initiatives and contribute to the global advancement of medical research and patient care in pancreatology.

Cystic Fluid Total Proteins, Low-Density Lipoprotein Cholesterol, Lipid Metabolites, and Lymphocytes: Worrisome Biomarkers for Intraductal Papillary Mucinous Neoplasms

Objectives: Pancreatic cystic neoplasms (PCNs), particularly intraductal papillary mucinous neoplasms (IPMNs), present a challenge for their potential malignancy. Despite promising biomarkers like CEA, amylase, and glucose, our study investigates whether metabolic indices in blood and cystic fluids (CFs), in addition to lymphocyte subsets and hematopoietic stem/progenitor cells (HSPCs), can effectively differentiate between high- and low-risk PCNs. Materials and Methods: A total of 26 patients (11 males, mean age 69.5 ± 9 years) undergoing Endoscopic Ultrasound-guided Fine Needle Aspiration were consecutively enrolled. Analyses included blood, serum, and CF, assessing glucose, CEA, cholesterol (total, HDL, and LDL), and total proteins. Flow cytometry examined immunophenotyping in peripheral blood and cystic fluids. Mass spectrometry was used for the metabolomic analysis of CF. Sensitivity, specificity, and ROC analyses evaluated discriminatory power. Results: A total of 25 out of 26 patients had IPMN. Patients were categorized as low or high risk based on multidisciplinary evaluation of clinical, radiological, and endoscopic data. High-risk patients showed lower CF total proteins and LDL cholesterol (p = 0.005 and p = 0.031), with a marked reduction in CF lymphocytes (p = 0.005). HSCPs were absent in CF. In blood, high-risk patients showed increased non-MHC-restricted cytotoxic T cells (p = 0.019). The metabolomic analysis revealed significantly reduced middle and long-chain acyl carnitines (AcCa) and tryptophan metabolites in high-risk patients. ROC curves indicated comparable discriminant abilities for CF lymphocytes (AUC 0.868), CF total proteins (AUC 0.859), and CF LDL cholesterol (AUC 0.795). The highest performance was achieved by the AcCa 14:2 and 16:0 (AUC: 0.9221 and 0.8857, respectively). Conclusions: CF levels of glucose, CEA, LDL cholesterol, and total proteins together with lymphocyte counts are easy translational biomarkers that may support risk stratification of PCNs in IPMN patients and might be endorsed by metabolomic analysis. Further studies are required for potential clinical integration.

A single-center study examining the safety and effectiveness of ERCP with pancreatoscopy and endoluminal radiofrequency ablation for main-duct IPMN treatment

To assess the safety and efficacy of treatment for intraductal papillary mucinous neoplasm (IPMN) involving the main pancreatic duct (MPD) using endoscopic retrograde cholangiopancreatography (ERCP) combined with digital single-operator pancreatoscopy and radiofrequency ablation (RFA). A retrospective analysis was performed. Patients with episodes of acute pancreatitis at the First Affiliated Hospital of Chongqing Medical University were screened. When the diagnosis of IPMN was confirmed by ERCP with pancreatoscopy, patients who underwent endoluminal RFA treatment were enrolled. The most frequent complications were monitored to assess the safety of treatment. Disease progression and recurrence of pancreatitis symptoms were regarded as the indicators of treatment efficacy. In total, 50 patients were screened, and 14 patients who undertook the lesion ablation using RFA were enrolled. Mild adverse events occurred, while they were relieved under symptomatic treatment. No severe complications were recorded. All patients received regular follow-ups, during which an episode of IPMN-related pancreatitis occurred in 1 patient, and disease progression was found in 1 patient who successively underwent pancreaticoduodenectomy. Regional treatment of IPMN lesions in the MPD exhibited satisfactory effect in preventing lesion progression and relieving pancreatitis symptoms through the combined use of ERCP with pancreatoscopy and RFA, without causing severe complications.

Clinical significance of intraductal papillary mucinous neoplasms incidentally detected in patients with extrapancreatic gastrointestinal malignancies with a focus on pancreatic cancer development

BACKGROUND

Intraductal papillary mucinous neoplasm is occasionally detected in the preoperative images of patients with gastrointestinal malignancies. Despite numerous studies examining the incidence of extrapancreatic malignancies in patients with intraductal papillary mucinous neoplasm, limited data exist on the prevalence of intraductal papillary mucinous neoplasm in those with gastrointestinal malignancies. Given that intraductal papillary mucinous neoplasm is a known risk factor for pancreatic cancer, this study aimed to evaluate the prevalence of intraductal papillary mucinous neoplasm in patients who underwent radical surgery for extrapancreatic gastrointestinal malignancies and its impact on pancreatic cancer development.

METHODS

We retrospectively reviewed the preoperative computed tomography images of patients who underwent radical surgery for gastrointestinal malignancies between January 2017 and December 2021 for the presence of intraductal papillary mucinous neoplasm. Patients were divided into intraductal papillary mucinous neoplasm and non-intraductal papillary mucinous neoplasm groups, and clinicopathologic features and long-term outcomes, including pancreatic cancer development, were compared between groups.

RESULTS

A total of 814 patients who underwent radical surgery for extrapancreatic gastrointestinal malignancies were included. Among them, 81 patients (10.0%) had intraductal papillary mucinous neoplasm. The median observation period was 39 (0-79) months. Notably, pancreatic cancer developed in 5 patients with intraductal papillary mucinous neoplasm and 1 without. The 5-year cumulative incidences of pancreatic cancer were 8.8% and 0.2% in the intraductal papillary mucinous neoplasm and non-intraductal papillary mucinous neoplasm groups, respectively (P < .001).

CONCLUSION

Intraductal papillary mucinous neoplasm is frequently detected in the preoperative images of patients with gastrointestinal malignancies and is associated with a significantly higher risk of developing pancreatic cancer. Consequently, long-term surveillance for pancreatic cancer is crucial in patients with intraductal papillary mucinous neoplasm, particularly those with extrapancreatic gastrointestinal malignancies.

Reducing the incidence of pancreatic cancer through radiofrequency ablation of mucinous cystic neoplasms: What is the evidence?

Pancreatic cystic lesions are mostly discovered incidentally during cross-sectional imaging for other indications. They range from benign cysts to premalignant lesions, posing a risk for development of pancreatic cancer. Surveillance of cysts with low-risk features and surgical resection of high-risk ones has been the standard of care. However, the lack of consensus between national society guidelines results in discordant management and follow-up. One of the upcoming therapeutic modalities for pancreatic cysts, including mucinous cystic neoplasms (MCN), is endoscopic ultrasound (EUS)-guided interventions, including injection of chemotherapeutic agents or EUS-guided radiofrequency ablation (EUS-RFA). EUS-RFA is emerging as a promising minimally invasive tool with the need for further investigation to understand its clinical utility. This review discusses the physiology, clinical studies, adverse events, and future perspectives of RFA for various pancreatic lesions, with particular regard with MCN.

Reducing the burden of pancreatic cancer by surveilling mucinous cystic neoplasms: are we there yet?

Pancreatic cystic neoplasms are a common condition, with intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs) being of particular concern due to their potential for malignant transformation. Resection of these lesions before progression to invasive cancer represents a crucial opportunity to reduce the burden of pancreatic cancer. However, the benefit of early-resection must be weighed against the risk of overtreatment. Applying current guidelines, nearly half of the patients who undergo resection for IPMN might not have required surgery, while malignancy is detected in only 16 % of resected MCNs. This raises concerns, particularly given the increasing detection of small cysts with the widespread use of radiological imaging and the significant postoperative risks, including exocrine and endocrine insufficiency. Emerging evidence suggests that surveillance strategies could be more broadly applied, reducing unnecessary surgeries. This review aims to reassess the current evidence regarding both surgical resection and surveillance of IPMNs and MCNs.

Adjunct mucin biomarkers MUC2+MUC5AC and MUC5AC+PSCA in a clinical setting identify and may improve correct selection of high-risk pancreatic lesions for surgery

BACKGROUND

Pancreatic cancer has dismal prognosis with a 5-year survival of 12 %. Cystic lesions have been identified as premalignant lesions. The challenge is to identify lesions with high risk of malignant progression, to offer patients prophylactic curative pancreatic surgery. Previous studies have identified mucin biomarker panels (MUCPs) as potential discriminators of pre- and malignant pancreatic cystic lesions. The present study assessed whether MUCPs contribute to more accurate identification of patients with high-risk pancreatic lesions and improve selection for surgery.

METHODS

This retrospective crossover study included 88 patients referred to endoscopic ultrasound because of unclear pancreatic cystic lesions. Clinical management and surgical decision-making with and without MUCP values were assessed by two expert teams with access to patient medical history, radiology, fine-needle aspirates, cytology, and cystic fluid carcinoembryonic antigen.

RESULTS

The adjunct of MUCPs improved decision-making in 2 of 21 cases with surgical pathology, identifying one cancer that otherwise would have been missed and sparing one patient from unnecessary surgery.

CONCLUSION

Access to MUCPs in a clinical setting improved correct selection of high-risk pancreatic lesions for surgery in single cases. A higher number of incorrect recommendations for surgery with the adjunct of MUCPs was also noted, which calls for caution.

Endoscopic sphincterotomy to prevent post-ERCP pancreatitis after self-expandable metal stent placement for distal malignant biliary obstruction (SPHINX): a multicentre, randomised controlled trial

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) with fully covered self-expandable metal stent (FCSEMS) placement is the preferred approach for biliary drainage in patients with suspected distal malignant biliary obstruction (MBO). However, FCSEMS placement is associated with a high risk of post-ERCP pancreatitis (PEP). Endoscopic sphincterotomy prior to FCSEMS placement may reduce PEP risk.

OBJECTIVE

To compare endoscopic sphincterotomy to no sphincterotomy prior to FCSEMS placement.

DESIGN

This multicentre, randomised, superiority trial was conducted in 17 hospitals and included patients with suspected distal MBO. Patients were randomised during ERCP to receive either endoscopic sphincterotomy (sphincterotomy group) or no sphincterotomy (control group) prior to FCSEMS placement. The primary outcome was PEP within 30 days. Secondary outcomes included procedure-related complications and 30-day mortality. An interim analysis was performed after 50% of patients (n=259) had completed follow-up.

RESULTS

Between May 2016 and June 2023, 297 patients were included in the intention-to-treat analysis, with 156 in the sphincterotomy group and 141 in the control group. After the interim analysis, the study was terminated prematurely due to futility. PEP did not differ between groups, occurring in 26 patients (17%) in the sphincterotomy group compared with 30 patients (21%) in the control group (relative risk 0.78, 95% CI 0.49 to 1.26, p=0.37). There were no significant differences in bleeding, perforation, cholangitis, cholecystitis or 30-day mortality.

CONCLUSION

This trial found that endoscopic sphincterotomy was not superior to no sphincterotomy in reducing PEP in patients with distal MBO. Therefore, there was insufficient evidence to recommend routine endoscopic sphincterotomy prior to FCEMS placement.

TRIAL REGISTRATION NUMBER

NL5130.

Diagnostic Accuracy of Detective Flow Imaging Endoscopic Ultrasonography for Evaluating Blood Flow Within Mural Nodules of Intraductal Papillary Mucinous Neoplasms

Background/Objectives: Detective flow imaging (DFI) endoscopic ultrasonography (EUS) can identify the microvascular flow imaging of a mural nodule (MN) in an intraductal papillary mucinous neoplasm (IPMN) without the use of contrast agents. This retrospective study evaluated the diagnostic accuracy of DFI-EUS and its ability to evaluate the blood flow of MNs in IPMNs. Methods: Between April 2021 and September 2023, 68 patients with MNs in IPMNs observed on EUS images were retrospectively analyzed. Both DFI-EUS and contrast-enhanced EUS (CE-EUS) were performed during the same session. Three expert endosonographers blinded to the patients' clinical data assessed the MN images obtained with CE-EUS and DFI-EUS. First, DFI-EUS images were evaluated using a predefined scoring system; thereafter, CE-EUS images were evaluated. The diagnostic capability of DFI-EUS to detect MN blood flow was assessed with CE-EUS as the gold standard. Secondary outcomes included inter-reader agreement, the correlation between MN size and detection rates, and the association between DFI blood flow signal patterns and malignancy of MNs in surgically resected cases. Results: CE-EUS showed a contrast effect in the MN in 24 cases. Among these, DFI-EUS detected blood flow signals in 20 cases; false-positive results were not observed. DFI-EUS demonstrated a sensitivity of 83%, specificity of 100%, and accuracy of 93% for detecting MN blood flow. Inter-reader agreement was substantial (kappa values, 0.6-0.8). The subgroup analysis revealed that all MNs ≥ 10 mm had detectable blood flow on DFI-EUS, whereas MNs < 10 mm had reduced detection rates (75%; 12/16 cases). No significant correlation between the DFI blood flow signal patterns and MN malignancy of resected cases was observed. Conclusions: DFI-EUS demonstrated high diagnostic accuracy for detecting MN blood flow. Because of its simplicity and cost-effectiveness, DFI-EUS could be an alternative to CE-EUS for patients with MNs inside IPMNs.

Endoscopic techniques for the diagnosis of pancreatic cystic lesions

Pancreatic cysts are mostly incidental findings on computed tomography or magnetic resonance imaging scans, with few patients presenting with abdominal pain or other symptoms. The accurate diagnosis of cysts is important as management depends on the type (neoplastic or non-neoplastic). Cross-sectional imaging is fast being replaced with endoscopic ultrasound (EUS) and various techniques based on that such as EUS-guided fine needle aspiration, EUS-guided needle confocal laser endomicroscopy, EUS-through-the-needle biopsy, and contrast-enhanced EUS. Clinical studies have reported varying diagnostic and adverse event rates with these modalities. In addition, American, European, and Kyoto guidelines for the diagnosis and management of pancreatic cysts have provided different recommendations. In this editorial, we elaborate on the clinical guidelines, recent studies, and comparison of different endoscopic methods for the diagnosis of pancreatic cysts.

Multi-omic biomarker panel in pancreatic cyst fluid and serum predicts patients at a high risk of pancreatic cancer development

Integration of multi-omic data for the purposes of biomarker discovery can provide novel and robust panels across multiple biological compartments. Appropriate analytical methods are key to ensuring accurate and meaningful outputs in the multi-omic setting. Here, we extensively profile the proteome and transcriptome of patient pancreatic cyst fluid (PCF) (n = 32) and serum (n = 68), before integrating matched omic and biofluid data, to identify biomarkers of pancreatic cancer risk. Differential expression analysis, feature reduction, multi-omic data integration, unsupervised hierarchical clustering, principal component analysis, spearman correlations and leave-one-out cross-validation were performed using RStudio and CombiROC software. An 11-feature multi-omic panel in PCF [PIGR, S100A8, REG1A, LGALS3, TCN1, LCN2, PRSS8, MUC6, SNORA66, miR-216a-5p, miR-216b-5p] generated an AUC = 0.806. A 13-feature multi-omic panel in serum [SHROOM3, IGHV3-72, IGJ, IGHA1, PPBP, APOD, SFN, IGHG1, miR-197-5p, miR-6741-5p, miR-3180, miR-3180-3p, miR-6782-5p] produced an AUC = 0.824. Integration of the strongest performing biomarkers generated a 10-feature cross-biofluid multi-omic panel [S100A8, LGALS3, SNORA66, miR-216b-5p, IGHV3-72, IGJ, IGHA1, PPBP, miR-3180, miR-3180-3p] with an AUC = 0.970. Multi-omic profiling provides an abundance of potential biomarkers. Integration of data from different omic compartments, and across biofluids, produced a biomarker panel that performs with high accuracy, showing promise for the risk stratification of patients with pancreatic cystic lesions.

Unraveling the Long-term Natural History of Branch Duct Intraductal Papillary Mucinous Neoplasm: Beyond 10 years

OBJECTIVE

To describe the long-term natural history of branch duct intraductal papillary mucinous neoplasm (BD-IPMN).

BACKGROUND

The BD-IPMN is a known precursor of pancreatic cancer, yet its long-term natural history is largely unknown.

METHODS

We retrospectively reviewed patients with BD-IPMN who were followed at the Massachusetts General Hospital for at least 10 years without surgical intervention. Patient and cyst characteristics, development of worrisome features (WF), need for surgery, and malignancy were recorded. The risk of pancreatic cancer in this cohort was compared with the general population by determining the standardized incidence ratio.

RESULTS

Three hundred sixteen patients with BD-IPMN who were followed for at least 10 years without intervention were identified. The median age was 63 years, and the median follow-up was 13.5 years (range: 10-28.8 years). Median cyst size at diagnosis was 1.2 cm (IQR: 0.8-1.7), was 1.8 cm (IQR: 1.2-2.6) at 10 years, and increased to 2.0 cm (IQR: 1.3-3.0) by the end of surveillance. At the 10-year mark, 24% of patients had WF, and by the end of surveillance, an additional 20% had developed WF or high-risk stigmata. 8.2% of patients developed pancreatic malignancy (high-grade dysplasia or invasive cancer). The standardized incidence ratio for pancreatic cancer was 9.28 (95% CI: 5.82-14.06), with almost two-thirds of invasive cancers occurring within the pancreatic cyst.

CONCLUSIONS

After 10 years of surveillance for BD-IPMN without intervention, the disease continues to progress, and 1 of every 12 patients will develop malignancy. The risk of pancreatic cancer appears to be 9 times higher than in the comparable age-matched population.

EUS-guided lauromacrogol ablation with different concentrations of lauromacrogol for the treatment of pancreatic cystic neoplasm: A randomized controlled study

Objectives

To explore the safety and efficacy of injections of 1%, 2%, or 3% lauromacrogol during EUS-guided lauromacrogol ablation (EUS-LA) for the treatment of pancreatic cystic neoplasms (PCNs) and to determine the optimal concentration of lauromacrogol for use in EUS-LA therapeutic regimens.

Methods

From May 2021 to January 2023, patients who met the indications for EUS-LA were randomly divided into 3 groups: A, B, and C; the patients in these groups were injected with 1%, 2%, and 3% lauromacrogol during EUS-LA, respectively. Safety was evaluated based on the incidence of postoperative complications. Efficacy was comprehensively evaluated by assessing the ablation rate and ablation effect.

Results

Forty-two patients underwent EUS-LA, and 31 patients completed at least 1 postoperative re-examination. No acute pancreatitis was observed in the 1% and 2% lauromacrogol groups, and 1 case of acute pancreatitis occurred in the 3% lauromacrogol group. The total complication rate was 2.4%. The median ablation rates of the groups were 94.1%, 82.0%, and 100.0%, respectively. There were statistically significant differences in the EUS-LA ablation rate between the 1% and 3% lauromacrogol groups and between the 2% and 3% lauromacrogol groups. There was a statistically significant difference in complete disappearance between the 1% and 3% lauromacrogol groups as well as between the 2% and 3% lauromacrogol groups.

Conclusion

The short-term outcomes showed that injections of 1%, 2%, and 3% lauromacrogol were safe for use in EUS-LA, and injection of 3% lauromacrogol was the most effective for EUS-LA.

Identifying an optimal cancer risk threshold for resection of pancreatic intraductal papillary mucinous neoplasms

BACKGROUND

IPMN consensus guidelines make implicit judgments on what cancer risk level should prompt surgery. We used decision modeling to estimate this cancer risk threshold (CRT) for BD-IPMN patients.

METHODS

We created a decision model to compare quality-adjusted life years (QALYs) following surgery or surveillance for BD-IPMNs. We simulated treatment decisions for hypothetical patients, varying age, comorbidities and lesion location (pancreatic head/tail). The base case was a 60-year-old patient with mild comorbidities and pancreatic head IPMN. Probabilities, life expectancies, and utilities were incorporated from literature/public datasets. CRT was defined as the level of cancer risk at which the expected value of QALYs for surgery first exceeded that of surveillance.

RESULTS

In the base case, surgery was preferred over surveillance, yielding 21.90 vs. 21.88 QALYs. The optimal CRT for a BD-IPMN patient depended on age, comorbidities, and location. CRT in the base case was 20 % and 3 % for an IPMN in the head and tail of the pancreas, respectively. Other drivers of preferred treatment were age and likelihood of postoperative mortality.

CONCLUSION

For BD-IPMNs, the optimal CRT varies depending on patient age and risk of surgical complications. Personalized risk threshold values could guide treatment decisions and inform future treatment consensus guidelines.

Association of Smoking with progression from low-risk to high-risk intraductal papillary mucinous neoplasms and pancreatic cancer

BACKGROUND

Factors associated with the risk of pancreatic adenocarcinoma (PDAC) may play a role in the development and progression of Intraductal Papillary Mucinous Neoplasms (IPMNs). However, data are limited.

AIM

To compare exposome factors in three groups of patients with "high or low-risk" IPMNs, as assessed at diagnosis and during a 24-months follow-up, and with PDAC.

METHODS

Patients were matched (same sex, age ±5) 1:1. Exposure variables were compared across groups using Kruskal-Wallis, ANOVA, or Chi-square tests with Bonferroni correction.

RESULTS

A total of 151 patients were enrolled in each of the three groups (453 overall). The proportion of current smokers was progressively higher in "low-risk", "high-risk" IPMNs and PDAC patients (8.1 %, 11.2 %, 23.3 %; p = 0.0002). The three groups did not differ in terms of ever or heavy smoking, BMI, history of diabetes, cancer, cholecystectomy or chronic pancreatitis, use of statins or aspirin, and family history of cancer. A history of peptic ulcer was more common in PDAC (7.2 %) than in either "low-risk" (2.0 %) or "high-risk" (2.6%) IPMNs (p = 0.02, not significant after Bonferroni correction).

CONCLUSION

Active smoking seems associated with the progression of IPMNs to malignancy, and cessation of active smoking might be advised in patients with IPMN.

Advances for Managing Pancreatic Cystic Lesions: Integrating Imaging and AI Innovations

Pancreatic cystic lesions (PCLs) represent a spectrum of non-neoplasms and neoplasms with varying malignant potential, posing significant challenges in diagnosis and management. While some PCLs are precursors to pancreatic cancer, others remain benign, necessitating accurate differentiation for optimal patient care. Conventional approaches to PCL management rely heavily on radiographic imaging, and endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA), coupled with clinical and biochemical data. However, the observer-dependent nature of image interpretation and the complex morphology of PCLs can lead to diagnostic uncertainty and variability in patient management strategies. This review critically evaluates current PCL diagnosis and surveillance practices, showing features of the different lesions and highlighting the potential limitations of conventional methods. We then explore the potential of artificial intelligence (AI) to transform PCL management. AI-driven strategies, including deep learning algorithms for automated pancreas and lesion segmentation, and radiomics for analyzing heterogeneity, can improve diagnostic accuracy and risk stratification. These advanced techniques can provide more objective and reproducible assessments, aiding clinicians in decision-making regarding follow-up intervals and surgical interventions. Early results suggest that AI-driven methods can significantly improve patient outcomes by enabling earlier detection of high-risk lesions and reducing unnecessary procedures for benign cysts. Finally, this review emphasizes that AI-driven approaches could potentially reshape the landscape of PCL management, ultimately leading to improved pancreatic cancer prevention.

Incidental pancreatic cystic lesions: retrospective analysis of natural history and efficacy of imaging surveillance guidelines

OBJECTIVES

To assess the natural history of incidental pancreatic cystic lesions (PCLs) and the sensitivity of surveillance guidelines to detect malignancy.

MATERIALS AND METHODS

We performed a single-center retrospective analysis of incidental PCLs discovered between 2012 and 2017. Patients were identified by searching radiology reports for relevant keywords, then search results were manually reviewed to exclude patients with < 5 years of follow-up, non-incidental PCLs, known pancreatic cancer, or pancreatitis. Baseline and follow-up imaging was reviewed to record size, growth (as defined by the American College of Radiology (ACR)), high-risk stigmata, and incidence of malignancy. Four major guidelines (International Consensus, European, ACR, and Canadian Association of Radiologists (CAR)) were retrospectively applied to assess sensitivity to detect invasive disease. Benign and malignant PCL outcomes were compared (Fisher's exact test), and PCL growth was modeled (mixed-effects regression).

RESULTS

Four hundred and forty-nine patients (67 ± 12 years, 284 women) with 556 PCLs were included. PCL natural growth was 0.33 mm/year (0.26-0.40 mm 95% CI), which overlaps with significant growth thresholds for ACR and CAR guidelines. Nine patients over 21,996 patient-years of follow-up developed pancreatic cancer (4.1 cases/10,000 patient-years). Malignancy was not associated with significant growth (4/9 vs 107/547, p = 0.084) but was with high-risk stigmata (3/9 vs 3/547, p < 0.001). Guideline sensitivities ranged from 33.3 to 66.7% (2-4/6 cases).

CONCLUSION

PCLs are common, overwhelmingly benign, and grow slowly. Development of high-risk stigmata is associated with malignancy but not "significant growth," which can overlap with natural PCL growth. Despite differences in recommended duration and frequency of follow-up, surveillance guidelines still miss 1/3-2/3 of cancers.

KEY POINTS

Question There is limited evidence on the natural growth and malignant potential of incidental pancreatic cystic lesions. Findings Incidental pancreatic cystic lesions grew slowly (0.3 mm/year) and were uncommonly malignant (2%). Retrospective application of surveillance guidelines missed 1/3-2/3 of cancers. Clinical relevance Radiologists and imaging surveillance guidelines should account for the natural growth of incidental pancreatic cystic lesions. Given the low rate of malignancy, high proportion of missed cancers, and risk of overtreatment, the effectiveness of imaging surveillance guidelines remains unclear.

Intracystic Glucose Measurement for On-Site Differentiation Between Mucinous and Non-Mucinous Pancreatic Cystic Lesions

BACKGROUND

Pancreatic cystic lesions (PCLs) are frequently detected incidentally and vary from benign to malignant. Accurate differentiation between mucinous (M-PCLs) and non-mucinous PCLs (NM-PCLs) is essential for appropriate management. This study aims to validate the accuracy of on-site glucose measurement using a glucometer with a cut-off of 50 mg/dL for distinguishing M-PCLs from NM-PCLs.

METHODS

In this prospective multicenter study, conducted at three European academic hospitals, patients who underwent endoscopic ultrasound-guided fine-needle aspiration for PCLs between 2019 and 2020 were included. On-site glucose measurement was performed using a conventional glucometer. Data on demographics, clinical features, EUS findings, and histopathology were collected.

RESULTS

Fifty patients were enrolled, with 37 having glucose levels < 50 mg/dL and 13 ≥ 50 mg/dL. M-PCLs were more common in the <50 mg/dL group (81%) compared to the ≥50 mg/dL group (23%, p < 0.001). The median CEA was higher in the <50 mg/dL group (146 ng/mL) than in the ≥50 mg/dL group (3 ng/mL, p = 0.047). On-site glucose testing < 50 mg/dl demonstrated a sensitivity of 93.2%, a specificity of 76.5%, and an accuracy of 89% for detecting M-PCLs with an AUC of 0.74 and an OR of 14.29 (p < 0.001). In comparison, CEA > 192 ng/mL had a sensitivity of 55.6%, a specificity of 87.5%, and an accuracy of 75.8% for M-PCLs, with an AUC of 0.65 and an OR of 4.44.

CONCLUSIONS

On-site glucose measurement using a glucometer with a cut-off of <50 mg/dL is a highly accurate, rapid, and cost-effective method for differentiating M-PCLs from NM-PCLs. Our results validate the glucose cut-off in a multicentric prospective cohort supporting its integration into standard diagnostic protocols for PCLs.

Endoscopic ultrasound is useful for the risk stratification of mucinous pancreatic cystic lesions: A long-term prospective study

OBJECTIVES

The aims of this prospective observational study were to test worrisome features on endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) as a stratification tool in patients with mucinous pancreatic cystic lesions (PCLs), and to assess these patients' long-term risk of adenocarcinoma and mortality.

METHODS

Patients with suspected PCLs on cross-sectional imaging who underwent EUS-FNA at Sahlgrenska University Hospital between February 2007 and February 2018 were consecutively enrolled. The main inclusion criterion was the final diagnosis of a mucinous PCL. The results from EUS-FNA were analyzed in the context of outcome gathered from medical records of follow-up until February 2021.

RESULTS

Of 334 patients undergoing EUS-FNA, 171 (51 %) had a final diagnosis of a mucinous PCL. 29/171 (17 %) patients were diagnosed with HGD or adenocarcinoma <6 months after EUS-FNA, with 28/29 (97 %) patients having at least one worrisome feature on EUS-FNA. A solid component in mucinous PCLs on EUS was independently associated with the presence of HGD or adenocarcinoma (OR 23.6, 95 % CI 6.1-91.6, p < .001). A total of 4/142 (3 %) patients developed adenocarcinoma during the follow-up period (median = 61.4 months). Overall, in 80/82 (98 %) of the patients without worrisome features on EUS-FNA, HGD or adenocarcinoma was not detected. Six of the 21 (29 %) patients with HGD or adenocarcinoma who underwent surgery as initial management died from pancreatic cancer during follow-up.

CONCLUSIONS

EUS-FNA is useful for the risk stratification of mucinous PCLs. The low incidence of adenocarcinoma over time after a negative EUS-FNA may allow for a less resource intensive surveillance strategy.

The Past, Present, and Future of Biomarkers for the Early Diagnosis of Pancreatic Cancer

Pancreatic cancer is one of the most aggressive cancers with a very poor 5-year survival rate and reduced therapeutic options when diagnosed in an advanced stage. The dismal prognosis of pancreatic cancer has guided significant efforts to discover novel biomarkers in order to anticipate diagnosis, increasing the population of patients who can benefit from curative surgical treatment. CA 19-9 is the reference biomarker that supports the diagnosis and guides the response to treatments. However, it has significant limitations, a low specificity, and is inefficient as a screening tool. Several potential biomarkers have been discovered in the serum, urine, feces, and pancreatic juice of patients. However, most of this evidence needs further validation in larger cohorts. The advent of advanced omics sciences and liquid biopsy techniques has further enhanced this field of research. The aim of this review is to analyze the historical evolution of the research on novel biomarkers for the early diagnosis of pancreatic cancer, focusing on the current evidence for the most promising biomarkers from different body fluids and the novel trends in research, such as omics sciences and liquid biopsy, in order to favor the application of modern personalized medicine.

Endoscopic Ultrasound-Guided Pancreatic Tissue Sampling: Lesion Assessment, Needles, and Techniques

Endoscopic ultrasound (EUS)-guided tissue sampling includes the techniques of fine needle aspiration (FNA) and fine needle biopsy (FNB), and both procedures have revolutionized specimen collection from the gastrointestinal tract, especially from remote/inaccessible organs. EUS-FNB has replaced FNA as the procedure of choice for tissue acquisition in solid pancreatic lesions (SPLs) across various society guidelines. FNB specimens provide a larger histological tissue core (preserving tissue architecture) with fewer needle passes, and this is extremely relevant in today's era of precision and personalized molecular medicine. Innovations in needle tip design are constantly under development to maximize diagnostic accuracy by enhancing histological sampling capabilities. But, apart from the basic framework of the needle, various other factors play a role that influence diagnostic outcomes, namely, sampling techniques (fanning, aspiration or suction, and number of passes), collection methods, on-site evaluation (rapid, macroscopic, or visual), and specimen processing. The choice taken depends strongly on the endoscopist's preference, available resources at the disposal, and procedure objectives. Hence, in this review, we explicate in detail the concepts and available literature at our disposal on the topic of EUS-guided pancreatic tissue sampling to best guide any practicing gastroenterologist/endoscopist in a not-to-ideal set-up, which EUS-guided tissue acquisition technique is the "best" for their case to augment their diagnostic outcomes.

The Revised Kyoto Criteria and Risk of Malignancy Among Patients With Intraductal Papillary Mucinous Neoplasms

BACKGROUND & AIMS

The revised Kyoto guidelines have a new catalog of high-risk stigmata and worrisome features for the risk stratification of intraductal papillary mucinous neoplasms (IPMNs). We aimed to validate the stratification system in terms of short- and long-term risks of pancreatic carcinoma.

METHODS

We included 3336 patients diagnosed with IPMNs in 2000-2021 and examined short-term (≤6 months) and long-term risks of pancreatic carcinoma diagnosis. We used the multivariable competing-risks proportional hazards regression model to calculate subdistribution hazard ratios for long-term incidence of pancreatic carcinoma with adjustment for potential confounders.

RESULTS

In short-term analyses, pancreatic carcinomas were prevalent predominantly in IPMNs with high-risk stigmata (49% vs 1.3% and 0.05% in IPMNs with worrisome features and no risk factors, respectively). In long-term analyses of worrisome features, the main pancreatic duct diameter of 5-9.9 mm, acute pancreatitis, and IPMN growth rate of 2.5 mm/y were associated with a high incidence with multivariable subdistribution hazard ratios of 3.46 (95% confidence interval [CI], 2.04-5.89), 5.65 (95% CI, 1.86-17.2), and 3.83 (95% CI, 2.14-6.86), respectively. An increasing number of worrisome features at baseline was associated with a higher prevalence and incidence of pancreatic carcinoma (Ptrend < .001). Patients with 1, 2, and 3-4 worrisome features had multivariable subdistribution hazard ratios for pancreatic cancer incidence of 1.43 (95% CI, 0.93-2.19), 2.17 (95% CI, 1.17-4.05), and 10.1 (95% CI, 4.20-24.5), respectively (vs no positive feature).

CONCLUSIONS

The revised Kyoto criteria stratify IPMN patients well in terms of the short- and long-term risks of pancreatic carcinoma diagnosis, potentially informing personalized patient management.

Survey of Experts' Opinions on the Diagnosis and Management of Pancreatic Cystic Neoplasms

OBJECTIVE

To survey experts' opinions in abdominal radiology (radiologists) and pancreas-specialized gastroenterology (pancreatologists) in South Korea regarding diagnosing and managing pancreatic cystic neoplasms (PCNs).

MATERIALS AND METHODS

Between August 25, 2023, and October 5, 2023, an online survey was conducted among members of the Korean Society of Abdominal Radiology and the Korean Pancreatobiliary Association via email invitation.

RESULTS

The responses from 100 radiologists and 41 pancreatologists were analyzed. Of the respondents, 55.3% (78/141) reported seeing more than 50 patients or reading more than 50 exams related to PCN each month. The most common and preferred diagnostic modality for PCN was contrast-enhanced computed tomography (CECT), favored by 87.8% (36/41) of pancreatologists. When discrepancies arose between CECT or magnetic resonance imaging (MRI) and endoscopic ultrasound, 31.2% (44/141) of the respondents opted for multidisciplinary team discussion, whereas 29.1% (41/141) chose short-term follow-up using CECT or MRI. A total of 88.7% (125/141) of the respondents adhered to the 2017 International Association of Pancreatology (IAP) guidelines in their practice. Among the radiologists, 51.0% (51/100) endorsed a cut-off value of 5 mm for enhancing mural nodules, and 22.0% (22/100) supported a 5 mm/2 yr growth rate in the IAP guidelines v.2017. Additionally, 73.0% (73/100) of radiologists favored discontinuing surveillance, whereas 41.5% (17/41) of pancreatologists disagreed with stopping surveillance.

CONCLUSION

The survey underscores the clinical burden PCN poses and identifies CECT as the foremost diagnostic tool. Variability was noted in the terminology, differential diagnosis, approaches for resolving discrepancies between imaging examinations, and opinions on surveillance discontinuation among the respondents as a whole, as well as between radiologists and pancreatologists. Although the 2017 IAP guidelines are primarily followed, there remains a level of dissatisfaction with risk stratification among radiologists. This highlights the need for more standardized diagnostic algorithms and improved consensus among specialists to address these challenges.