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Pancreatology : Official Journal of the... Feb 2024This systematic review aimed to assess the diagnostic accuracy of the International Consensus Fukuoka Guidelines (ICG2017) in identifying high-risk lesions of... (Review)
Review
BACKGROUND
This systematic review aimed to assess the diagnostic accuracy of the International Consensus Fukuoka Guidelines (ICG2017) in identifying high-risk lesions of Intraductal Papillary Mucinous Neoplasms (IPMNs).
METHODS
The ICG2017 revision committee conducted a comprehensive literature review to establish evidence-based statements on IPMNs. The review focused on articles examining the diagnostic value of imaging features (e.g., cyst or main pancreatic duct diameter), clinical symptoms associated with IPMN, and serum biomarkers. Five clinical questions regarding high-risk stigmata (HRS) and worrisome features (WF) in the ICG2017 guidelines were addressed.
RESULTS
A total of 210 articles were reviewed. The findings revealed a significant association between the presence of mural nodules ≥5 mm in diameter or solid components with contrast enhancement and the diagnosis of high-grade dysplasia or invasive carcinoma. Contrast-enhanced diagnostic tools, such as CT, MRI, or EUS, demonstrated the highest prediction rate and were recommended. Positive cytology was identified as an HRS, while symptoms like acute pancreatitis and cyst diameter growth ≥2.5 mm per year were considered WFs. The use of nomograms and multiple diagnostic factors was recommended for optimal IPMN management.
CONCLUSIONS
This systematic review provides evidence supporting the improved diagnostic accuracy of ICG2017 in identifying high-risk lesions of IPMN. The multidisciplinary incorporation of HRS and WF based on imaging findings and clinical symptoms is crucial. These findings should inform the revision of ICG2017, enhancing the evaluation and management of IPMN patients. By implementing these recommendations, clinicians can make more informed decisions, leading to better diagnosis and treatment outcomes for high-risk IPMN cases.
Topics: Humans; Acute Disease; Carcinoma, Pancreatic Ductal; Cysts; Neoplasms, Cystic, Mucinous, and Serous; Pancreatic Ducts; Pancreatic Intraductal Neoplasms; Pancreatic Neoplasms; Pancreatitis; Retrospective Studies
PubMed: 38161091
DOI: 10.1016/j.pan.2023.12.002 -
Modern Pathology : An Official Journal... Jan 2022The literature is highly conflicted on what percentage of pancreatic ductal adenocarcinomas (PDACs) arise in association with intraductal papillary mucinous neoplasms... (Comparative Study)
Comparative Study
Pancreatic ductal adenocarcinomas associated with intraductal papillary mucinous neoplasms (IPMNs) versus pseudo-IPMNs: relative frequency, clinicopathologic characteristics and differential diagnosis.
The literature is highly conflicted on what percentage of pancreatic ductal adenocarcinomas (PDACs) arise in association with intraductal papillary mucinous neoplasms (IPMNs). Some studies have claimed that even small (Sendai-negative) IPMNs frequently lead to PDAC. Recently, more refined pathologic definitions for mucin-lined cysts were provided in consensus manuscripts, but so far there is no systematic analysis regarding the frequency and clinicopathologic characteristics of IPMN-mimickers, i.e., pseudo-IPMNs. In this study, as the first step in establishing frequency, we performed a systematic review of the pathologic findings in 501 consecutive ordinary PDACs, which disclosed that 10% of PDACs had associated cysts ≥1 cm. While 31 (6.2%) of these were IPMN or mucinous cystic neoplasm (MCN), 19 (3.8%) were other cyst types that mimicked IPMN (pseudo-IPMNs) per recent WHO/consensus criteria. As the second step of the study, we performed a comparative clinicopathologic analysis by also including our entire surgical pathology/consultation databases that was comprised of 60 IPMN-associated PDACs, 30 MCN-associated PDACs and 40 pseudo-IPMN-associated PDACs. We found that 84% of true IPMNs were pre-operatively recognized, whereas IPMN was considered in differential diagnosis of 33% of pseudo-IPMNs. Of the 40 pseudo-IPMNs, there were 15 secondary duct ectasias; 6 large-duct-type PDACs; 5 pseudocysts; 5 cystic tumor necrosis; 4 simple mucinous cysts; 3 groove pancreatitis-associated paraduodenal wall cysts; and 2 congenital cysts. Microscopically, pseudo-IPMNs had at least partial mucinous-lining mimicking IPMN but had smaller cystic (mean = 1.9 cm) and larger PDAC (mean = 3.8 cm) components compared to true IPMNs (cyst = 5.7 cm; PDAC = 2.0 cm). In summary, in this pathologically verified analysis that utilized refined criteria, 10% of PDACs were discovered to have cysts ≥1 cm, about two-thirds of which were IPMN/MCN but about one-third were pseudo-IPMNs. True IPMNs underlying the PDACs are often large and are already diagnosed pre-operatively as having an IPMN component, whereas only a third of the pseudo-IPMNs receive IPMN diagnosis by imaging and their cysts are smaller. At the histopathologic level, pseudo-IPMNs are highly prone to misdiagnosis as IPMN, which presumably accounts for much higher association of IPMNs with PDAC as reported in some studies. The subtle but salient characteristics of pseudo-IPMNs elucidated in this study should be combined with careful radiological/clinical correlation in order to exclude pseudo-IPMNs.
Topics: Adenocarcinoma; Adult; Aged; Aged, 80 and over; Bile Duct Neoplasms; Carcinoma, Pancreatic Ductal; Diagnosis, Differential; Female; Humans; Male; Middle Aged; Pancreatic Intraductal Neoplasms; Pancreatic Neoplasms
PubMed: 34518632
DOI: 10.1038/s41379-021-00902-x -
HPB : the Official Journal of the... May 2015Endoscopic ultrasonography with fine needle aspiration (EUS-FNA) has become an integral tool in the diagnosis of pancreatic cystic lesions (PCLs) and the analysis of... (Review)
Review
BACKGROUND
Endoscopic ultrasonography with fine needle aspiration (EUS-FNA) has become an integral tool in the diagnosis of pancreatic cystic lesions (PCLs) and the analysis of molecular/DNA abnormalities might improve the accuracy of pre-operative diagnosis. A review was conducted of all studies using EUS-FNA aspirates of PCLs to assess the accuracy and added benefit that molecular analysis provides to cytological analysis.
METHODS
A systematic review of the literature was conducted using PRISMA guidelines and electronic databases: PubMed/SCOPUS/EMBASE/Cochrane/CINAHL. Surgical pathology was used as the definitive reference standard. The QUADAS-2 tool was used for quality assessment.
RESULTS
In total, 162 articles were identified; 12 articles met inclusion/exclusion criteria. Ten studies reported on cytology and 8 studies reported k-ras mutational analysis. 362 patients (of 1115 total) had surgical pathology available. The sensitivity and specificity of cytology was 0.42 and 0.99; the sensitivity and specificity of k-ras was 0.39 and 0.95; and the sensitivity and specificity of the combined test of cytology and k-ras was 0.71 and 0.88, respectively.
CONCLUSIONS
k-ras mutational analysis used as an individual screening test has a poor diagnostic accuracy, as does cytology when used alone. The benefit comes with utilization in a combined fashion. More studies are needed to evaluate the correct sequence and utility of these tests for cyst differentiation.
Topics: DNA; DNA Mutational Analysis; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Genes, ras; Humans; Molecular Diagnostic Techniques; Pancreas; Pancreatic Cyst
PubMed: 25428782
DOI: 10.1111/hpb.12364 -
Zentralblatt Fur Chirurgie Aug 2020A steady improvement in modern imaging as well as increasing age in society have led to an increasing number of cystic pancreatic tumours being detected. Pancreatic...
A steady improvement in modern imaging as well as increasing age in society have led to an increasing number of cystic pancreatic tumours being detected. Pancreatic cysts are a clinically challenging entity because they span a broad biological spectrum and their differentiation is often difficult, especially in small tumours. Therefore, they require a differentiated indication for indication of surgery. To determine recommendations for the surgical indication in cystic tumours of the pancreas, a quality committee for pancreatic diseases of the German Society for General and Visceral Surgery performed a systematic literature search and created this review. Based on the current evidence, signs of malignancy and high-risk criteria (icterus due to cystic pancreatic duct obstruction in the bile duct, enhancing mural nodules ≥ 5 mm or solid components in the cyst or pancreatic duct ≥ 10 mm), as well as symptoms, are a surgical indication, independently of the cyst entity (except pseudocysts). If the entity of the pancreatic cyst is detectable by diagnostic imaging, all main duct IPMN and IPMN of the mixed type, all MCN > 4 cm and all SPN should be resected. SCN and branch-duct IPMN without worrisome features do not constitute an indication for surgery. The indication of operation in branch-duct IPMN with relative risk criteria and MCN < 4 cm is the subject of current discussions and should be individualised. By defining indication recommendations, the present work aims to improve the indication quality in cystic pancreatic tumours. However, the surgical indication should always be individualised, taking into account age, comorbidities and the patient's wishes.
Topics: Carcinoma, Pancreatic Ductal; Humans; Pancreas; Pancreatic Cyst; Pancreatic Ducts; Pancreatic Neoplasms
PubMed: 32498095
DOI: 10.1055/a-1158-9536 -
Annals of Surgical Oncology Feb 2022The consensus guidelines for branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) of the pancreas are mostly based on imaging features. This study aimed to... (Meta-Analysis)
Meta-Analysis Review
Imaging Features for Predicting High-Grade Dysplasia or Malignancy in Branch Duct Type Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Systematic Review and Meta-Analysis.
BACKGROUND
The consensus guidelines for branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) of the pancreas are mostly based on imaging features. This study aimed to determine imaging features and their diagnostic accuracy for predicting high-grade dysplasia (HGD)/malignancy in BD-IPMN, including mixed type.
METHODS
The PubMed, Embase, and Cochrane databases were searched, and data were extracted from relevant studies. As the main diagnostic accuracy index, diagnostic odds ratios (DORs) of imaging features for diagnosing HGD/malignancy in BD-IPMNs were pooled using the random-effects model. A bivariate random-effects approach was used to construct summary receiver operating characteristic curves for sensitivity and specificity estimation.
RESULTS
The pooled DOR was the highest for the enhanced solid component/mural nodule (MN) (DOR, 12.21; 95 % confidence interval [CI], 6.14-24.27), followed by a main pancreatic duct (MPD) diameter of 10 mm or greater (DOR, 7.93; 95 % CI, 3.02-20.83), solid component (DOR, 4.85; 95 % CI, 2.49-9.42), lymphadenopathy (DOR, 4.84; 95 % CI, 1.11-21.06), MN (DOR, 4.48; 95 % CI, 3.15-6.39), an MPD diameter of 5 mm or greater (DOR, 3.69; 95 % CI, 2.62-5.19), abrupt change in MPD caliber with distal pancreatic atrophy (DOR, 2.65; 95 % CI, 1.66-4.24), thickened/enhancing walls (DOR, 2.38; 95 % CI, 1.57-3.60), and cyst size of 3 cm or larger (DOR, 1.98; 95 % CI, 1.48-2.64). The largest area under the curve (0.89 and 0.95, respectively) and high specificity (0.95 and 0.98, respectively) also were found for enhanced solid component/MN and an MPD diameter of 10 mm or greater, albeit with low sensitivity (0.38 and 0.14, respectively).
CONCLUSIONS
The aforementioned imaging features could aid in predicting HGD/malignancy of BD-IPMN. Furthermore, enhanced solid component/MN and an MPD diameter of 10 mm or greater were the most important predictors of HGD/malignancy in BD-IPMN and should be considered as indications for surgery.
Topics: Adenocarcinoma, Mucinous; Carcinoma, Pancreatic Ductal; Humans; Pancreas; Pancreatic Ducts; Pancreatic Neoplasms; Retrospective Studies
PubMed: 34554343
DOI: 10.1245/s10434-021-10662-2 -
Pancreas Oct 2017The aim of this study was to pool incidences of increased cyst size, malignant branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs), pancreatic malignancy,...
Incidences of Pancreatic Malignancy and Mortality in Patients With Untreated Branch-Duct Intraductal Papillary Mucinous Neoplasms Undergoing Surveillance: A Systematic Review.
OBJECTIVE
The aim of this study was to pool incidences of increased cyst size, malignant branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs), pancreatic malignancy, and pancreatic malignancy-related death during follow-up (FU) of BD-IPMN patients.
METHODS
Searches were performed from January 2010 to April 2016. All hits were checked on inclusion criteria, and outcomes were extracted. Incidences were pooled. Three subgroups were defined: (1) including only BD-IPMN patients, (2) short-interval FU (maximum 6 months), and (3) long-interval FU (>6 months).
RESULTS
Thirty-one articles were enrolled, including 8455 patients (mean age, 66.4 years). Twenty-two studies included subgroup 1; 10 and 6 studies included, respectively, subgroups 2 and 3. Incidence of increased cyst size was 17.4%. In subgroups 1, 2, and 3, incidences were, respectively, 20.0%, 17.2%, and 31.7%. Incidence of malignant BD-IPMN was 2.5. In subgroups 1, 2, and 3, incidences were, respectively, 3.0%, 2.4%, and 3.3%. Incidence of pancreatic malignancy was 2.6%. In subgroups 1, 2, and 3, incidences were, respectively, 2.3%, 1.2%, and 4.0%. Incidence of death was 0.5%. In subgroups 1, 2, and 3, incidences were, respectively, 0.4%, 0.04%, and 0.12%.
CONCLUSIONS
Although not significant, all incidences on long-interval FU were higher; therefore, short-interval FU seems necessary to find resectable lesions.
Topics: Adenocarcinoma, Mucinous; Aged; Carcinoma, Pancreatic Ductal; Female; Humans; Incidence; Male; Pancreatic Ducts; Pancreatic Neoplasms; Survival Rate
PubMed: 28902778
DOI: 10.1097/MPA.0000000000000907 -
Clinical and Translational... Jun 2015There is significant research interest in developing and validating novel pancreatic cyst-fluid biomarkers given the increasing recognition of the prevalence of...
There is significant research interest in developing and validating novel pancreatic cyst-fluid biomarkers given the increasing recognition of the prevalence of pancreatic cysts and their associated malignant potential. Although current international consensus guidelines are helpful, they fail to diagnose with certainty the cyst type and the level of epithelial dysplasia. They also fall short in predicting the future likelihood of malignant transformation. A systematic review was performed with the objective of summarizing cyst-fluid-based biomarkers that have been published in the medical literature over the past 10 years and characterizing the current quality of evidence. Our review demonstrates that there is an increasing interest in this topic with several different and innovative approaches including DNA, RNA, proteomic, and metabolomics profiling. Further techniques to improve upon cytological yield have also been studied. Besides identifying potentially useful clinical biomarkers, these empiric approaches have provided further insight into their pathogenesis. The level of evidence for the vast majority of these studies, however, is limited to retrospective early validation studies. The path forward will be to select out the most promising biomarkers and develop multicenter consortiums capable of capturing adequate sample sizes with appropriate study designs.
PubMed: 26065716
DOI: 10.1038/ctg.2015.17 -
Annals of Surgical Oncology Jul 2024Pancreatoduodenectomy (PD) has a considerable surgical risk for complications and late metabolic morbidity. Parenchyma-sparing resection of benign tumors has the... (Meta-Analysis)
Meta-Analysis
Long-Term Oncologic Outcome following Duodenum-Preserving Pancreatic Head Resection for Benign Tumors, Cystic Neoplasms, and Neuroendocrine Tumors: Systematic Review and Meta-analysis.
BACKGROUND
Pancreatoduodenectomy (PD) has a considerable surgical risk for complications and late metabolic morbidity. Parenchyma-sparing resection of benign tumors has the potential to cure patients associated with reduced procedure-related short- and long-term complications.
MATERIALS AND METHODS
Pubmed, Embase, and Cochrane libraries were searched for studies reporting surgery-related complications following PD and duodenum-preserving total (DPPHRt) or partial (DPPHRp) pancreatic head resection for benign tumors. A total of 38 cohort studies that included data from 1262 patients were analyzed. In total, 729 patients underwent DPPHR and 533 PD.
RESULTS
Concordance between preoperative diagnosis of benign tumors and final histopathology was 90.57% for DPPHR. Cystic and neuroendocrine neoplasms (PNETs) and periampullary tumors (PATs) were observed in 497, 89, and 31 patients, respectively. In total, 34 of 161 (21.1%) patients with intraepithelial papillar mucinous neoplasm exhibited severe dysplasia in the final histopathology. The meta-analysis, when comparing DPPHRt and PD, revealed in-hospital mortality of 1/362 (0.26%) and 8/547 (1.46%) patients, respectively [OR 0.48 (95% CI 0.15-1.58); p = 0.21], and frequency of reoperation of 3.26 % and 6.75%, respectively [OR 0.52 (95% CI 0.28-0.96); p = 0.04]. After a follow-up of 45.8 ± 26.6 months, 14/340 patients with intraductal papillary mucinous neoplasms/mucinous cystic neoplasms (IPMN/MCN, 4.11%) and 2/89 patients with PNET (2.24%) exhibited tumor recurrence. Local recurrence at the resection margin and reoccurrence of tumor growth in the remnant pancreas was comparable after DPPHR or PD [OR 0.94 (95% CI 0.178-5.34); p = 0.96].
CONCLUSIONS
DPPHR for benign, premalignant neoplasms provides a cure for patients with low risk of tumor recurrence and significantly fewer early surgery-related complications compared with PD. DPPHR has the potential to replace PD for benign, premalignant cystic and neuroendocrine neoplasms.
Topics: Humans; Pancreatic Neoplasms; Neuroendocrine Tumors; Pancreaticoduodenectomy; Duodenum; Organ Sparing Treatments; Pancreatic Cyst; Postoperative Complications; Prognosis; Pancreatectomy
PubMed: 38578553
DOI: 10.1245/s10434-024-15222-y -
Digestive Diseases and Sciences Jan 2019Ethnic health disparity is a well-acknowledged issue in many disease settings, but not diseases of the exocrine pancreas. A systematic review and meta-analysis was... (Meta-Analysis)
Meta-Analysis
Ethnic health disparity is a well-acknowledged issue in many disease settings, but not diseases of the exocrine pancreas. A systematic review and meta-analysis was conducted to explore the race- and ethnicity-specific burden of diseases of the exocrine pancreas. Studies that compared health-related endpoints between two or more ethnicities were eligible for inclusion. Proportion meta-analyses were conducted to compare burden between groups. A total of 42 studies (24 on pancreatic cancer, 17 on pancreatitis, and one on pancreatic cyst) were included in the systematic review, of which 19 studies were suitable for meta-analyses. The incidence of pancreatic cancer was 1.4-fold higher among African-Americans, while the incidence of acute pancreatitis was 4.8-fold higher among an indigenous population (New Zealand Māori) compared with Caucasians. The prevalence of post-pancreatitis diabetes mellitus was up to 3.0-fold higher among certain ethnicities, including Asians, Pacific Islanders, and indigenous populations compared with Caucasians. The burden of diseases of the exocrine pancreas differs between ethnicities, with African-Americans and certain indigenous populations being at the greatest risk of developing these diseases. Development of race- and ethnicity-specific screening as well as protocols for lifestyle modifications may need to be considered with a view to reducing the disparities in burden of diseases of the exocrine pancreas.
Topics: Black or African American; Diabetes Mellitus; Health Status Disparities; Humans; Incidence; Life Style; Minority Health; Pancreas, Exocrine; Pancreatic Cyst; Pancreatic Diseases; Pancreatic Neoplasms; Pancreatitis; Population Groups; Risk Factors
PubMed: 30259278
DOI: 10.1007/s10620-018-5291-1 -
Clinical and Translational... Dec 2015Pancreatic intraductal papillary mucinous neoplasias (IPMNs) represent 25% of all cystic neoplasms and are precursor lesions for pancreatic ductal adenocarcinoma. This...
OBJECTIVES
Pancreatic intraductal papillary mucinous neoplasias (IPMNs) represent 25% of all cystic neoplasms and are precursor lesions for pancreatic ductal adenocarcinoma. This study aims to identify the best imaging modality for detecting malignant transformation in IPMN, the sensitivity and specificity of risk features on imaging, and the usefulness of tumor markers in serum and cyst fluid to predict malignancy in IPMN.
METHODS
Databases were searched from November 2006 to March 2014. Pooled sensitivity and specificity of diagnostic techniques/imaging features of suspected malignancy in IPMN using a hierarchical summary receiver operator characteristic (HSROC) approach were performed.
RESULTS
A total of 467 eligible studies were identified, of which 51 studies met the inclusion criteria and 37 of these were incorporated into meta-analyses. The pooled sensitivity and specificity for risk features predictive of malignancy on computed tomography/magnetic resonance imaging were 0.809 and 0.762 respectively, and on positron emission tomography were 0.968 and 0.911. Mural nodule, cyst size, and main pancreatic duct dilation found on imaging had pooled sensitivity for prediction of malignancy of 0.690, 0.682, and 0.614, respectively, and specificity of 0.798, 0.574, and 0.687. Raised serum carbohydrate antigen 19-9 (CA19-9) levels yielded sensitivity of 0.380 and specificity of 0903. Combining parameters yielded a sensitivity of 0.743 and specificity of 0.906.
CONCLUSIONS
PET holds the most promise in identifying malignant transformation within an IPMN. Combining parameters increases sensitivity and specificity; the presence of mural nodule on imaging was the most sensitive whereas raised serum CA19-9 (>37 KU/l) was the most specific feature predictive of malignancy in IPMNs.
PubMed: 26658837
DOI: 10.1038/ctg.2015.60