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Abdominal Radiology (New York) Apr 2021There have been many publications detailing imaging features of malignant transformation of intraductal papillary mucinous neoplasms (IPMN), management and... (Review)
Review
Intraductal papillary mucinous neoplasm (IPMN) of the pancreas: recommendations for Standardized Imaging and Reporting from the Society of Abdominal Radiology IPMN disease focused panel.
There have been many publications detailing imaging features of malignant transformation of intraductal papillary mucinous neoplasms (IPMN), management and recommendations for imaging follow-up of diagnosed or presumed IPMN. However, there is no consensus on several practical aspects of imaging IPMN that could serve as a clinical guide for radiologists and enable future data mining for research. These aspects include how to measure IPMN, define reporting terminology, standardize reporting and unify guidelines for surveillance. The Society of Abdominal Radiology (SAR) created multiple Disease-Focused Panels (DFP) comprised multidisciplinary panel members who focus on a particular disease, with the goal to develop ways for radiologists to improve patient care, education, and research. DFP members met to identify the current controversies and limitations of imaging pancreatic IPMN. This paper aims to provide a practical review of the key imaging characteristics of IPMN for trainees and practicing radiologists, to guide uniformity of performance and interpretation of surveillance imaging studies, and to improve communication with clinicians by providing a lexicon and reporting template based on the experience of the SAR-DFP panel members.
Topics: Humans; Pancreas; Pancreatic Intraductal Neoplasms; Pancreatic Neoplasms; Radiography, Abdominal; Radiology
PubMed: 33185741
DOI: 10.1007/s00261-020-02853-4 -
JAMA Surgery Apr 2024Despite the increasing prevalence of intraductal papillary mucinous neoplasm (IPMN), data on the growth and malignant conversion rates based on long-term surveillance...
IMPORTANCE
Despite the increasing prevalence of intraductal papillary mucinous neoplasm (IPMN), data on the growth and malignant conversion rates based on long-term surveillance cohorts are limited. Many international guidelines recommend surveillance for benign lesions, but the optimal interval and duration are unclear.
OBJECTIVE
To determine the optimal surveillance protocol for IPMN and propose which patients may be exempted from surveillance.
DESIGN, SETTING, AND PARTICIPANTS
This large-scale, international cohort study examined data of 3825 patients with IPMN treated at 5 tertiary pancreatic centers. Included were patients with branch duct (BD) IPMN who underwent surveillance or surgery between January 1, 1988, and December 31, 2020. After a thorough review, 3656 patients were included in the analytic sample. Changes in cyst size, worrisome features or high-risk stigmata, and malignant conversion rates were assessed. Patients who underwent surveillance over 5 years were compared to suggest discontinuation of surveillance protocol. Clinical data collection began in January 1, 2021, and the mean (SD) follow-up duration was 84 (47.7) months. The data analysis was performed from May 2, 2022, through September 14, 2022.
EXPOSURE
The patients with BD-IPMN were followed up based on International Association of Pancreatology guidelines. Patients with suspicious malignant neoplasms during surveillance underwent surgical resection.
MAIN OUTCOME AND MEASURES
The main outcome of this study was the optimal follow-up interval and duration of BD-IPMN surveillance. The association among cyst size, growth rate, and progression was examined using descriptive statistics.
RESULTS
Of the 3656 patients with BD-IPMN in the analytic sample (1973 [54.0%] female; mean [SD] age, 63.7 [10.2] years), 172 (4.7%) were confirmed to have malignant lesions through surgery. Considering cyst growth, the time to develop worrisome features, and malignant conversion, a 1.5-, 1-, and 0.5-year surveillance interval could be optimal for cysts smaller than 20 mm, 20 to 30 mm, and 30 mm, respectively, after initial short-term (6-month) follow-up. Patients with cysts smaller than 20 mm, no worrisome features, and no growth during 5-year surveillance did not show malignant conversion after 5 years of follow-up and had time to progression of greater than 10 years.
CONCLUSIONS
These findings suggest that BD-IPMN surveillance may depend on the size of the cyst and morphologic changes at the initial 6-month follow-up. For patients with small cysts (ie, <20 mm) with no morphologic changes during the initial 5-year surveillance period, surveillance may be discontinued for those unfit for surgery or who have a limited life expectancy of 10 years or less.
Topics: Humans; Female; Middle Aged; Male; Pancreatic Intraductal Neoplasms; Cohort Studies; Retrospective Studies; Pancreatic Neoplasms; Pancreas; Cysts; Carcinoma, Pancreatic Ductal
PubMed: 38231494
DOI: 10.1001/jamasurg.2023.7010 -
Journal of Medical Ultrasonics (2001) Apr 2024Advancements in diagnostic radiology have amplified the incorporation of these techniques into routine clinical practice. Concurrently, the frequency of incidentally... (Review)
Review
Advancements in diagnostic radiology have amplified the incorporation of these techniques into routine clinical practice. Concurrently, the frequency of incidentally identifying pancreatic cystic lesions (PCLs) has surged. PCLs encompass diverse categories contingent upon their origin. Among them, branch duct-intraductal papillary mucinous neoplasms (BD-IPMN) and mucinous cystic neoplasms (MCN) are categorized as mucinous cystic lesions that have malignant potential. Even solid neoplasms occasionally show cystic degeneration. Therefore, precise differential PCL diagnosis is crucial to optimize clinical management strategies and detect malignant transformations. Endoscopic ultrasound (EUS) affords comprehensive visualization of the pancreas with high-resolution ultrasound, complemented by fine-needle aspiration (FNA) under real-time EUS guidance, which is a minimally invasive procedure for obtaining pathological samples. This synergy has established EUS and EUS-FNA as vital procedures in the management of PCLs, enabling differentiation of PCLs. Cyst fluid analysis has played a pivotal role in deciding the optimal management strategy. The efficacy of cytological analysis is limited by scant cytologic material. The "string sign" test evaluates fluid viscosity, and its simplicity warrants initial consideration. Amylase and tumor markers, such as CEA, have been studied, but they yield varied sensitivity and specificity. Glucose and genetic mutations (KRAS, GNAS) exhibit promise, while comprehensive genomic profiling underscores genetic insights. Through-the-needle biopsy and needle-based confocal laser endomicroscopy also show high diagnostic yield. EUS-FNA, however, entails risks like infection and needle tract seeding, emphasizing the need for proper utilization. Pancreatic cyst fluid analysis augments diagnostic accuracy and informs clinical decisions, making it a valuable adjunct to imaging.
Topics: Humans; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Pancreatic Cyst; Pancreas; Pancreatic Neoplasms; Diagnosis, Differential
PubMed: 38051460
DOI: 10.1007/s10396-023-01389-6 -
The American Journal of Gastroenterology Sep 2023Guidelines endorse pancreatic cancer screening in genetically susceptible individuals. We conducted a prospective, multicenter study to determine yield, harms, and...
INTRODUCTION
Guidelines endorse pancreatic cancer screening in genetically susceptible individuals. We conducted a prospective, multicenter study to determine yield, harms, and outcomes of pancreatic cancer screening.
METHODS
All high-risk individuals undergoing pancreatic cancer screening at 5 centers from 2020 to 2022 were prospectively enrolled. Pancreas findings were designated as low-risk (fatty or chronic pancreatitis-like changes), intermediate-risk (neuroendocrine tumor [NET] <2 cm or branch-duct intraductal papillary mucinous neoplasm [IPMN]), or high-risk lesions (high-grade pancreatic intraepithelial neoplasia/dysplasia, main-duct IPMN, NET >2 cm, or pancreatic cancer). Harms from screening included adverse events during screening or undergoing low-yield pancreatic surgery. Annual screening was performed using endoscopic ultrasound and or magnetic resonance cholangiopancreatography. Annual screening for new-onset diabetes using fasting blood sugar was also performed ( ClinicalTrials.gov : NCT05006131).
RESULTS
During the study period, 252 patients underwent pancreatic cancer screening. Mean age was 59.9 years, 69% were female, and 79.4% were White. Common indications were BRCA 1/2 (36.9%), familial pancreatic cancer syndrome kindred (31.7%), ataxia telangiectasia mutated (3.5%), Lynch syndrome (6.7%), Peutz-Jeghers (4.3%), and familial atypical multiple mole melanoma (3.5%). Low-risk lesions were noted in 23.4% and intermediate-risk lesions in 31.7%, almost all of which were branch-duct IPMN without worrisome features. High-risk lesions were noted in 2 patients (0.8%), who were diagnosed with pancreas cancer at stages T2N1M0 and T2N1M1. Prediabetes was noted in 18.2% and new-onset diabetes in 1.7%. Abnormal fasting blood sugar was not associated with pancreatic lesions. There were no adverse events from screening tests, and no patient underwent low-yield pancreatic surgery.
DISCUSSION
Pancreatic cancer screening detected high-risk lesions with lower frequency than previously reported. No harms from screening were noted.
Topics: Humans; Female; Middle Aged; Male; Pancreatic Intraductal Neoplasms; Prospective Studies; Early Detection of Cancer; Pancreas; Pancreatic Neoplasms; Carcinoma, Pancreatic Ductal
PubMed: 37141538
DOI: 10.14309/ajg.0000000000002314 -
Japanese Journal of Radiology Feb 2021A variety of neoplastic and non-neoplastic lesions of the pancreas can present with a predominantly cystic architecture. These lesions are increasingly being detected as... (Review)
Review
A variety of neoplastic and non-neoplastic lesions of the pancreas can present with a predominantly cystic architecture. These lesions are increasingly being detected as incidental findings on routine cross-sectional imaging following technological advances in these techniques and their widespread use. The different histopathological behaviors show various common and uncommon imaging findings, and some cases show similar appearance in spite of different histopathology. Each lesion requires specific management because of the differing risk of progression to malignancy, and an accurate imaging diagnosis is crucial. The typical imaging characteristics that differentiate pancreatic cystic lesions have been well described and fully summarized. However, in addition to a small percentage of cases that shows uncommon imaging findings, a substantial percentage of cystic lesions shows overlapping imaging findings that can lead to radiological misdiagnosis. For appropriate diagnosis and optimal treatment strategy, it is important to know the uncommon and overlapping imaging findings of these lesions, in addition to familiarity with the typical aspects. In this article, we reconfirm the well-known characteristic imaging features of pancreatic cystic lesions and present several diagnostically challenging cases, focusing on the uncommon and overlapping imaging findings.
Topics: Diagnosis, Differential; Female; Humans; Magnetic Resonance Imaging; Male; Pancreas; Pancreatic Cyst; Pancreatic Neoplasms; Tomography, X-Ray Computed
PubMed: 32840742
DOI: 10.1007/s11604-020-01032-1 -
Archives of Pathology & Laboratory... Nov 2019According to the 2017 World Health Organization classification, pancreatic neuroendocrine neoplasms (PanNENs) include a new category of pancreatic neuroendocrine tumor,... (Review)
Review
CONTEXT.—
According to the 2017 World Health Organization classification, pancreatic neuroendocrine neoplasms (PanNENs) include a new category of pancreatic neuroendocrine tumor, grade 3, which is often difficult to differentiate from pancreatic neuroendocrine carcinoma. However, pancreatic neuroendocrine tumor grade 3 and pancreatic neuroendocrine carcinoma are distinct entities with very different clinical presentation, prognosis, and therapeutic strategies. Recent discoveries on the molecular characteristics of pancreatic neuroendocrine tumors also play an essential role in the pathologic differential diagnosis of PanNENs. In addition, the histopathologic varieties of PanNENs bring in many differential diagnoses with other pancreatic neoplasms, especially acinar cell carcinoma, solid pseudopapillary neoplasm, and ductal adenocarcinoma.
OBJECTIVE.—
To provide a brief update of the World Health Organization classification; the clinical, histopathologic, immunohistochemical, and molecular characteristics; and the differential diagnoses and biological behavior of PanNENs.
DATA SOURCES.—
Analysis of the pertinent literature (PubMed) and authors' clinical practice experience based on institutional and consultation materials.
CONCLUSIONS.—
The evolving clinical, histopathologic, immunohistochemical, and molecular features of PanNENs are reviewed. Important differential diagnoses with other neoplasms of the pancreas are discussed.
Topics: Diagnosis, Differential; Humans; Immunohistochemistry; Neoplasm Grading; Neuroendocrine Tumors; Pancreas; Pancreatic Neoplasms; Prognosis; World Health Organization
PubMed: 31509453
DOI: 10.5858/arpa.2019-0338-RA -
ANZ Journal of Surgery Sep 2020Solid pseudopapillary tumour of the pancreas (SPTP) is a rare pancreatic tumour characterized by a non-specific clinical presentations and vague radiologic features. The... (Review)
Review
BACKGROUND
Solid pseudopapillary tumour of the pancreas (SPTP) is a rare pancreatic tumour characterized by a non-specific clinical presentations and vague radiologic features. The aim of this study is to identify these tumours from other pancreatic neoplasms because complete resection is curative in most cases and provides long-term survival.
METHODS
A retrospective analysis of patients operated for SPTP between January 2000 and December 2018 was conducted. The collected data included age, gender, clinical findings, laboratory tests, radiological findings, anatomopathological examination, immunohistochemistry results, surgical treatment, mortality, morbidity and recurrence.
RESULTS
Ten cases of SPTP have been diagnosed between January 2000 and December 2018 representing 5.1% of all pancreatic tumours operated during this period (male/female: 2/8; median age 41.2 years; range 19-78 years). The most common symptom was abdominal pain and physical examination was normal in four of 10 cases. The most common tumour localization was the tail of the pancreas. The main tumour size was 7.2 cm (range 2-15 cm). One patient had abdominal disseminated disease. Surgical interventions were distal pancreatectomy in five cases, enucleation in one case, cephalic duodeno-pancreatectomy in two cases, central pancreatectomy in one case and pancreatic biopsy in one case. Only one patient received adjuvant chemotherapy. During follow-up, one patient died after 12 months and another developed unique hepatic metastasis that was resected.
CONCLUSION
Although it is delayed in diagnosis, the overall prognosis of these tumours remains good even with local recurrence and metastasis. Complete surgical resection is the treatment of choice even in cases of recurrence.
Topics: Adult; Aged; Female; Humans; Male; Middle Aged; Neoplasm Recurrence, Local; Pancreas; Pancreatectomy; Pancreatic Neoplasms; Retrospective Studies; Young Adult
PubMed: 31989788
DOI: 10.1111/ans.15701 -
World Journal of Gastroenterology Jun 2022We described the case of a peripancreatic paraganglioma (PGL) misdiagnosed as pancreatic lesion. Surgical exploration revealed an unremarkable pancreas and a large...
We described the case of a peripancreatic paraganglioma (PGL) misdiagnosed as pancreatic lesion. Surgical exploration revealed an unremarkable pancreas and a large well-defined cystic mass originating at the mesocolon root. Radical enucleation of the mass was performed, preserving the pancreatic tail. Histologically, a diagnosis of PGL was rendered. Interestingly, two previously unreported mutations, one affecting the gene in exon 7 and another on the gene in exon 4 were detected. Both mutations are known to be pathogenetic. Imaging and cytologic findings were blindly reviewed by an expert panel of clinicians, radiologists, and pathologists to identify possible causes of the misdiagnosis. The major issue was lack of evidence of a cleavage plane from the pancreas at imaging, which prompted radiologists to establish an intra-parenchymal origin. The blinded revision shifted the diagnosis towards an extra-pancreatic lesion, as the pancreatic parenchyma showed no structural alterations and no dislocation of the Wirsung duct. , the identified biases were the emergency setting of the radiologic examination and the very thin mesocolon sheet, which hindered clear definition of the lesion borders. Original endoscopic ultrasonography diagnosis was confirmed, emphasizing the intrinsic limit of this technique in detecting large masses. Finally, pathologic review favored a diagnosis of PGL due to the morphological features and immonohistochemical profile. Eighteen months after tumor excision, the patient is asymptomatic with no disease relapse evident by either radiology or laboratory tests. Our report strongly highlights the difficulties in rendering an accurate pre-operative diagnosis of PGL.
Topics: Endosonography; Female; Humans; Neoplasm Recurrence, Local; Pancreas; Pancreatic Neoplasms; Paraganglioma; Young Adult
PubMed: 35800185
DOI: 10.3748/wjg.v28.i21.2396 -
Asian Journal of Endoscopic Surgery Oct 2023Mesenchymal chondrosarcoma is a rare subset of sarcomas accounting for 3%-10% of all cases of chondrosarcomas. Radical resection is the only curative strategy, even in...
Mesenchymal chondrosarcoma is a rare subset of sarcomas accounting for 3%-10% of all cases of chondrosarcomas. Radical resection is the only curative strategy, even in patients with metastatic tumors. However, data regarding treatment strategies remain limited owing to the small number of cases. Herein, we report a patient who underwent repeated robotic pancreatectomy for recurrent pancreatic metastasis originating from extraskeletal mesenchymal chondrosarcoma of the pelvis. First, robotic pancreaticoduodenectomy with a reconstruction of pancreaticogastrostomy was performed for synchronous pancreatic metastasis 5 months after the primary resection of mesenchymal chondrosarcoma. Ten months after robotic pancreaticoduodenectomy, tumor recurrence was observed at the tail end of the pancreas, which was removed by reperforming robotic distal pancreatectomy. Given the precise tissue manipulation that can be achieved with robotic articulated forceps, the peripheral splenic artery and pancreas were easily isolated and divided in close proximity to the tumor. The central part of the pancreas was preserved. Robotic surgery allowed safe and effective resection of the reconstructed remnant pancreas. The patient survived for 28 months after primary tumor resection. Repeated pancreatectomy with minimally invasive techniques is a feasible and curative treatment for metastatic mesenchymal chondrosarcoma.
Topics: Humans; Pancreatectomy; Robotic Surgical Procedures; Chondrosarcoma, Mesenchymal; Neoplasm Recurrence, Local; Pancreatic Neoplasms; Pancreaticoduodenectomy; Neoplasms, Second Primary
PubMed: 37574440
DOI: 10.1111/ases.13240 -
Annali Italiani Di Chirurgia Sep 2022Solid pseudopapillary tumors (SPT) of the pancreas are rare, low malignancy and predominantly affect young women, but it may be locally aggressive. Pancreatic resection... (Review)
Review
BACKGROUND
Solid pseudopapillary tumors (SPT) of the pancreas are rare, low malignancy and predominantly affect young women, but it may be locally aggressive. Pancreatic resection is the main treatment for SPTs. However, low malignancy SPT may give insidious extrapancreatic invasions.
CASE REPORT
A 20-year-old woman was admitted with non-specific abdominal pain and diarrhea. A 9-cm SPT of the pancreas was discovered with extra-pancreatic invasion of the left adrenal gland and the spleen, in close contact with the body-tail of the pancreas, proximal portion of the jejunum, splenic flexure of the colon and the gastric fundus, with no signs of infiltration. For the young patient, a pancreas-preserving tumor excision was performed, with en-bloc resection of the spleen and adrenal gland, lymphadenectomy of the splenic vessels (13 lymph-nodes) and pre-pancreatic lymph node dissection, with no need for distal pancreatectomy. The duration of the surgery was 145 min, with no transfusion. The woman's postoperative course was complicated by a splenic lodge abscess treated via CT-guided percutaneous drainage, and a left pleural effusion treated medically, with a hospital stay of 16 days. Histology confirmed the diagnosis of a 9- cm low-grade SPT of the pancreas. In a close follow-up, the patient was asymptomatic 21 months later, with no tumor recurrence and good health.
CONCLUSIONS
Low-grade SPT of the pancreas with extra-pancreatic invasion of loco-regional organs can be treated by a pancreas-preserving approach to avoid a pancreatectomy. Moreover, still few cases of extra-pancreatic SPT are reported in the literature and there is an urgent need for more relevant evidence.
KEY WORDS
Extrapancreatic, Frantz's tumor, Pancreas preserving, Pancreas, Pancreatic neoplasm, Solid pseudopapillary tumor, Solid pancreatic tumor.
Topics: Female; Humans; Young Adult; Adult; Neoplasm Recurrence, Local; Pancreas; Pancreatectomy; Spleen; Pancreatic Neoplasms; Abdominal Abscess
PubMed: 36412249
DOI: No ID Found