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Der Pathologe Dec 2019Cytology has a key role in the step-wise diagnostic approach to pancreatic mass lesions. Brush cytology and ultrasound-guided endoscopic fine-needle aspiration provide... (Review)
Review
BACKGROUND
Cytology has a key role in the step-wise diagnostic approach to pancreatic mass lesions. Brush cytology and ultrasound-guided endoscopic fine-needle aspiration provide specimens for diagnosis prior to surgical or conservative therapy. The diagnostic system of the Papanicolaou Society of Cytopathology provides a conceptual framework for reporting these specimens. Cystic lesions represent a particular challenge in pancreatic cytology, as in many instances a purely morphological approach will not result in an adequate diagnostic interpretation. Noteworthy from a conceptual point of view is how the Papanicolaou Society System incorporates non-morphological methods: laboratory chemical (CEA >192 ng/ml) and molecular (KRAS and/or GNAS mutations) findings are part of the formal diagnostic criteria for neoplastic cysts.
RESULTS
The Bern experience shows that such an integrated approach results in a significantly increased diagnostic yield. Among 83 samples analyzed, adequate DNA could be extracted in 79 samples (95%). Next generation sequencing identified pathogenic mutations in 46 cases (58%). Of these, in 35 (76%) a neoplastic cyst could not have been diagnosed by morphology alone.
CONCLUSION
These findings illustrate a new perspective for diagnostic situations, where morphology alone does allow for a sufficient diagnostic work-up. Along this line of thinking, liquid biopsy should not be regarded as a replacement, but rather an extension of the cytology's diagnostic armamentarium, according to the principle of "doing more with less."
Topics: DNA Mutational Analysis; DNA, Neoplasm; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Humans; Mutation; Pancreas; Pancreatic Cyst; Pancreatic Neoplasms
PubMed: 31705231
DOI: 10.1007/s00292-019-00697-4 -
Gastrointestinal Endoscopy Clinics of... Jul 2024Endoscopic ultrasound (EUS) has rapidly evolved from a diagnostic to a therapeutic tool with applications for various pancreaticobiliary diseases. As part of this... (Review)
Review
Endoscopic ultrasound (EUS) has rapidly evolved from a diagnostic to a therapeutic tool with applications for various pancreaticobiliary diseases. As part of this evolution, EUS-guided chemoablation for neoplastic pancreatic cysts is developing as a minimally invasive treatment option for appropriately selected mucinous cysts, which can spare patients major resective surgery and may reduce progression to pancreatic cancer. Chemotherapeutic cyst ablation has demonstrated encouraging complete resolution rates, while an alcohol-free chemoablation protocol has demonstrated a significant decrease in adverse events without a compromise to complete ablation rates when compared with previous alcohol-based protocols. Most pancreatic cysts are small, low risk, and best managed by surveillance per accepted guidelines. Cysts with features suggestive of overt malignancy are best discussed by a multidisciplinary committee, and surgery is considered if appropriate. However, for patients in the middle ground with cysts that are structurally suitable for chemoablation, alcohol-free chemoablation has been shown to allow effective, safe, and durable results especially for those who are not ideal operative candidates. EUS-guided alcohol-free chemoablation is promising and continues to evolve; however, as a relatively novel treatment option it has areas of uncertainty that will require further investigation and development.
Topics: Humans; Pancreatic Cyst; Endosonography; Ablation Techniques; Pancreatic Neoplasms; Ultrasonography, Interventional
PubMed: 38796298
DOI: 10.1016/j.giec.2024.02.005 -
Gastrointestinal Endoscopy Oct 2021Recently, low levels of intracystic glucose acquired with EUS-guided pancreatic cyst fluid sampling have been shown to help to differentiate mucinous from nonmucinous... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND AIMS
Recently, low levels of intracystic glucose acquired with EUS-guided pancreatic cyst fluid sampling have been shown to help to differentiate mucinous from nonmucinous cystic neoplasms. The aim of this study was to perform a systematic review and meta-analysis to evaluate the diagnostic characteristics of pancreatic cyst fluid glucose compared with carcinoembryonic antigen (CEA) for pancreatic cystic lesions.
METHODS
Individualized searches were developed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines and meta-analysis analyzed according to Cochrane Diagnostic Test Accuracy working group methodology. A bivariate model was used to compute pooled sensitivity and specificity, likelihood ratio, diagnostic odds ratio, and summary receiver operating characteristics curve for intracystic glucose or CEA alone or combination testing.
RESULTS
Eight studies (609 lesions; mean patient age, 63.56 ± 2.75 years; 60.36% women) were included. The pooled sensitivity for pancreatic cyst fluid glucose was significantly higher compared with CEA alone (91% [95% confidence interval {CI}, 88-94; I = .00] vs 56% [95% CI, 46-66; I = 537.14]; P < .001) with no difference in specificity (86% [95% CI, 81-90; I = 24.16] vs 96% [95% CI, 90-99; I = 38.06]; P > .05). Diagnostic accuracy was significantly higher for pancreatic cyst fluid glucose versus CEA alone (94% [95% CI, 91-96] vs 85% [95% CI, 82-88]; P < .001). Combination testing with pancreatic cyst fluid glucose and CEA did not improve the diagnostic accuracy compared with glucose alone (97% [95% CI, 95-98] vs 94% [95% CI, 91-96]; P > .05).
CONCLUSIONS
Low pancreatic cyst fluid glucose was associated with a high sensitivity and specificity with significantly improved diagnostic accuracy compared with CEA alone for the diagnosis of mucinous versus nonmucinous pancreatic cystic lesions.
Topics: Aged; Carcinoembryonic Antigen; Cyst Fluid; Female; Glucose; Humans; Male; Middle Aged; Pancreatic Cyst; Pancreatic Neoplasms; Sensitivity and Specificity
PubMed: 33964311
DOI: 10.1016/j.gie.2021.04.025 -
The American Journal of Gastroenterology Mar 2022Differentiating mucinous neoplastic pancreatic cysts (MNPC) from cysts without malignant potential can be challenging. Guidelines recommend using fluid carcinoembryonic...
INTRODUCTION
Differentiating mucinous neoplastic pancreatic cysts (MNPC) from cysts without malignant potential can be challenging. Guidelines recommend using fluid carcinoembryonic antigen (CEA) to differentiate MNPC; however, its sensitivity and specificity vary widely. Intracystic glucose concentration has shown promise in differentiating MNPC, but data are limited to frozen specimens and cohorts of patients without histologic diagnoses. This study aimed to compare glucose and CEA concentrations in differentiating MNPC using fresh fluid obtained from cysts with confirmatory histologic diagnoses.
METHODS
This multicenter cohort study consisted of patients undergoing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic cysts during January 2013-May 2020. Patients were included if the cyst exhibited a histologic diagnosis and if both CEA and glucose were analyzed from fresh fluid. Receiver operating curve (ROC) characteristics were analyzed, and various diagnostic parameters were compared.
RESULTS
Ninety-three patients, of whom 59 presented with MNPC, met the eligibility criteria. The area under the receiver operating curve (AUROC) was 0.96 for glucose and 0.81 for CEA (difference 0.145, P = 0.003). A CEA concentration of ≥192 ng/mL had sensitivity of 62.7% and specificity of 88.2% in differentiating MNPC, whereas glucose concentration of ≤25 mg/dL had sensitivity and specificity of 88.1% and 91.2%, respectively.
DISCUSSION
Intracystic glucose is superior to CEA concentration for differentiating MNPC when analyzed from freshly obtained fluid of cysts with histologic diagnoses. The advantage of glucose is augmented by its low cost and ease of implementation, and therefore, its widespread adoption should come without barriers. Glucose has supplanted CEA as the best fluid biomarker in differentiating MNPC.
Topics: Carcinoembryonic Antigen; Cohort Studies; Cyst Fluid; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Glucose; Humans; Pancreatic Cyst; Pancreatic Neoplasms
PubMed: 35034045
DOI: 10.14309/ajg.0000000000001623 -
Deutsche Medizinische Wochenschrift... Feb 2021Cystic pancreatic lesions are a frequent incidental finding on ultrasound or cross sectional imaging. The incidence of pancreatic lesions experience a steady climb in... (Review)
Review
Cystic pancreatic lesions are a frequent incidental finding on ultrasound or cross sectional imaging. The incidence of pancreatic lesions experience a steady climb in recent years due to an increased number of cross sectional imaging and an increasing life expectancy. The clinical challenge is to identify individuals bearing lesions with potentially malignant or pre-malignant features. Indeed, by far most cystic pancreatic lesions are not associated with an increased risk for the development of cancer. Taking into account the increasing incidence rates of cystic pancreatic lesions a rational and economic use of diagnostics is warranted. This review provides an overview on the different types of cystic lesions, the appropriate use of diagnostics and a clinical management algorithm balancing intervention and surveillance.
Topics: Female; Humans; Male; Pancreas; Pancreatic Cyst; Pancreatic Neoplasms
PubMed: 33592661
DOI: 10.1055/a-1221-7266 -
Journal of Gastrointestinal Surgery :... May 2020The prevalence of incidental pancreatic cystic neoplasms (PCNs) has increased dramatically with advancements in cross-sectional imaging. Diagnostic imaging is limited in... (Review)
Review
BACKGROUND
The prevalence of incidental pancreatic cystic neoplasms (PCNs) has increased dramatically with advancements in cross-sectional imaging. Diagnostic imaging is limited in differentiating between benign and malignant PCNs. The aim of this review is to provide an overview of biomarkers that can be used to distinguish PCNs.
METHODS
A review of the literature on molecular diagnosis of cystic neoplasms of the pancreas was performed.
RESULTS
Pancreatic cysts can be categorized into inflammatory and non-inflammatory lesions. Inflammatory cysts include pancreatic pseudocysts. Noninflammatory lesions include both mucinous and non-mucinous lesions. Mucinous lesions include intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasm. Non-mucinous lesions include serous cystadenoma and solid-pseudopapillary tumor of the pancreas. Imaging, cyst aspiration, and histologic findings, as well as carcinoembryonic antigen and amylase are commonly used to distinguish between cyst types. However, molecular techniques to detect differences in genetic mutations, protein expression, glycoproteomics, and metabolomic profiling are important developments in distinguishing between cyst types.
DISCUSSION
Nomograms incorporating common clinical, laboratory, and imaging findings have been developed in a better effort to predict malignant IPMN. The incorporation of top molecular biomarker candidates to nomograms may improve the predictive ability of current models to more accurately diagnose malignant PCNs.
Topics: Cystadenoma, Serous; Humans; Pancreas; Pancreatic Cyst; Pancreatic Neoplasms; Pancreatic Pseudocyst
PubMed: 32128679
DOI: 10.1007/s11605-020-04537-2 -
Abdominal Radiology (New York) Aug 2021Pancreatic cystic neoplasms (PCN) comprise of a diverse array of pancreatic cysts, including intraductal papillary mucinous neoplasms (IPMN), mucinous cystic neoplasms... (Review)
Review
Pancreatic cystic neoplasms (PCN) comprise of a diverse array of pancreatic cysts, including intraductal papillary mucinous neoplasms (IPMN), mucinous cystic neoplasms (MCN), serous cystic neoplasms (SCN), cystic neuroendocrine tumors (cNET), and many others. Increasing use of cross-sectional imaging has resulted in greater numbers of PCNs discovered incidentally. The overall risk of malignancy is low, but can vary considerably between different classes of PCNs. Furthermore, many pancreatic cysts are indeterminate on imaging, and the inability to reliably predict the course of disease remains a challenge for radiologists. Due to the variability in disease course and a lack of high-quality studies on PCNs, there is no universal consensus when it comes to balancing optimal surveillance while avoiding the risk for overtreatment. Currently, there are three widely accepted international guidelines outlining guidelines for surveillance and management of PCNs: the American Gastroenterological Association (AGA) in 2015, the International Association of Pancreatology (IAP) last revised in 2017, and the European Study Group on Cystic Tumours of the Pancreas (European) last revised in 2018. In 2017, the American College of Radiology released its own comprehensive set of recommendations for managing indeterminate pancreatic cysts that are detected incidentally on CT or MRI. The purpose of this paper is to describe the key differences between the ACR recommendations and the aforementioned three sets of guidelines regarding cyst management, imaging surveillance, performance, and cost-effectiveness.
Topics: Humans; Magnetic Resonance Imaging; Neuroendocrine Tumors; Pancreas; Pancreatic Cyst; Pancreatic Neoplasms
PubMed: 33742217
DOI: 10.1007/s00261-021-03030-x -
Der Internist Apr 2022Pancreatic cancer is one of the most aggressive solid tumors and still has a poor prognosis. A delayed diagnosis at advanced stages and a poor response to systemic... (Review)
Review
Pancreatic cancer is one of the most aggressive solid tumors and still has a poor prognosis. A delayed diagnosis at advanced stages and a poor response to systemic treatment frequently make a curative treatment impossible. Therefore, the identification of high-risk patients and screening them regularly is the most promising approach to improve the prognosis. Chronic pancreatitis as well as neoplastic pancreatic cysts can greatly increase the risk of developing pancreatic cancer. Furthermore, familial syndromes and germline mutations also confer an increased risk for development of pancreatic cancer. This article provides an overview of the various premalignant diseases of the pancreas. The value of the various imaging modalities, such as magnetic resonance imaging and endosonography are particularly discussed as well as the screening interval and the indications for surgical treatment are explained.
Topics: Endosonography; Humans; Pancreas; Pancreatic Cyst; Pancreatic Neoplasms; Pancreatitis, Chronic
PubMed: 35234978
DOI: 10.1007/s00108-022-01308-w -
The American Journal of Gastroenterology Oct 2020Numerous guidelines exist for the management of pancreatic cysts. We sought to compare the guideline-directed management strategies for pancreatic cysts by comparing 2...
INTRODUCTION
Numerous guidelines exist for the management of pancreatic cysts. We sought to compare the guideline-directed management strategies for pancreatic cysts by comparing 2 approaches (2017 International Consensus Guidelines and 2015 American Gastroenterological Association Guidelines) that differ significantly in their thresholds for imaging, surveillance, and surgery.
METHODS
We developed a Monte Carlo model to evaluate the outcomes for a cohort of 10,000 patients managed per each guideline. The primary outcome was mortality related to pancreatic cyst management. Secondary outcomes included all-cause mortality, missed cancers, number of surgeries, number of imaging studies, cumulative cost, and quality-adjusted life years.
RESULTS
Deaths because of pancreatic cyst management and quality-adjusted life years were similar in both guidelines at a significantly higher cost of $3.6 million per additional cancer detected in the Consensus Guidelines. Deaths from "unrelated" causes (1,422) vastly outnumbered deaths related to pancreatic cysts (125). Secondary outcomes included more missed cancers in the American Gastroenterological Association guideline (71 vs 49), more surgeries and imaging studies in the Consensus guideline (711 vs 163; 116,997 vs 68,912), and higher cost in the Consensus guideline ($168.3 million vs $89.4 million). As the rate of malignant transformation increases, a more-intensive guideline resulted in fewer deaths related to pancreatic cyst management.
DISCUSSION
Our study demonstrates trade-offs between more- and less-intensive management strategies for pancreatic cysts. Although deaths related to pancreatic cyst management were similar in each strategy, fewer missed cancers in the more-intensive surveillance strategy is offset by a greater number of surgical deaths and higher cost. In conclusion, our study identifies that if the rate malignant transformation of pancreatic cysts is low (0.12% annually), a less-intensive guideline will result in similar deaths to a more-intensive guideline at a much lower cost.
Topics: Aged; Computer Simulation; Early Detection of Cancer; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Female; Health Care Costs; Humans; Incidental Findings; Male; Middle Aged; Missed Diagnosis; Monte Carlo Method; Mortality; Pancreatic Cyst; Pancreatic Neoplasms; Practice Guidelines as Topic; Quality-Adjusted Life Years; Treatment Outcome
PubMed: 32558682
DOI: 10.14309/ajg.0000000000000730 -
Archives of Pathology & Laboratory... Jan 2020Pancreatic cystic lesions (PCLs) are very common, and their detection is increasing with the advances in imaging techniques. Because of the major implications for... (Review)
Review
CONTEXT.—
Pancreatic cystic lesions (PCLs) are very common, and their detection is increasing with the advances in imaging techniques. Because of the major implications for management, distinguishing between neoplastic and nonneoplastic PCLs is critical. Neoplastic cysts with potential to progress into cancer include mucinous PCLs (intraductal papillary mucinous neoplasms and mucinous cystic neoplasms) and nonmucinous cysts (solid pseudopapillary tumors, serous cystic neoplasms, and neuroendocrine tumors with cystic degeneration). Nonneoplastic cysts with no risk of malignant transformation include pseudocysts, retention cysts, lymphoepithelial cysts, cystic pancreatic lymphangioma, and duplication cyst/ciliated foregut cysts. The role of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) cytology with cyst fluid analysis in the diagnosis of PCLs has evolved during the last decade; however, a definitive diagnosis on cytologic specimens is hampered by the sparse cellularity and can be challenging. EUS-FNA can play an important role to differentiate low-risk from high-risk pancreatic cysts and to distinguish between patients with cysts who need clinical follow-up versus those who require surgery.
OBJECTIVE.—
To provide an integrative approach to diagnose pancreatic cystic lesions using EUS-FNA cytology and cyst fluid analysis, along with clinical, radiologic, histologic, genetic, and molecular characteristics.
DATA SOURCES.—
The review and analysis of the latest literature describing pancreatic cystic lesions.
CONCLUSIONS.—
Accurate diagnosis of PCLs requires a multidisciplinary and multimodal team approach, including the integration of clinical findings, imaging, cytology, cyst fluid analysis, and molecular testing.
Topics: Endoscopic Ultrasound-Guided Fine Needle Aspiration; Humans; Pancreatic Cyst; Pancreatic Neoplasms
PubMed: 31538798
DOI: 10.5858/arpa.2019-0308-RA