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Archives of Pathology & Laboratory... Mar 2022Because of new and improved imaging techniques, cystic/intraductal pancreatobiliary tract lesions are increasingly being discovered, and brushings or endoscopic...
CONTEXT.—
Because of new and improved imaging techniques, cystic/intraductal pancreatobiliary tract lesions are increasingly being discovered, and brushings or endoscopic ultrasound/computed tomography/magnetic resonance imaging-guided fine-needle aspiration biopsies from these lesions have become an integral part of pathologists' daily practice. Because patient management has become increasingly conservative, accurate preoperative diagnosis is critical. Cytologic distinction of low-risk (pseudocysts, serous cystadenoma, lymphoepithelial cysts, and squamoid cysts of the pancreatic duct) from high-risk pancreatic cysts (intraductal papillary mucinous neoplasm and mucinous cystic neoplasm) requires incorporation of clinical, radiologic, and cytologic findings, in conjunction with chemical and molecular analysis of cyst fluid. Cytopathologists must ensure appropriate specimen triage, along with cytologic interpretation, cyst classification, and even grading of some (mucinous) cysts. Epithelial atypia in mucinous cysts (intraductal papillary mucinous neoplasm and mucinous cystic neoplasm) has transitioned from a 3-tiered to a 2-tiered classification system, and intraductal oncocytic papillary neoplasms and intraductal tubulopapillary neoplasms have been separately reclassified because of their distinctive clinicopathologic characteristics. Because these lesions may be sampled on brushing or fine-needle aspiration biopsy, knowledge of their cytomorphology is critical.
OBJECTIVE.—
To use an integrated, multidisciplinary approach for the evaluation of cystic/intraductal pancreatobiliary tract lesions (incorporating clinical, radiologic, and cytologic findings with [chemical/molecular] cyst fluid analysis and ancillary stains) for definitive diagnosis and classification.
DATA SOURCES.—
Review of current literature on the cytopathology of cystic/intraductal pancreatobiliary tract lesions.
CONCLUSIONS.—
Our knowledge/understanding of recent updates in cystic/intraductal pancreatobiliary lesions can ensure that cytopathologists appropriately triage specimens, judiciously use and interpret ancillary studies, and incorporate the studies into reporting.
Topics: Cystadenoma, Serous; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Humans; Magnetic Resonance Imaging; Pancreatic Cyst; Pancreatic Neoplasms
PubMed: 33836534
DOI: 10.5858/arpa.2020-0553-RA -
Cancer Letters Jan 2020Pancreatic cystic lesions (PCLs) are well-known precursors of pancreatic cancer. Their diagnosis can be challenging as their behavior varies from benign to malignant... (Review)
Review
Pancreatic cystic lesions (PCLs) are well-known precursors of pancreatic cancer. Their diagnosis can be challenging as their behavior varies from benign to malignant disease. Precise and timely management of malignant pancreatic cysts might prevent transformation to pancreatic cancer. However, the current consensus guidelines, which rely on standard imaging features to predict cyst malignancy potential, are conflicting and unclear. This has led to an increased interest in radiomics, a high-throughput extraction of comprehensible data from standard of care images. Radiomics can be used as a diagnostic and prognostic tool in personalized medicine. It utilizes quantitative image analysis to extract features in conjunction with machine learning and artificial intelligence (AI) methods like support vector machines, random forest, and convolutional neural network for feature selection and classification. Selected features can then serve as imaging biomarkers to predict high-risk PCLs. Radiomics studies conducted heretofore on PCLs have shown promising results. This cost-effective approach would help us to differentiate benign PCLs from malignant ones and potentially guide clinical decision-making leading to better utilization of healthcare resources. In this review, we discuss the process of radiomics, its myriad applications such as diagnosis, prognosis, and prediction of therapy response. We also discuss the outcomes of studies involving radiomic analysis of PCLs and pancreatic cancer, and challenges associated with this novel field along with possible solutions. Although these studies highlight the potential benefit of radiomics in the prevention and optimal treatment of pancreatic cancer, further studies are warranted before incorporating radiomics into the clinical decision support system.
Topics: Artificial Intelligence; Humans; Machine Learning; Pancreas; Pancreatic Cyst; Pancreatic Neoplasms; Precancerous Conditions; Precision Medicine; Prognosis; Radiometry; Support Vector Machine
PubMed: 31629933
DOI: 10.1016/j.canlet.2019.10.023 -
Saudi Journal of Gastroenterology :... 2022Diagnosis of malignant pancreatic cystic lesions (PCLs) is challenging as there is no investigation that offers both high diagnostic sensitivity and specificity for a...
BACKGROUND
Diagnosis of malignant pancreatic cystic lesions (PCLs) is challenging as there is no investigation that offers both high diagnostic sensitivity and specificity for a definite diagnosis. Accurate diagnosis of cyst type is vital in order to not miss opportunities for early treatment of potentially malignant lesions and to avoid unnecessary surgeries. Serine protease inhibitor Kazal type I (SPINK1) and glucose are promising cyst fluid markers for differentiation of mucinous from non-mucinous cysts. We aim to validate the value of SPINK1 and glucose in detecting potentially malignant PCLs.
METHODS
A prospective study was conducted on 80 patients presenting with PCLs. Endoscopic ultrasound (EUS) evaluation of detailed cyst morphology and EUS with fine needle aspiration (FNA) were done. Fluid analysis for carcinoembryonic antigen (CEA), glucose and SPINK1 and cytopathology were done. We compared these data with the final diagnosis based on cytopathological and postoperative histopathological examination.
RESULTS
Cyst fluid SPINK1 was significantly higher in malignant or potentially malignant cysts compared to benign cysts (0.91 vs 0.47 ng/ml; P = 0.001). Also, glucose was significantly lower in malignant or potentially malignant cysts compared to benign cysts (21.5 vs 68.5 mg/dl; P = 0.0001). Glucose and SPINK1 had the best sensitivity and specificity for differentiating mucinous from non-mucinous cysts with 84.78% and 73.53% (AUC 0.76; 95% CI [0.65-0.88]; cutoff value = 42 mg/dl), and 70.59% and 65.22% (AUC 0.72; 95% CI [0.64-0.86]; cutoff value = 0.58 ug/L) respectively. CEA level >192 ng/ml, high SPINK1 level and lymph node enlargement were the independent predictors of malignant cysts.
CONCLUSION
Cyst fluid SPINK1 and glucose are promising diagnostic markers for the diagnosis of potentially malignant PCLs.
Topics: Carcinoembryonic Antigen; Cyst Fluid; Endoscopic Ultrasound-Guided Fine Needle Aspiration; Glucose; Humans; Pancreatic Cyst; Pancreatic Neoplasms; Prospective Studies; Serine Proteinase Inhibitors; Trypsin Inhibitor, Kazal Pancreatic
PubMed: 35848704
DOI: 10.4103/sjg.sjg_81_22 -
Polski Przeglad Chirurgiczny Jun 2018Introduction Frequency of detection of pancreatic cystic lesions increased recent years. The majorities are pseudocysts, the remaining cysts are mainly neoplasms. Proven... (Comparative Study)
Comparative Study
Introduction Frequency of detection of pancreatic cystic lesions increased recent years. The majorities are pseudocysts, the remaining cysts are mainly neoplasms. Proven risk of malignancy affects intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN). Material and methods 145 patients operated on at the Department of General and Transplant Surgery in Barlicki Hospital in Lodz, Poland, in 2007-2016 due to pancreatic cystic lesion. The type of surgery, histopathological diagnosis and basic demographic data were analyzed. Results Nonneoplastic cyst (mainly pseudocysts) was found in 66.9% of patients, neoplasms were detected in 33.1%. The mean age was significantly higher in patients with neoplasms than without neoplasm (57.06 years vs. 50.88 years, p = 0.009). Neoplastic cyst occurred more frequently in women (68.75% of women, 31.25% of men, p = 0.001), Nonneoplastic cyst was found significantly more often in men (64.95% of men, 35.05% of women, p = 0.001). Malignant tumor was found in 14.58% of neoplasms cases. Pancreatic resections in neoplastic cysts were performed in 77,08%. In patients with nonneoplastic cysts drainage operations were performed most frequently (80.41%). Conclusions Neoplastic cysts are more common in women. The average age in the group of patients with neoplasms is higher than in the group with nonneoplastic cysts. In women with pancreatic cystic lesion without history for pancreatitis, the probability of neoplasms diagnosis is high. Discussion Pancreatic cystic tumors are treated radically due to the lack of sufficiently sensitive and specific pre-operative examinations. The natural history of mucinous neoplasms (IPMN and MCN) ranges from dysplasia to cancer. There are no guidelines that could be in satisfactory way used in follow up patients with pancreatic cysts.
Topics: Adult; Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Pancreas; Pancreatic Cyst; Pancreatic Neoplasms; Poland; Retrospective Studies
PubMed: 30426941
DOI: 10.5604/01.3001.0012.1267 -
World Journal of Gastroenterology Jun 2013Endoscopic ultrasonography (EUS) has evolved into a useful therapeutic tool for treating a broad range of tumors since being introduced into clinical practice as a... (Review)
Review
Endoscopic ultrasonography (EUS) has evolved into a useful therapeutic tool for treating a broad range of tumors since being introduced into clinical practice as a diagnostic modality nearly three decades ago. In particular, EUS-guided fine-needle injection has proven a successful minimally invasive approach for treating benign lesions such as pancreatic cysts, relieving pancreatic pain through celiac plexus neurolysis, and controlling local tumor growth of unresectable malignancies by direct delivery of anti-tumor agents. One such ablative agent, ethanol, is capable of safely ablating solid or cystic lesions in hepatic tissues via percutaneous injection. Recent research and clinical interest has focused on the promise of EUS-guided ethanol ablation as a safe and effective method for treating pancreatic tumor patients with small lesions or who are poor operative candidates. Although it is not likely to replace radical resection of localized lesions or systemic treatment of metastatic tumors in all patients, EUS-guided ablation is an ideal method for patients who refuse or are not eligible for surgery. Moreover, this treatment modality may play an active role in the development of future pancreatic tumor treatments. This article reviews the most recent clinical applications of EUS-guided ethanol ablation in humans for treating pancreatic cystic tumors, pancreatic neuroendocrine tumors, and metastatic lesions.
Topics: Ablation Techniques; Endosonography; Ethanol; Humans; Neoplasms, Cystic, Mucinous, and Serous; Neuroendocrine Tumors; Pancreatic Cyst; Pancreatic Neoplasms; Treatment Outcome; Ultrasonography, Interventional
PubMed: 23801831
DOI: 10.3748/wjg.v19.i22.3397 -
Journal of Computer Assisted Tomography 2016The aim of this study was to evaluate the feasibility and reproducibility of diffusion-weighted imaging in distinguishing between mucin-producing and serous pancreatic...
OBJECTIVE
The aim of this study was to evaluate the feasibility and reproducibility of diffusion-weighted imaging in distinguishing between mucin-producing and serous pancreatic cysts.
METHODS
Forty-four pancreatic cysts (43 patients, 27 women; mean age, 57 years; 26 mucin-producing cysts, 18 serous cysts) that underwent histological examination or cyst analysis after diffusion-weighted magnetic resonance imaging were retrospectively reviewed. Three blinded readers independently evaluated signal intensity and apparent diffusion coefficient (ADC). Intraobserver and interobserver agreements were calculated. Fisher exact test and Welch t test were used to compare signal intensity and ADC values, respectively, with pathological results. Receiver operating characteristic analysis was used to determine diagnostic accuracy of various thresholds for ADC. A P value less than 0.05 was considered statistically significant.
RESULTS
Mean ADC values of the mucin-producing cysts were 3.26 × 10, 3.27 × 10, and 3.35 × 10 mm/s for the 3 readers, respectively. Mean ADC values of the serous cysts were 2.86 × 10, 2.85 × 10, and 2.85 × 10 mm/s for the 3 readers, respectively. Differences in ADC values between the 2 cyst groups were 12.4%, 12.9%, and 14.8% for the 3 readers, respectively (P < 0.001). Intraobserver and interobserver agreement was excellent. A threshold ADC of 3 × 10 mm/s resulted in correct identification of cysts in 77% to 81% of cases, with sensitivity and specificity ranging between 84% and 88% and 66% and 72%, respectively.
CONCLUSIONS
Diffusion-weighted imaging may be a helpful tool in distinguishing between mucin-producing and serous pancreatic cysts.
Topics: Adult; Aged; Aged, 80 and over; Cystadenoma, Mucinous; Cystadenoma, Serous; Diagnosis, Differential; Diffusion Magnetic Resonance Imaging; Female; Humans; Image Enhancement; Image Interpretation, Computer-Assisted; Male; Middle Aged; Observer Variation; Pancreatic Cyst; Pancreatic Neoplasms; Reproducibility of Results; Sensitivity and Specificity
PubMed: 27023856
DOI: 10.1097/RCT.0000000000000403 -
Journal of B.U.ON. : Official Journal... 2013Incidentally discovered pancreatic lesions that are asymptomatic have become much more common in recent years. It is important to characterize these lesions and to... (Review)
Review
Incidentally discovered pancreatic lesions that are asymptomatic have become much more common in recent years. It is important to characterize these lesions and to determine which patients can be safely observed and which should undergo an operation, as a substantial proportion of them might be malignant or premalignant. This review focus on the diagnostic approach and management of the different types of cystic and solid incidental pancreatic lesions based on appropriate clinical input, imaging screening and histological criteria. The task of developing guidelines to deal with an incidentally found pancreatic lesion, however, is much more complex and controversial than with other organs incidentalomas. In most series, pancreatic incidentalomas (PIs) <2 cm and of cystic appearance are likely to be benign, whereas those >2 cm are usually premalignant or malignant. Serous cystadenomas can reach very large size and are usually benign lesions. The presence of a solid mass or a mural nodule in a cystic lesion along with main pancreatic duct dilatation, thick septations and biliary obstruction are considered features suspicious of malignancy. Mucinous cystic neoplasms and intraductal papillary mucinous neoplasms are malignant or lesions of malignant potential and need surgical exploration. Solid lesions are much more likely to be premalignant or malignant and most of patients will undergo resection. The decision to operate rather than follow a solid lesion is a matter of tumor size and of clinical judgment based on the age and patient comorbidities. The present study should serve as a general guide and not applied as strict principles. Key words: cystic pancreatic incidentalomas, diagnostic approach, management, solid pancreatic incidentalomas.
Topics: Asymptomatic Diseases; Diagnostic Imaging; Disease Progression; Humans; Incidental Findings; Pancreatectomy; Pancreatic Cyst; Pancreatic Neoplasms; Patient Selection; Precancerous Conditions; Predictive Value of Tests; Risk Factors; Time Factors; Treatment Outcome; Watchful Waiting
PubMed: 23613384
DOI: No ID Found -
The Turkish Journal of Gastroenterology... Feb 2014Pancreatic cysts are challenging to the gastroenterologist. Detection rate is increasing and neither criteria for a definitive diagnosis, nor a validated surveillance... (Review)
Review
Pancreatic cysts are challenging to the gastroenterologist. Detection rate is increasing and neither criteria for a definitive diagnosis, nor a validated surveillance strategy is available. Pancreatic endosonography with or without sampling is necessary in most of the cases. However this technique requires expertise and is not widely available. While some cysts have a malignant potential or already malign at the diagnosis, most are benign and remain so for decades. We are going to review the existing data on this controversial subject.
Topics: Endosonography; Humans; Pancreatic Cyst; Pancreatic Neoplasms
PubMed: 24918124
DOI: 10.5152/tjg.2014.0001 -
World Journal of Gastroenterology Aug 2019Pancreatic cysts are identified at an increasing frequency. Although mucinous cystic neoplasms represent a pre-malignant condition, the majority of these lesions do not... (Comparative Study)
Comparative Study Review
Pancreatic cysts are identified at an increasing frequency. Although mucinous cystic neoplasms represent a pre-malignant condition, the majority of these lesions do not progress to cancer. Over the last 10 years several societies have established guidelines for the diagnosis, initial evaluation and surveillance of these lesions. Here we provide an overview of five commonly used guidelines: 2015 American Gastroenterological Association, 2017 International Association of Pancreatology, American College of Gastroenterology 2018, European Study Group and American College of Radiology. We describe the similarities and differences between the methods used to formulate these guidelines, the population they target and their approaches towards initial evaluation and surveillance of cystic lesions.
Topics: Aftercare; Cystadenoma; Disease Progression; Europe; Gastroenterology; Humans; Magnetic Resonance Imaging; Pancreas; Pancreatectomy; Pancreatic Cyst; Pancreatic Neoplasms; Pancreatic Pseudocyst; Practice Guidelines as Topic; Radiology; Risk Assessment; Societies, Medical; United States; Watchful Waiting
PubMed: 31496620
DOI: 10.3748/wjg.v25.i31.4405 -
World Journal of Gastroenterology Dec 2015Pancreatic fluid collections (PFCs) are seen in up to 50% of cases of acute pancreatitis. The Revised Atlanta classification categorized these collections on the basis... (Review)
Review
Pancreatic fluid collections (PFCs) are seen in up to 50% of cases of acute pancreatitis. The Revised Atlanta classification categorized these collections on the basis of duration of disease and contents, whether liquid alone or a mixture of fluid and necrotic debris. Management of these different types of collections differs because of the variable quantity of debris; while patients with pseudocysts can be drained by straight-forward stent placement, walled-off necrosis requires multi-disciplinary approach. Differentiating these collections on the basis of clinical severity alone is not reliable, so imaging is primarily performed. Contrast-enhanced computed tomography is the commonly used modality for the diagnosis and assessment of proportion of solid contents in PFCs; however with certain limitations such as use of iodinated contrast material especially in renal failure patients and radiation exposure. Magnetic resonance imaging (MRI) performs better than computed tomography (CT) in characterization of pancreatic/peripancreatic fluid collections especially for quantification of solid debris and fat necrosis (seen as fat density globules), and is an alternative in those situations where CT is contraindicated. Also magnetic resonance cholangiopancreatography is highly sensitive for detecting pancreatic duct disruption and choledocholithiasis. Endoscopic ultrasound is an evolving technique with higher reproducibility for fluid-to-debris component estimation with the added advantage of being a single stage procedure for both diagnosis (solid debris delineation) and management (drainage of collection) in the same sitting. Recently role of diffusion weighted MRI and positron emission tomography/CT with (18)F-FDG labeled autologous leukocytes is also emerging for detection of infection noninvasively. Comparative studies between these imaging modalities are still limited. However we look forward to a time when this gap in literature will be fulfilled.
Topics: Acute Disease; Cholangiopancreatography, Magnetic Resonance; Diagnostic Imaging; Drainage; Endosonography; Humans; Multimodal Imaging; Necrosis; Pancreas; Pancreatic Cyst; Pancreatic Pseudocyst; Pancreatitis; Positron-Emission Tomography; Predictive Value of Tests; Prognosis; Severity of Illness Index; Stents; Tomography, X-Ray Computed
PubMed: 26730150
DOI: 10.3748/wjg.v21.i48.13403