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United European Gastroenterology Journal Sep 2023Surveillance of pancreatic cysts focuses on the detection of (mostly morphologic) features warranting surgery. European guidelines consider elevated CA19.9 as a relative...
BACKGROUND
Surveillance of pancreatic cysts focuses on the detection of (mostly morphologic) features warranting surgery. European guidelines consider elevated CA19.9 as a relative indication for surgery. We aimed to evaluate the role of CA19.9 monitoring for early detection and management in a cyst surveillance population.
METHODS
The PACYFIC-registry is a prospective collaboration that investigates the yield of pancreatic cyst surveillance performed at the discretion of the treating physician. We included participants for whom at least one serum CA19.9 value was determined by a minimum follow-up of 12 months.
RESULTS
Of 1865 PACYFIC participants, 685 met the inclusion criteria for this study (mean age 67 years, SD 10; 61% female). During a median follow-up of 25 months (IQR 24, 1966 visits), 29 participants developed high-grade dysplasia (HGD) or pancreatic cancer. At baseline, CA19.9 ranged from 1 to 591 kU/L (median 10 kU/L [IQR 14]), and was elevated (≥37 kU/L) in 64 participants (9%). During 191 of 1966 visits (10%), an elevated CA19.9 was detected, and these visits more often led to an intensified follow-up (42%) than those without an elevated CA19.9 (27%; p < 0.001). An elevated CA19.9 was the sole reason for surgery in five participants with benign disease (10%). The baseline CA19.9 value was (as continuous or dichotomous variable at the 37 kU/L threshold) not independently associated with HGD or pancreatic cancer development, whilst a CA19.9 of ≥ 133 kU/L was (HR 3.8, 95% CI 1.1-13, p = 0.03).
CONCLUSIONS
In this pancreatic cyst surveillance cohort, CA19.9 monitoring caused substantial harm by shortening surveillance intervals (and performance of unnecessary surgery). The current CA19.9 cutoff was not predictive of HGD and pancreatic cancer, whereas a higher cutoff may decrease false-positive values. The role of CA19.9 monitoring should be critically appraised prior to implementation in surveillance programs and guidelines.
Topics: Humans; Female; Aged; Male; Prospective Studies; CA-19-9 Antigen; Pancreatic Neoplasms; Pancreatic Cyst
PubMed: 37435855
DOI: 10.1002/ueg2.12422 -
The Korean Journal of Gastroenterology... Jul 2017Cystic lesions of the pancreas are increasingly observed due to increased use of abdominal images. The malignant rate of pancreas cystic lesion varies widely between... (Review)
Review
Cystic lesions of the pancreas are increasingly observed due to increased use of abdominal images. The malignant rate of pancreas cystic lesion varies widely between various types. Identification of malignant or high-risk lesions is important when determining the appropriate course of management. Using these image findings, including cyst size, presence of solid components, and pancreatic duct involvement, the 2012 International Association of Pancreatology (IAP) and the 2015 American Gastroenterological Association (AGA) guidelines provide a rationale in identifying higher risk patients requiring further workups using an endoscopic ultrasound (EUS). EUS with fine needle aspiration and cytology allows confirmation of the cyst type and determines the risk of malignancy. Small cysts with no suspicious features may undergo the regular imaging study for regular surveillance due to low risk for malignancy. In this review, the differences between the 2012 IAP and 2015 AGA guidelines are presented, In addition to possible recommendations for management and surveillance.
Topics: Endosonography; Humans; Outpatients; Pancreatic Cyst; Pancreatic Neoplasms; Tomography, X-Ray Computed
PubMed: 28728311
DOI: 10.4166/kjg.2017.70.1.13 -
Gastrointestinal Endoscopy Aug 2013Better pancreatic cyst fluid biomarkers are needed.
BACKGROUND
Better pancreatic cyst fluid biomarkers are needed.
OBJECTIVE
To determine whether metabolomic profiling of pancreatic cyst fluid would yield clinically useful cyst fluid biomarkers.
DESIGN
Retrospective study.
SETTING
Tertiary-care referral center.
PATIENTS
Two independent cohorts of patients (n = 26 and n = 19) with histologically defined pancreatic cysts.
INTERVENTION
Exploratory analysis for differentially expressed metabolites between (1) nonmucinous and mucinous cysts and (2) malignant and premalignant cysts was performed in the first cohort. With the second cohort, a validation analysis of promising identified metabolites was performed.
MAIN OUTCOME MEASUREMENTS
Identification of differentially expressed metabolites between clinically relevant cyst categories and their diagnostic performance (receiver operating characteristic [ROC] curve).
RESULTS
Two metabolites had diagnostic significance-glucose and kynurenine. Metabolomic abundances for both were significantly lower in mucinous cysts compared with nonmucinous cysts in both cohorts (glucose first cohort P = .002, validation P = .006; and kynurenine first cohort P = .002, validation P = .002). The ROC curve for glucose was 0.92 (95% confidence interval [CI], 0.81-1.00) and 0.88 (95% CI, 0.72-1.00) in the first and validation cohorts, respectively. The ROC for kynurenine was 0.94 (95% CI, 0.81-1.00) and 0.92 (95% CI, 0.76-1.00) in the first and validation cohorts, respectively. Neither could differentiate premalignant from malignant cysts. Glucose and kynurenine levels were significantly elevated for serous cystadenomas in both cohorts.
LIMITATIONS
Small sample sizes.
CONCLUSION
Metabolomic profiling identified glucose and kynurenine to have potential clinical utility for differentiating mucinous from nonmucinous pancreatic cysts. These markers also may diagnose serous cystadenomas.
Topics: Adult; Aged; Aged, 80 and over; Biomarkers, Tumor; Carcinoma, Pancreatic Ductal; Cohort Studies; Cyst Fluid; Cystadenocarcinoma; Cystadenocarcinoma, Mucinous; Cystadenoma; Cystadenoma, Mucinous; Cystadenoma, Serous; Female; Glucose; Humans; Kynurenine; Male; Metabolomics; Middle Aged; Pancreatic Cyst; Pancreatic Neoplasms; Pancreatic Pseudocyst; Retrospective Studies; Sensitivity and Specificity
PubMed: 23566642
DOI: 10.1016/j.gie.2013.02.037 -
World Journal of Gastroenterology Jun 2020Pancreatic cancer has a high mortality rate with minimal proven interventions. Intraductal Papillary Mucinous Neoplasms (IPMNs) are known precursor lesions for... (Review)
Review
Pancreatic cancer has a high mortality rate with minimal proven interventions. Intraductal Papillary Mucinous Neoplasms (IPMNs) are known precursor lesions for pancreatic cancer. Identification of pancreatic cysts has improved from advances in abdominal imaging. Despite multiple revisions of the international consensus recommendations and various guidelines by other major societies, successful risk stratification of the malignant potential of mucinous pancreatic cysts remains challenging. Specifically, detection and accurate classification of advanced neoplasia (high-grade dysplasia and/or adenocarcinoma) in IPMNs is suboptimal with current diagnostic strategies. Development of interventional techniques utilizing endoscopic ultrasound include - through-the-needle microforceps biopsy, next-generation or whole genome molecular analysis of cyst fluid, and needle-based confocal laser endomicroscopy. These techniques suffer from a series of limitations in technical success, diagnostic yield, and clinical feasibility, but a combination approach may offer a solution that optimizes their cyst evaluation and risk stratification. Assessment and comparison of these techniques is restricted by lack of adequate surgical specimens for testing of diagnostic accuracy, resulting in a possible sample bias. Additional large-scale multicenter studies are needed to accumulate evidence for the utility and feasibility of their translation into clinical practice. Great strides have been made in pancreatic cyst evaluation, but further research is required to improve diagnostic accuracy and clinical management of IPMNs.
Topics: Carcinoma, Pancreatic Ductal; Cyst Fluid; Endosonography; Humans; Pancreatic Cyst; Pancreatic Neoplasms
PubMed: 32684735
DOI: 10.3748/wjg.v26.i23.3201 -
Internal Medicine (Tokyo, Japan) May 2023A 64-year-old man with a history of diabetes and gallstones was admitted to our institution with suspected pancreatic malignancy. Computed tomography (CT) revealed...
A 64-year-old man with a history of diabetes and gallstones was admitted to our institution with suspected pancreatic malignancy. Computed tomography (CT) revealed multiple pancreatic cysts and massive ascites, and endoscopic ultrasonography (EUS) revealed a 28×27-mm hypoechoic mass in the pancreatic head. An EUS-guided fine-needle aspiration biopsy was performed, and there were no malignant findings. Based on the test results and imaging findings, type 1 autoimmune pancreatitis was suspected. The patient was administered 30 mg of prednisolone daily. After 11 days, CT revealed that the pancreatic cysts and ascites had reduced in size.
Topics: Male; Humans; Middle Aged; Autoimmune Pancreatitis; Pancreatitis; Ascites; Autoimmune Diseases; Pancreatic Neoplasms; Endosonography; Pancreatic Cyst; Endoscopic Ultrasound-Guided Fine Needle Aspiration
PubMed: 36198587
DOI: 10.2169/internalmedicine.0003-22 -
HPB : the Official Journal of the... Jul 2021Unidimensional size is commonly used to risk stratify pancreatic cysts (PCs) despite inconsistent performance. The current study aimed to determine if unidimensional...
BACKGROUND
Unidimensional size is commonly used to risk stratify pancreatic cysts (PCs) despite inconsistent performance. The current study aimed to determine if unidimensional size, demonstrated by maximum axial diameter (MAD), is an appropriate surrogate measurement for volume and surface area.
METHODS
Patients with cross-sectional imaging of PCs from 2012 to 2013 were identified. Cyst MAD, volume, and surface area were measured using quantitative imaging software. Non-pseudocystic PCs >1 cm were selected for inclusion to assess MAD correlation with volume and surface area. Cysts imaged twice >1 year apart were selected to evaluate volumetric growth rate.
RESULTS
In total, 195 cysts were included. Overall, MAD was strongly correlated with volume (r = 0.83) and surface area (r = 0.93). However, cysts 1-2 cm and 2-3 cm were weakly correlated with volume and surface area: r = 0.78, 0.57 and 0.82, 0.61, respectively. Cyst volumes and surface areas varied widely within unidimensional size groups with 51% and 40% of volumes and surface areas overlapping unidimensional size groups, respectively. Estimated changes in volume poorly predicted measured changes in volume with 42% of cysts having >100% absolute percent difference.
CONCLUSIONS
Pancreatic cyst volume and surface area may be useful adjunct measurements to risk stratify patients and surveil cyst changes and deserves further study.
Topics: Humans; Pancreatic Cyst
PubMed: 33317934
DOI: 10.1016/j.hpb.2020.10.026 -
Surgical Endoscopy May 2023More accurate diagnosis of mucinous cysts will reduce the risk of unnecessary pancreatic surgery. Carcinoembryonic antigen (CEA) and glucose in pancreatic cyst fluid...
BACKGROUND
More accurate diagnosis of mucinous cysts will reduce the risk of unnecessary pancreatic surgery. Carcinoembryonic antigen (CEA) and glucose in pancreatic cyst fluid (PCF) can differentiate mucinous from non-mucinous pancreatic cystic neoplasms (PCN). The current study assessed the value of combined CEA and glucose testing in PCF.
METHODS
Cross-sectional validation study including prospectively collected PCF from patients undergoing endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) and pancreatic surgery. We performed laboratory measurements for CEA and glucose and measured glucose levels by a hand glucometer. Primary outcome was diagnostic accuracy evaluated by receiver operator curves (ROC), sensitivity, specificity, positive, and negative predictive value (PPV, NPV).
RESULTS
Overall, PCF was collected from 63 patients, including 33 (52%) with mucinous and 30 (48%) with non-mucinous PCN. Histopathology (n = 36; 57%), cytopathology (n = 2; 3%), or clinical and/or radiological diagnosis (n = 25; 40%) was used as reference standard. Combined CEA (cut-off ≥ 192 ng/ml) and laboratory glucose testing (cut-off ≤ 50 mg/dL) reached 92% specificity and 48% sensitivity, whereas either positive CEA (cut-off ≥ 20 ng/ml) or glucose testing (cut-off ≤ 50 mg/dL) showed 97% sensitivity and 50% specificity. Sensitivity and specificity were 80% and 68% for CEA ≥ 20 ng/mL versus 50% and 93% for CEA ≥ 192 ng/mL (the conventional cut-off level). Laboratory and glucometer glucose both reached 100% sensitivity and 60% and 45% specificity, respectively. None of the biomarkers and cut-offs reached a PPV exceeding 90%, whereas both glucose measurements had a NPV of 100% (i.e., high glucose excludes a mucinous cyst).
CONCLUSION
Combined CEA and glucose testing in PCF reached high specificity and sensitivity for differentiating mucinous from non-mucinous PCN. Glucose testing, whether alone or combined with the new CEA cut-off (≥ 20 ng/mL), reached > 95% sensitivity for mucinous cysts, whereas only glucose reached a NPV > 95%.
Topics: Humans; Carcinoembryonic Antigen; Pancreatic Cyst; Pancreatic Neoplasms; Cross-Sectional Studies; Retrospective Studies; Mucocele; Glucose; Cyst Fluid; Endoscopic Ultrasound-Guided Fine Needle Aspiration
PubMed: 36656409
DOI: 10.1007/s00464-022-09822-6 -
Surgical Oncology Clinics of North... Apr 2016Management of cystic neoplasms of the pancreas is challenging as it relies on radiologic and cyst fluid markers to discriminate between benign and pre-cancerous lesions,... (Review)
Review
Management of cystic neoplasms of the pancreas is challenging as it relies on radiologic and cyst fluid markers to discriminate between benign and pre-cancerous lesions, however their ability to predict malignancy is limited. While asymptomatic serous cystadenomas can be managed conservatively, mucinous cystic neoplasms and intraductal papillary mucinous neoplasms are more difficult to manage. A selective approach, based on the preoperative likelihood of high-grade dysplasia or invasive disease, is the standard of care. Research is focusing on the development of pre-operative markers for identifying high risk lesions, which will spare patients with low-risk or benign lesions the risks of pancreatectomy.
Topics: Cystadenocarcinoma, Mucinous; Cystadenoma, Mucinous; Cystadenoma, Serous; Humans; Pancreatic Cyst; Pancreatic Neoplasms
PubMed: 27013369
DOI: 10.1016/j.soc.2015.11.006 -
Archives of Pathology & Laboratory... Oct 2017- According to the 2014 Baltimore Consensus Meeting, simple mucinous cysts are defined as macroscopic cysts that are greater than 1 cm in size with gastric-type flat... (Review)
Review
CONTEXT
- According to the 2014 Baltimore Consensus Meeting, simple mucinous cysts are defined as macroscopic cysts that are greater than 1 cm in size with gastric-type flat mucinous lining and minimal cytologic atypia without ovarian-type stroma. This lesion has not been widely recognized and has undergone a recent nomenclature change owing to unclear pathogenesis and biologic behavior. Mucinous pancreatic cystic lesions are generally considered precursor lesions of pancreatic adenocarcinoma. However, simple mucinous cysts generally have benign behavior with no recurrence or malignant transformation during short follow-up periods.
OBJECTIVE
- To provide a brief update and summary of the evolving nomenclature and current knowledge of simple mucinous cysts with an overview of their clinical, histopathologic, immunohistochemical, and molecular characteristics, as well as discussion of their differential diagnoses and biological behavior.
DATA SOURCES
- Analysis of the pertinent literature (PubMed) and authors' clinical practice experience based on institutional and consultation materials.
CONCLUSIONS
- Simple mucinous cyst has undergone a nomenclature evolution from mucinous nonneoplastic cyst to the current recommended name of simple mucinous cyst to reflect its unclear pathogenesis and progression. The malignant potential of simple mucinous cyst is still debatable. Recent molecular studies support a neoplastic process, but these cysts generally exhibit benign behavior without recurrence or malignant transformation. Therefore, accurate diagnosis of simple mucinous cysts is critical to distinguish them from other more common and aggressive mucinous pancreatic cysts. Studies with larger cohorts and longer clinical follow-up data are needed to further determine the biologic behavior of this cyst and implications for prognosis.
Topics: Humans; Pancreatic Cyst
PubMed: 28968161
DOI: 10.5858/arpa.2017-0232-RA -
Archives of Surgery (Chicago, Ill. :... Apr 2003Widespread use of computed tomography and ultrasound has led to the identification of increasing numbers of patients with asymptomatic cystic lesions of the pancreas. (Comparative Study)
Comparative Study
HYPOTHESIS
Widespread use of computed tomography and ultrasound has led to the identification of increasing numbers of patients with asymptomatic cystic lesions of the pancreas.
DESIGN
Retrospective case series of patients with pancreatic cystic lesions.
SETTING
University-affiliated tertiary care referral center.
PATIENTS
Two hundred twelve patients with pancreatic cystic lesions seen in our surgical practice during 5 years (April 1997-March 2002).
MAIN OUTCOME MEASURES
Presence or absence of symptoms, cyst size and location, cytologic or pathologic diagnosis, surgical treatment, and outcome.
RESULTS
Seventy-eight (36.7%) of 212 patients were asymptomatic. Incidental cysts were smaller (3.3 +/- 1.9 vs 4.6 +/- 2.7 cm; P<.001) and were found in older patients (65 +/- 13 vs 56 +/- 15 years; P<.001). Seventy-eight percent of the asymptomatic patients and 87% of those with symptoms underwent surgery, with a single operative death in the entire group (0.5%). Seventeen percent of asymptomatic cysts were serous cystadenomas; 28%, mucinous cystic neoplasms; 27%, intraductal papillary mucinous neoplasms; and 2.5%, ductal adenocarcinomas. The respective numbers for symptomatic cysts were 7%, 16%, 40%, and 9%. Ten percent of asymptomatic patients had a variety of other cystic lesions, and in 12%, no definitive cytologic or pathologic diagnosis was obtained. Overall, 17% of asymptomatic patients had in situ or invasive cancer, and 42% had a premalignant lesion. When evaluated as a function of size, only 1 (3.5%) of 28 asymptomatic cysts smaller than 2 cm had cancer compared with 13 (26%) of 50 cysts larger than 2 cm (P =.04). The proportion of premalignant lesions, however, remained high in both groups (46% and 38%, respectively). Pseudocysts comprised only 3.8% of asymptomatic cysts compared with 19.4% of symptomatic cysts (P =.003).
CONCLUSIONS
Incidental pancreatic cysts are common, occur in older patients, are smaller than symptomatic cysts, and are unlikely to be pseudocysts. More than half of them are either malignant or premalignant lesions and therefore cannot be dismissed.
Topics: Aged; Algorithms; Female; Humans; Male; Middle Aged; Pancreatic Cyst; Retrospective Studies
PubMed: 12686529
DOI: 10.1001/archsurg.138.4.427