Branch Intraductal Papillary Mucinous Neoplasm Research Articles

Outcomes of the IMMray PanCan-d Test in High-Risk Individuals Undergoing Pancreatic Surveillance: Pragmatic Data and Lessons Learned.

An effective blood-based test for pancreatic cancer (PC) screening has remained elusive. The IMMray PanCan-d is the first commercially available blood-based test specifically designed for early detection of PC; however, outcomes from its use in clinical practice have not been reported. We performed a blinded spike-in study of 100 individuals who had an IMMray PanCan-d test, including 94 high-risk individuals (HRIs) undergoing PC surveillance and six individuals with known PC. Specimens were processed blindly following the commercial laboratory's standardized operating procedure. Positive predictive value (PPV) and negative predictive value (NPV) were calculated. Cohort characteristics included a median age of 63 (IQR, 55-70) years, 57% female, 96% non-Hispanic White, 57% with a pathogenic variant in a PC risk gene (BRCA2 most commonly-18%), and 83% with a family history of PC. Among IMMray PanCan-d results from 94 HRIs undergoing PC surveillance, there was one positive (1%), seven borderlines (7%), 73 negatives (78%), and 13 tests not performed because of low CA19-9 expression (14%). No PC was diagnosed among these HRIs; however, there were two sub-cm pancreatic neuroendocrine tumors, seven clinically diagnosed side branch intraductal papillary mucinous neoplasms ≥1 cm, and a sub-cm solid mass with indeterminate cytology requiring close follow-up; all these individuals had negative IMMray PanCan-d tests. Of the six spiked-in PCs, four (67%) yielded a positive and two (33%) yielded a negative. With an estimated disease prevalence of 2%, the PPV and NPV are 52% and 99%, respectively, if borderline results are considered negative and 12% and 99%, respectively, if borderline tests are considered positive. In clinical practice, IMMray PanCan-d has a robust NPV; however, PPV is dramatically influenced by whether borderline results are characterized as a positive or negative result.

P241 Gastrointestinal ultrasound instead of magnetic resonance enterography: Large potential cost savings with limited clinical downsides

Abstract Background Gastrointestinal ultrasound (GIUS) is a non-invasive imaging modality capable of detecting intestinal inflammation & associated complications. It has comparable sensitivity & specificity to magnetic resonance enterography (MRE) in detecting ileocolonic disease, however it is less expensive (£24 vs £180) & can be performed at point of care. We aimed to establish the proportion of MREs that could have been performed as GIUS at a tertiary inflammatory bowel disease (IBD) unit, the potential cost savings, & the predicted pathology miss-rates. Methods All MREs performed in January 2018 were retrospectively reviewed. Demographics, scan indication, IBD characteristics, surgical history, & gastrointestinal & non-gastrointestinal findings were collected. Indications deemed suitable for GIUS included: assessment of disease activity of known small bowel (SB) Crohn’s disease; first assessment for presence of SB disease in IBD; & investigation for SB disease in patients without a known diagnosis of IBD. Obesity, complicated surgical history (>1 resection or strictureplasty involving different segments, or stoma), & known proximal SB disease were deemed unsuitable. Results 105 MREs were performed in January 2018. 59 (56%) were deemed suitable for GIUS instead of MRE. Most common reasons for unsuitability included complex surgical history (n=17, 37%), obesity (n=14, 30%), non-appropriate indication (n=12, 26%) & known upper gastrointestinal disease (n=10, 22%). Of suitable cases, 32/59 (54%) had active inflammation detected including 17 (53%) isolated ileal, 8 (25%) ileocolonic, & 6 (19%) isolated colonic. In one case performed as first assessment for SB disease, both ileal & jejunal disease were found, the latter likely to be missed with GIUS. No cases of isolated upper gastrointestinal inflammation were found. Regarding non-gastrointestinal findings in potential GIUS patients, there were two cases of pancreatic cysts necessitating further investigation with serial MRIs & endoscopic ultrasound, yielding a side branch intraductal papillary mucinous neoplasm & a benign serous cyst adenoma. One case of multiple high T2 skeletal lesions was deemed clinically insignificant following further investigations. No other significant extra-intestinal findings not expected to be seen on GIUS were identified. Conclusion Over 50% of MREs could have been performed as GIUS instead, with a potential annual cost saving of over £110,000. No instances of inflammation would have been missed based on distribution, although in one case the full extent of disease may not have been identified on GIUS. Incidental non-gastrointestinal findings resulted in multiple investigations but were of limited clinical significance.

113 Are Antibiotics Necessary for EUS-FNA of Pancreatic Cysts: A Retrospective Study

INTRODUCTION: Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is commonly used to further characterize cystic lesions of the pancreas. Antibiotic prophylaxis has been recommended by the Americal Society for Gastrointestinal Endoscopy for EUS-FNA of cystic pancreatic lesions. The aim of this study was to compare the rate of post-procedural infection in patients who received periprocedural antibiotics for EUS-FNA of pancreatic cystic lesions versus those who did not. METHODS: A retrospective review of medical records of individuals with pancreatic cysts who underwent EUS-FNAs at a tertiary academic hospital between January 2015 and March 2018 was performed. All procedures were performed by four board-certified gastroenterologists. The data reviewed included patient demographics, cyst description, FNA needle size, cytology and use of antibiotics. Post-procedural infections were identified by the presence of leukocytosis, fever, or positive blood cultures during follow-up clinic or hospital visits for 30 days after FNA. Excluded from the study were solid neoplasms, obvious side branch intraductal papillary mucinous neoplasm without high risk features and subjects with evidence of infection or leukocytosis before the FNA. RESULTS: Two hundred and ten EUS-FNA procedures were included in this analysis. Ninety six were males and 114 were females; median age was 65 years. Cysts were 1–5 cm in diameter and evenly distributed throughout the pancreas. One hundred and fifteen of the 210 (55%) cysts were >2 cm and 95 (44%) were <2 cm. 27 out of 210 (13%) were pancreatitis related cysts. 22-gauge needle was used for 55% of the procedures with the remaining procedures using 19 and 25-gauge needles. Eighty nine of 210 (43%) patients received periprocedural antibiotics. Only one of the total 210 patients (0.4%) developed post-procedural gram-negative bacteremia related to EUS within 1 week of procedure. This patient had received periprocedural antibiotics. None of the patients in the “no antibiotic” group had post-procedural infections (Table 1). CONCLUSION: The evidence supporting universal use of antibiotics for all cystic lesions as recommended is lacking and overall infection risk with FNA is low, at approximately 0.3% based on small studies. Our study of 210 patients including pancreatitis related cysts demonstrate that routine use of antibiotics may not be required for FNA of pancreatic cysts. Further prospective studies may be required to support this.

Risk of pancreatic cancer in patients with pancreatic cyst

Certain pancreatic cysts (mucinous cystic neoplasm and side branch intraductal papillary mucinous neoplasm [IPMN]) have malignant potential and require surveillance. However, whether patients with pancreatic cysts have a higher long-term risk of pancreatic cancer (PaCa) has still not been established. This was a retrospective study of Veterans Administration patients. Patients noted to have pancreatic cysts on CT/magnetic resonance imaging (n= 1050) were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients aged<15 years (n= 425), patients with<1 year of follow-up (n=13,259), and patients diagnosed to have PaCa within 1 year of identification of a pancreatic cyst (n=102) or within 1 year of follow-up in the remaining patients in the database (n= 200) were excluded. Patients with pancreatic cystic lesions (group A, n= 755) and the remaining patients in the database without cysts (group B, n= 520,215) were followed from 1998 to2007. During the study period, in group A and B PaCa was diagnosed in 17 and 1206 patients, respectively, and the incidence rate of PaCa was 5.08 and .32 per 1000 patient-years, respectively. The hazard ratio of PaCa in all patients with cysts was 19.64 (95% CI, 12.12-31.82; P< .0001) when compared with the rest of the patients without cysts. In the subset of patients with cysts, without a history of acute or chronic pancreatitis (n=241), the hazard ratio of PaCa (n= 5) was 18.80 (95% CI, 7.80-45.31; P< .0001). Patients with pancreatic cysts have a significantly higher overall risk of PaCa. The etiologic distribution of cysts in our study patients is not available. Patients with mucinous cystic neoplasm and side branch IPMN are likely to have a higher risk of PaCa than our estimation of risk based on all etiologies.

Prevalence and Characteristics of Pancreatic Cystic Lesions in Patients With Cirrhosis

Introduction: little is known about the prevalence and characteristics of pancreatic cystic lesions among patients with cirrhosis. Many cirrhotic patients undergo transplant evaluation and the presence of potential neoplastic lesions in the pancreas warrants further investigation and follow up. Methods: after obtaining IRB approval, we performed a Natural Language Processing search of high quality imaging studies (CT scan, MRI/MRCP and EUS) of patients with documented liver cirrhosis seen in our institution between January 2008 and December 2014. Keywords searched within reports were: cyst, cystic, pseudocyst, IPMN, mucinous and lesion within 20 word distance of the word “Pancreas”. Results: 2605 individual patients with cirrhosis were identified. The prevalence of any cystic lesion in the pancreas was 4.9% (95% CI: 3.8%-5.6). Mean age was 59 year. Cysts were classified as potential neoplastic (mainly mucinous) in 26.7% (95% CI: 19.8-35.1), indeterminate in 11% (95% CI: 6.6-17.8) and pseudocyst/ simple in 62.3 (95%CI: 53.5-70.8%). Cysts were multiple in 19.7% of patients. All potentially neoplastic cysts were considered “low risk” for progression with no worrisome features and consisted mainly of side branch intraductal papillary mucinous neoplasm (82.4%). None of the potentially neoplastic cysts was >30mm in maximum dimension compared to 60.8% of pseudocysts (p Conclusion: The prevalence of pancreatic cystic lesions in patients with cirrhosis is close to 5%. Cyst size and underlying cirrhosis etiology are associated with cyst type with larger cysts and alcoholic cirrhosis are less likely to be neoplastic. A substantial number of pancreatic cystic lesions in cirrhotic patients are potentially low risk neoplastic cysts with side branch IPMN constituting the majority of it.

High risk of acute pancreatitis after endoscopic ultrasound-guided fine needle aspiration of side branch intraductal papillary mucinous neoplasms.

Background and Objectives:Data on the risk of acute pancreatitis following endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of pancreatic cystic lesions are limited. The aim of our study was to evaluate the frequency of acute pancreatitis after EUS-FNA of pancreatic cysts and solid lesions, and determine whether there was a difference in pancreatitis risk in patients with side branch intraductal papillary mucinous neoplasms (SB-IPMN).Patients and Methods:A retrospective review of patients who underwent EUS-FNA of pancreatic cysts and solid lesions was performed. The primary outcome measure was development of acute pancreatitis after EUS-FNA. Factors associated with acute pancreatitis were examined by statistical analysis to determine independent predictors of acute pancreatitis. Statistical significance was determined at a P ≤ 0.05.Results:We identified 186 patients with pancreatic cystic lesions and 557 with solid lesions in which EUS-FNA was performed. The median size of the cysts was 19 mm (range: 10-66 mm). There were 37 IPMNs, 33 mucinous cystic neoplasms, 58 serous cysts and 46 pseudocysts and 12 solid-cystic ductal carcinomas. The majority of patients (75%) with solid lesions were diagnosed with adenocarcinoma. Patients with pancreatic cysts had a statistically greater frequency of developing pancreatitis after EUS-FNA when compared to those with solid lesions (2.6% vs. 0.36% respectively; P = 0.13). In patients with cysts, there were no statistically significant differences between the two groups (with and without pancreatitis) with regard to a cyst location, size of the cyst, and number of needle passes or trainee involvement. Patients with SB-IPMN had a statistically higher frequency of pancreatitis after EUS-FNA compared to those with other cyst types (8% vs. 1.3% respectively; odds ratio = 6.4, 95% confidence intervals = 1.0-40.3, P = 0.05).Discussion:Patients with SB-IPMN are at a higher risk of developing acute pancreatitis after a EUS-FNA. Alternative means of diagnosis such as magnetic resonance cholangiopancreatogram might be necessary to avoid risk of EUS-FNA.

Su1522 High Risk of Acute Pancreatitis After Endoscopic Ultrasound-Guided Fine Needle Aspiration of Side Branch Intraductal Papillary Mucinous Neoplasms

Su1522 High Risk of Acute Pancreatitis After Endoscopic Ultrasound-Guided Fine Needle Aspiration of Side Branch Intraductal Papillary Mucinous Neoplasms

Coexistent Serous Cystadenoma and Intraductal Papillary Mucinous Neoplasm of Pancreas? Yes, It Can Happen!

Purpose: A 63-year-old white male presented with six week history of intermittent, mild right flank discomfort. His physical examination, apart from moderate obesity, was unremarkable. His serum CA 19-9 and serum amylase levels were normal. A biphasic CT scan of abdomen revealed a 2cm water density lesion located in the posterior pancreatic tail. Endoscopic ultrasound (EUS) revealed three cysts ranging in size from 4mm to 10mm in pancreas body and a multi-loculated cystic lesion measuring 2.1cmx1.4cm (lesion #1) located in the pancreas tail. The sonographic features were suggestive of multiside branch intraductal papillary mucinous neoplasm (MS-IPMN) (Image 1, arrowhead). Immediately inferior to the largest MS-IPMN lesion and adjacent to the left kidney, a well-circumscribed, more solid-appearing lesion with anechoic (microcysts) intervening spaces was seen (lesion# 2) (Image 1, arrow). Lesion #2 measured 22mm in the greatest diameter. Based on sonographic features of lesion #2, a differential diagnosis of likely synchronous serous cystadenoma (SCT) versus other cystic solid lesions (neuroendocrine tumor) was rendered. An EUS guided fine needle aspiration (EUS-FNA) using a 22 G needle of lesion#1 yielded 3cc of clear viscous fluid with elevated CEA 203.7 ng/ml and amylase 17,514 U/L levels. EUS-FNA cytology was consistent with a side branch IPMN. The location of lesion #2 immediately inferior to the MS-IPMN precluded safe and uncontaminated advancement of the FNA needle. A subsequent distal pancreatectomy and splenectomy revealed synchronous SCT and MS-IPMN. This is an unusual case of concomitant SCT and IPMN. This report highlights the clinical impact of EUS and EUS-FNA in evaluation and management of cystic lesions of the pancreas and illustrates the limitation of biphasic pancreas protocol CT to ascertain the presence of multiple MS-IPMN lesions in the pancreas.Figure

Central pancreatectomy without anastomosis

BackgroundCentral pancreatectomy has a unique application for lesions in the neck of the pancreas. It preserves the distal pancreas and its endocrine functions. It also preserves the spleen.MethodsThis is a retrospective review of 10 patients who underwent central pancreatectomy without pancreatico-enteric anastomosis between October 2005 and May 2009. The surgical indications, operative outcomes, and pathologic findings were analyzed.ResultsAll 10 lesions were in the neck of the pancreas and included: 2 branch intraductal papillary mucinous neoplasms (IPMNs), a mucinous cyst, a lymphoid cyst, 5 neuroendocrine tumors, and a clear cell adenoma.ConclusionCentral pancreatectomy without pancreatico-enteric anastomosis for lesions in the neck and proximal pancreas is a safe and effective procedure. Morbidity is low because there is no anastomosis. Long term endocrine and exocrine function has been maintained.

Branch intraductal papillary mucinous neoplasms: just the tip of the iceberg?

Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas have drawn considerable interest in recent years as we begin to learn more about the natural history of this disease. It is...

407 Comparison of K-RAS-2 and LOH Mutational Analysis with Pancreas Cyst Fluid CEA Levels and Histology

BACKGROUND: The main objective of pancreatic cyst fluid analysis is to differentiate cysts of mucinous or malignant variety from other cysts which have a benign course. Previous investigators have reported that K-ras-2 point mutation and at least two mutations of allelic imbalance or loss of heterozygosity (LOH) with good quality DNA is characteristic of mucinous cystic neoplasm (MCN). OBJECTIVE: Identify the clinical impact of DNA analysis of pancreatic cyst fluid with its correlation to cyst fluid chemistry and histologic analysis. METHODS: This is a retrospective analysis of all consecutive patients with pancreatic cysts who presented for endoscopic ultrasound (EUS) examination with fine-needle aspiration (FNA) biopsy over an 18 month period until October 2007. DNA analysis was performed by RedPath Integrated Pathology (Pittsburg, PA). Fluid analysis included carcinogenic embryonic antigen (CEA) with values >192ng/dL suggestive of MCN. The standard for comparison was surgical histopathology when available. RESULTS: 27 consecutive patients with cysts and samples submitted for DNA analysis were examined including 15 men and 12 women (mean age 62.8 and 61.3 years, respectively). In 20 patients, all parameters including cyst fluid, DNA analysis, and histology were available for comparison. Consistent findings were seen in 7/20 (35%) in which all parameters suggested negative benign findings. 3/20 (15%) had positive K-ras-2 mutations of which only 2/3 had true histologic MCN suggesting a 33% false positivity. 7/20 (35%) of patients had at least 2 LOH mutations; however only 2/7 were actually positive on histology for MCN suggesting 71% false positivity. In the same group, CEA levels >192ng/dL were seen in 7/20 of which 4/7 had histologic malignancy demonstrating 42.9% false positivity. In a group of 9 malignant cysts (MCN, side branch intraductal papillary mucinous neoplasm, and cystic degeneration of adenocarcinoma), 7 (78%) had CEA levels >192ng/dL. In this group, 7 had DNA analysis of which 4/7 (57.1%) were falsely negative for K-ras-2 and 3/7 (42.9%) falsely negative for LOH. CONCLUSIONS: Consistency in histology, CEA levels, and K-ras-2 and LOH mutations was seen in only 35% of cases, all of which were benign cysts. In the detection of malignant cysts, elevated CEA levels were more predictive of histology in comparison to K-ras-2 or LOH mutations. Additionally, false positivity of LOH mutations was noted to be considerably higher than K-ras-2mutations or even fluid CEA levels. These findings suggest that DNAmutation analysis should not be used routinely but rather selectively in the evaluation of pancreatic cysts.

Treatment Guidelines for Branch Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas: When Can We Operate or Observe?

The objectives of this study were to investigate the clinicopathological features of branch intraductal papillary mucinous neoplasm (IPMN) and to determine safe criteria for its observation. Most clinicians agree that surgical resection is required to treat main duct-type IPMN because of its high malignancy rate. However, no definite treatment guideline (with respect to surgery or observation) has been issued on the management of branch duct type IPMN. We retrospectively reviewed the clinicopathological data of 138 patients who underwent operations for IPMN between 1993 and 2006 at five institutes in Korea. Of 138 patients (mean age, 60.6 years; 87 men, 51 women), 76 underwent pancreatoduodenectomy, 39 distal pancreatectomy, 4 total pancreatectomy, and 20 limited pancreatic resection. There were 112 benign cases: 47 adenoma, 63 borderline cases, and 26 malignant cases, with 9 of these being noninvasive and 17 invasive. By univariate analysis, tumor size and the presence of a mural nodule were identified as meaningful predictors of malignancy. By receiver operating characteristic curve analysis, a tumor size of >2 cm was found to be the most valuable predictor of malignancy. When cases were classified according to tumor size and the presence of a mural nodule, the malignancy rate for a tumor </=2 cm without a mural nodule was 9.2%, for a tumor of </=2 cm plus a mural nodule was 25%, and for other conditions such as tumor >2 cm, >25%. Many branch duct IPMNs are malignant. Surgical treatment is recommended, except in cases that are strongly suspected to be benign or cases that present a high operative risk. Observation is only recommended in patients with a tumor size of </=2 cm without a mural nodule.

Small cystic lesions of the pancreas: clinical significance and findings at follow-up

Our purpose was to correlate the imaging findings of small cystic pancreatic lesions to the incidence of growth on follow-up imaging and their pathologic diagnoses. CT images for 159 patients with cystic pancreatic lesions were retrospectively evaluated and lesions were assessed for size, number, connection to the main pancreatic duct (MPD), MPD dilatation, and any presence of loculation, wall irregularity, thick septations, or solid components. A total of 86 patients had follow-up imaging with time periods of less than 6 months (n = 21), 6-12 months (n = 22), 1-2 years (n = 14), and greater than 2 years (n = 29). Lesion histology was available in 20 patients. Lesions with pathologic correlation proved to be: side branch intraductal papillary mucinous neoplasm or tumor (IPMT) (n = 5), combined type IPMT (n = 4), nonmucinous cyst (n = 4), chronic pancreatitis (n = 2), and reactive atypia with nonmucinous fluid (n = 1), combined type IMPT with foci of adenocarcinoma (n = 1), mucinous adenocarcinoma (n = 2), and nonmucinous adenocarcinoma (n = 1). Lesions with solid components were significantly more likely to grow and be malignant (P < 0.05). The presence of MPD dilatation was more common in patients with combined type IPMTs or malignancies. No other factors were predictive of malignancy. Solid components are predictive of malignancy, and MPD dilatation should prompt consideration of surgery. Other cystic lesions can be followed.