Malignant Intraductal Papillary Mucinous Neoplasms Research Articles

Surgery for cystic tumors of pancreas: Report of high-volume, multicenter Indian experience over a decade

BackgroundPancreatic cystic neoplasms remain uncommon. Although data are accumulating on the incidence of pancreatic cystic neoplasms in the published literature, Indian data on these tumors are sparse. Material and MethodsWe collated data from prospectively maintained databases of patients operated for cystic tumors of the pancreas from 2007 to 2016 at 7 academic centers across India to gain insights into clinical presentation and outcome of the operative treatment of these tumors. Data were compared with large series across the world to understand the regional differences in this pathology. ResultsOf the 423 patients, there were 98 (23.2%) serous cystic neoplasms, 128 (30.2%) mucinous neoplasms, 34(8%) intraductal papillary mucinous neoplasms, and 121 (28.6%) solid pseudopapillary epithelial neoplasms managed in these 7 academic centers. Malignancy (adenocarcinoma, malignant intraductal papillary mucinous neoplasms, and mucinous cystadenocarcinoma) was reported in 39 (9.2%) patients. Median age at presentation was 41 years, and the female-to-male ratio was 3.4:1. At presentation, 81% of patients were symptomatic. A total of 66.7% of lesions were located in body and tail region of the pancreas. Median tumor size was 6 cm. Operative resection with curative intent was performed in 405 of these 423 patients. Major morbidity occurred in 12%, and 30-day perioperative mortality was 0.9%. Laparoscopic resections were performed in 18% and spleen-preserving resections were performed in 3% of patients. ConclusionFemale preponderance, young age, and a benign nature of most pancreatic cystic neoplasms were observed. Large size of tumors on presentation, fewer intraductal papillary mucinous neoplasm resections, and a much greater incidence of solid pseudopapillary epithelial neoplasms were distinctive of this study. Although the proportion of laparoscopic resections and splenic preservation was less compared with Western centers, the perioperative morbidity and mortality was on par with established standards.

Increased Risk of Second Primary Cancers Following Diagnosis of Malignant Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Population-Based Study.

Introduction: Several studies have reported that intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are associated with extra-pancreatic malignancies. However, there have been no population-based studies evaluating the risk of second primary cancers (SPCs) in patients with pancreatic IPMN.Methods: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify and characterize data from patients with IPMN of the pancreas. The standard incidence ratio (SIR) of this cancer was calculated by estimating the relative risk (RR). A multivariate Cox regression model was used to estimate hazards ratios (HRs) of death and associated 95% CIs.Results: Of 2,850 patients with IPMN of the pancreas, 104 patients (3.65%) developed 118 SPCs. The SIR for all SPCs combined was 1.22 (95% confidence interval [CI] = 1.01–1.46; P < 0.05). There was an elevated risk of site-specific SPCs in the small intestine (SIR = 8.68; 95% CI = 2.36–22.22), pancreas (SIR = 2.66; 95% CI = 1.15–5.25), urinary bladder (SIR = 2.02; 95% CI = 1.05–3.54), and eye and orbit (SIR = 13.47; 95% CI = 1.63–48.67) in patients with pancreas IPMN. In age subgrouping, people aged younger than 50 years had an increased risk of all-site SPC with an SIR of 6.44 (95% CI = 2.78–12.68). Cox regression modeling showed that advanced disease stage and a short latency period carried a higher risk of death in IPMN patients with SPC.Conclusions: Patients diagnosed with pancreatic IPMNs were at higher risk than the general population for developing a second primary malignancy. Meanwhile, advanced historic stage and short latency period were associated with an elevated HR in IPMN patients who develop an SPC.

MRI Combined with Magnetic Resonance Cholangiopancreatography for Diagnosis of Benign and Malignant Pancreatic Intraductal Papillary Mucinous Neoplasms.

Intraductal papillary mucinous neoplasms (IPMNs) are among the important premalignant lesions. Early detection and intervention are critical to positive patient outcomes. Magnetic resonance imaging (MRI) can be used to evaluate the malignancy of IPMNs, and magnetic resonance cholangiopancreatography (MRCP) is recommended for follow-up of pancreatic cystic lesions. To evaluate the diagnostic performance of MRI combined with MRCP in determining the malignant potential of pancreas IPMN. This is a retrospective study of 55 patients with 58 pancreatic lesions confirmed after surgery, which were analyzed and divided into two groups, a benign IPMN group (n = 27) and a malignant IPMN group (n = 31). Two radiologists analyzed the high-risk stigmata and worrisome features of pancreas IPMN to evaluate the malignant potential. Score all the lesions as proposed by the international consensus guidelines 2012, and calculate the sensitivity, specificity and accuracy. There were significant differences of size, enhancement of solid components, and degree of dilation of the main pancreatic duct between benign and malignant IPMN (P < 0.05). However, differences in gender, age and location of disease between the two groups were not statistically significant (P > 0.05). The sensitivity, specificity and accuracy of MRI combined with MRCP in preoperative diagnosis of malignant IPMNs were 90.3% (28/31), 70.4% (19/27) and 81.0% (47/58) respectively, when at least one worrisome feature was present. MRI combined with MRCP is useful in the evaluation of the benign and malignant pancreas IPMN.

12 Years of prospective pancreatic cancer surveillance: Results of the Dutch nationwide program in high-risk individuals

To assess the value of 18F-FDG PET/CT in differentiating between benign and malignant intraductal papillary mucinous neoplasms (IPMN) of the pancreas.Malignant or high-risk IPMN require surgical resection but surgery should be avoided in patients with IPMN carrying a low risk of malignancy. 18F-FDG PET has been studied mostly in small, single center, retrospective series.Prospective, non-comparative, multicenter French study. The primary endpoint was the specificity of PET/CT for identifying malignant IPMN (in situ or invasive carcinoma). Final diagnosis was obtained from pathological examination of the resected specimen.Among 120 patients analyzed, 99 had confirmed IPMN, including 24 with malignant lesions, namely 9 with carcinoma in situ and 15 with invasive carcinoma. The 18F-FDG PET/CT was positive in 44 and 31 patients in the overall and IPMN populations respectively. In the 99 IPMN patients, PET/CT showed 13 true positive, 18 false positive, 57 true negative and 11 false negative results. The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) for the diagnosis of malignancy were 54.2%, 76.0%, 83.8% and 41.9% respectively, versus 64.9%, 75.9%, 82.9% and 54.5% in the overall population. We could not identify a cut-off value for SUVmax to distinguish benign from malignant lesions. Conventional imaging included computed tomography, magnetic resonance cholangiopancreatography and endoscopic ultrasound. In IPMN patients who underwent the 3 techniques, sensitivity, specificity, NPV and PPV were 66.7%, 84.4%, 84.4% and 66.7% respectively.In this study, 18F-FDG PET/CT did not perform better than conventional imaging to differentiate malignant from benign IPMN.

Comparison of 2012 and 2017 international consensus guideline in terms of mural nodule for predicting malignant intraductal papillary mucinous neoplasms

Comparison of 2012 and 2017 international consensus guideline in terms of mural nodule for predicting malignant intraductal papillary mucinous neoplasms

Incidental Pancreatic Cystic Neoplasms: Detection of Malignancy

To assess the value of 18F-FDG PET/CT in differentiating between benign and malignant intraductal papillary mucinous neoplasms (IPMN) of the pancreas.Malignant or high-risk IPMN require surgical resection but surgery should be avoided in patients with IPMN carrying a low risk of malignancy. 18F-FDG PET has been studied mostly in small, single center, retrospective series.Prospective, non-comparative, multicenter French study. The primary endpoint was the specificity of PET/CT for identifying malignant IPMN (in situ or invasive carcinoma). Final diagnosis was obtained from pathological examination of the resected specimen.Among 120 patients analyzed, 99 had confirmed IPMN, including 24 with malignant lesions, namely 9 with carcinoma in situ and 15 with invasive carcinoma. The 18F-FDG PET/CT was positive in 44 and 31 patients in the overall and IPMN populations respectively. In the 99 IPMN patients, PET/CT showed 13 true positive, 18 false positive, 57 true negative and 11 false negative results. The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) for the diagnosis of malignancy were 54.2%, 76.0%, 83.8% and 41.9% respectively, versus 64.9%, 75.9%, 82.9% and 54.5% in the overall population. We could not identify a cut-off value for SUVmax to distinguish benign from malignant lesions. Conventional imaging included computed tomography, magnetic resonance cholangiopancreatography and endoscopic ultrasound. In IPMN patients who underwent the 3 techniques, sensitivity, specificity, NPV and PPV were 66.7%, 84.4%, 84.4% and 66.7% respectively.In this study, 18F-FDG PET/CT did not perform better than conventional imaging to differentiate malignant from benign IPMN.

Investigation on the frequency of the combination of the pancreatic malignant tumors and the methods of follow-up of patients with IPMN

To assess the value of 18F-FDG PET/CT in differentiating between benign and malignant intraductal papillary mucinous neoplasms (IPMN) of the pancreas.Malignant or high-risk IPMN require surgical resection but surgery should be avoided in patients with IPMN carrying a low risk of malignancy. 18F-FDG PET has been studied mostly in small, single center, retrospective series.Prospective, non-comparative, multicenter French study. The primary endpoint was the specificity of PET/CT for identifying malignant IPMN (in situ or invasive carcinoma). Final diagnosis was obtained from pathological examination of the resected specimen.Among 120 patients analyzed, 99 had confirmed IPMN, including 24 with malignant lesions, namely 9 with carcinoma in situ and 15 with invasive carcinoma. The 18F-FDG PET/CT was positive in 44 and 31 patients in the overall and IPMN populations respectively. In the 99 IPMN patients, PET/CT showed 13 true positive, 18 false positive, 57 true negative and 11 false negative results. The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) for the diagnosis of malignancy were 54.2%, 76.0%, 83.8% and 41.9% respectively, versus 64.9%, 75.9%, 82.9% and 54.5% in the overall population. We could not identify a cut-off value for SUVmax to distinguish benign from malignant lesions. Conventional imaging included computed tomography, magnetic resonance cholangiopancreatography and endoscopic ultrasound. In IPMN patients who underwent the 3 techniques, sensitivity, specificity, NPV and PPV were 66.7%, 84.4%, 84.4% and 66.7% respectively.In this study, 18F-FDG PET/CT did not perform better than conventional imaging to differentiate malignant from benign IPMN.

Management algorithm for pancreatic cystic lesions

To assess the value of 18F-FDG PET/CT in differentiating between benign and malignant intraductal papillary mucinous neoplasms (IPMN) of the pancreas.Malignant or high-risk IPMN require surgical resection but surgery should be avoided in patients with IPMN carrying a low risk of malignancy. 18F-FDG PET has been studied mostly in small, single center, retrospective series.Prospective, non-comparative, multicenter French study. The primary endpoint was the specificity of PET/CT for identifying malignant IPMN (in situ or invasive carcinoma). Final diagnosis was obtained from pathological examination of the resected specimen.Among 120 patients analyzed, 99 had confirmed IPMN, including 24 with malignant lesions, namely 9 with carcinoma in situ and 15 with invasive carcinoma. The 18F-FDG PET/CT was positive in 44 and 31 patients in the overall and IPMN populations respectively. In the 99 IPMN patients, PET/CT showed 13 true positive, 18 false positive, 57 true negative and 11 false negative results. The sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) for the diagnosis of malignancy were 54.2%, 76.0%, 83.8% and 41.9% respectively, versus 64.9%, 75.9%, 82.9% and 54.5% in the overall population. We could not identify a cut-off value for SUVmax to distinguish benign from malignant lesions. Conventional imaging included computed tomography, magnetic resonance cholangiopancreatography and endoscopic ultrasound. In IPMN patients who underwent the 3 techniques, sensitivity, specificity, NPV and PPV were 66.7%, 84.4%, 84.4% and 66.7% respectively.In this study, 18F-FDG PET/CT did not perform better than conventional imaging to differentiate malignant from benign IPMN.

Usefulness of 18-FDG PET/CT in Detecting Malignancy in Intraductal Papillary Mucinous Neoplasms of the Pancreas.

Identifying malignancy in intraductal papillary mucinous neoplasm (IPMN) of the pancreas remains challenging. This study aimed to evaluate the usefulness of 18-fluorodeoxyglucose positron emission tomography/computed tomography (18-FDG PET/CT) in distinguishing malignant from benign IPMN of the pancreas. The cases of 79 patients with IPMN of the pancreas who underwent surgical resections between 1996 and 2016 at our Institution were enrolled in the present retrospective analysis of predictors for malignancy in IPMN of the pancreas. 18-FDG PET/CT evaluations were performed in 38 patients, and the usefulness of 18-FDG PET/CT for detecting malignancy in IPMN of the pancreas was evaluated. Three factors were significantly related to malignancy in IPMN; the diameter of the main pancreatic duct, the serum value of carcinoembryonic antigen (CEA), and the neutrophil-to-lymphocyte ratio (NLR). 18-FDG PET accumulation was significantly related to malignancy in IPMN; sensitivity 0.82 and specificity 0.71. Independent predictors for malignancy in IPMN were as follows: 18-FDG PET accumulation, CEA >1.0 ng/ml, and NLR >2.63. 18-FDG PET accumulation is a potent new marker for distinguishing malignant from benign IPMNs of the pancreas.

Usefulness of septal thickness measurement on endoscopic ultrasound as a predictor of malignancy of branched-duct and mixed-type intraductal papillary mucinous neoplasm of the pancreas.

Septal thickness (ST) can predict a malignant branch-duct (BD) and mixed-type intraductal papillary mucinous neoplasm (IPMN) of the pancreas, but its cut-off value has not been established. The aim of the present study was to determine the optimal ST cut-off value to predict malignancy using endoscopic ultrasound (EUS). We retrospectively identified 200 patients with IPMN, including 132 with BD- and mixed-IPMN, who underwent surgical resection between 1989 and 2017. ST was defined as the septum or lesion wall with the maximum diameter in BD- and mixed-IPMN. The possibility of ST as a malignant predictor was examined, as well as the diagnostic ability of ST combined with mural nodule (MN) height for malignant IPMN. Among the 132 IPMN patients, pathological diagnosis was benign in 81 (61.4%) and malignant in 51 (38.6%). Area under the curve for the diagnosis of malignancy using ST was 0.74 for pathological specimens, 0.70 for EUSand 0.56 for computed tomography. Multivariate analysis showed that the odds ratios for ST ≥2.5mm and MN height≥5mm were 3.51 [95% confidence interval (CI), 1.55-7.97, P=0.003] and 3.36 (95% CI, 1.52-7.45, P=0.003), respectively. Septal thickness was an independent predictive factor similar to MN height for malignant IPMN in a multivariate analysis. The ST on EUS appeared to be the thickness of a fibrotic septum associated with the malignant transformation of IPMN. An ST cut-off value of 2.5mm might provide an accurate prediction of malignant IPMN.

Evaluation of efficacy of pancreatic juice cytology for risk classification according to international consensus guidelines in patients with intraductal papillary mucinous neoplasm; a retrospective study

ObjectivesPancreatic juice cytology (PJC) for intraductal papillary mucinous neoplasm (IPMN) is a possible tool to enhance preoperative diagnostic ability by improving risk classification for malignant IPMN, but its efficacy is controversial. This study evaluated the efficacy of PJC for risk classification according to international guidelines. MethodsWe retrospectively analyzed 127 IPMN patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) preoperatively. PJC was performed in 125 of the 127 cases. High-risk stigmata (HRS, n = 57), worrisome features (WF, n = 64), and other characteristics (n = 6) were classified according to the 2017 international guidelines. ResultsAmong the 127 IPMN patients, 71 (55.9%) had malignant IPMN (invasive and non-invasive intraductal papillary mucinous carcinoma). The accuracy of WF for classifying malignant IPMN was increased by the addition of PJC, but the accuracy of HRS was not (WF to WF + PJC: 33.1% [42/127] to 48.8% [61/125], HRS to HRS + PJC: 65.4% [83/127] to 52.8% [66/125]). Post-ERCP pancreatitis (PEP) occurred in 32 (25.2%) of 127 IPMN patients. Severe PEP was not detected. Significant risk factors for PEP were female sex, obesity, and endoscopic naso-pancreatic drainage (ENPD) (P = .03, P = .0006, and P = .02, respectively). In patients with ENPD tube placement, a main pancreatic duct size of <5 mm was a significant risk factor for PEP (P = .02). ConclusionPJC could increase the accuracy of WF for classifying malignant IPMN. The additive effect of PJC for risk classification may be limited, however, and it is not recommended for all IPMN cases due to the high frequency of PEP.

Neutrophil to Lymphocyte Ratio is a Predictive Factor of Malignant Potential for Intraductal Papillary Mucinous Neoplasms of the pancreas.

Intraductal papillary mucinous neoplasms (IPMNs) are cystic neoplasms with the potential for progression to pancreatic cancer. Accurate prediction of the malignant potential is challenging and a proper treatment strategy has not been well established. Preoperative neutrophil-to-lymphocyte ratio (NLR) is a biomarker of the malignant potential in patients with several types of malignancy. We explored malignant potential in patients with IPMN. The present study included 56 patients aged of 73 ± 9 years (mean ± standard deviation) who underwent curative resection for IPMN from 1996 to 2017. We analyzed the relationship between the characteristics including NLR and malignant component for predicting pathological results. The nonmalignant IPMN group (N = 21) included patients with low-grade dysplasia (LGD) and intermediate-grade dysplasia (IGD), and the malignant IPMN group (N = 35) included patients with high-grade dysplasia (HGD) and invasive carcinoma. In a univariate analysis, NLR ⩾ 2.2 (P = .001), prognostic nutritional index (PNI) < 45 (P = .016), CA 19-9 > 37 U/mL (P = .039), and cystic diameter ⩾ 30 mm (P = .010), and mural nodule (P = .010) were significantly different between the malignant IPMN and the nonmalignant IPMN groups. Multivariate analysis showed that high NLR (⩾2.2) (odds ratio 9.79; 95% confidence interval: 2.06-45.6), cystic diameter ⩾ 30 mm (4.65; 1.14-18.9), and mural nodule (4.91; 1.20-20.1) were independently predictive of malignant IPMN. These results suggest that preoperative NLR is a useful predictive biomarker for evaluating malignant potential in patients with IPMN.1

Clinical validation of the 2017 international consensus guidelines on intraductal papillary mucinous neoplasm of the pancreas.

PurposeThe 2017 international consensus guidelines (ICG) for intraductal papillary mucinous neoplasm (IPMN) of the pancreas were recently released. Important changes included the addition of worrisome features such as elevated serum CA 19-9 and rapid cyst growth (>5 mm over 2 years). We aimed to clinically validate the 2017 ICG and compare the diagnostic performance between the 2017 and 2012 ICG.MethodsThis was a retrospective cohort study. During January 2000–January 2017, patients who underwent complete surgical resection and had pathologic confirmation of branch-duct or mixed-type IPMN were included. To evaluate diagnostic performance, the areas under the receiver operating curves (AUCs) were evaluated.ResultsA total of 448 patients were included. The presence of mural nodule (hazard ratio [HR], 9.12; 95% confidence interval [CI], 4.60–18.09; P = 0.001), main pancreatic duct dilatation (>5 mm) (HR, 5.32; 95% CI, 2.67–10.60; P = 0.001), thickened cystic wall (HR, 3.40; 95% CI, 1.51–7.63; P = 0.003), and elevated CA 19-9 level (>37 unit/mL) (HR, 5.25; 95% CI, 2.05–13.42; P = 0.001) were significantly associated with malignant IPMN. Malignant lesions showed a cyst growth rate >5 mm over 2 years more frequently than benign lesions (60.9% vs. 29.7%, P = 0.012). The AUC was higher for the 2017 ICG than the 2012 ICG (0.784 vs. 0.746).ConclusionThe new 2017 ICG for IPMN is clinically valid, with a superior diagnostic performance to the 2012 ICG. The inclusion of elevated serum CA 19-9 level and cyst growth rate to the 2017 ICG is appropriate.

Clinical validation of the 2017 international consensus guidelines on intraductal papillary mucinous neoplasm of the pancreas

Introduction: The 2017 international consensus guidelines (ICG) for intraductal papillary mucinous neoplasm (IPMN) of the pancreas were recently released. Important changes included the addition of the relevant risk indicators elevated serum carbohydrate antigen 19-9 (CA 19-9) and rapid cyst growth (>5 mm over 2 years). We aimed to clinically validate the 2017 ICG and compare the diagnostic performance between the 2017 and 2012 ICG. Method: This was a retrospective cohort study. During January 2000–January 2017, patients who underwent complete surgical resection and had pathologic confirmation of branch-duct or mixed-type IPMN were included. Demographic, laboratory, and radiologic data were compiled in a prospectively collected database. To evaluate diagnostic performance, the areas under the receiver operating curves (AUCs) were evaluated. Result: A total of 448 patients were included. The presence of mural nodule (hazard ratio [HR] 9.12, 95% confidence interval [CI] 4.60–18.09, p=0.001), main pancreatic duct dilatation (>5 mm) (HR 5.32, 95% CI 2.67–10.60, p=0.001), thickened cystic wall (HR 3.40, 95% CI 1.51–7.63, p=0.003), and elevated CA 19-9 level (>37 unit/mL) (HR 5.25, 95% CI 2.05–13.42, p=0.001) were significantly associated with malignant IPMN. Malignant lesions showed a cyst growth rate >5 mm over 2 years more frequently than benign lesions (60.9 vs 29.7%, p=0.012). The AUC was higher for the 2017 ICG than the 2012 ICG (0.784 vs. 0.746). Conclusion: The new 2017 ICG for IPMN is clinically valid, with a superior diagnostic performance to the 2012 ICG. The inclusion of elevated serum CA 19-9 level and cyst growth rate to the 2017 ICG is appropriate.

External validation of a nomogram to predict malignancy risk in patients with intraductal papillary mucinous neoplasms, using Eastern and Western cohorts

Introduction: Intraductal papillary mucinous neoplasm (IPMN) is premalignant pancreatic lesion. International guidelines suggest several treatments and malignancy predictors but offer limited predictors of individual risk. A nomogram to predict individual IPMN malignancy risk was released with good diagnostic performance, based on a cohort of 2258 Korean or Japanese patients with IPMN. This study validated a nomogram to predict malignancy risk and invasiveness of IPMN, using Eastern and Western cohorts. Method: We collected clinicopathological and radiological data of patients who underwent pancreas resection for IPMN at 4 centers each in Eastern and Western countries. After excluding patients with ≥1 missing malignancy predictor in the nomogram (main pancreatic duct diameter, cyst size, presence of mural nodule, serum CEA and CA19-9 levels, and age), we analyzed data of the remaining 393 patients (Eastern: n=265; Western: n=128). Result: Although mean age, sex, log value of serum CA19-9, tumor location, main duct diameter, cyst size and presence of mural nodule differed between the Korea/Japan, Eastern and Western cohorts, rates of malignancy and invasive cancer did not significantly differ. Areas under the receiver operating characteristics curve (AUC) values using the nomogram to predict malignancy were Eastern: 0.745, Western: 0.856, and combined cohorts: 0.776; and to predict invasiveness were Eastern: 0.736, Western: 0.891, and combined cohorts: 0.788. Conclusion: External validation of the nomogram showed good performance in predicting malignancy and invasive cancer in both Eastern and Western IPMN patients. The nomogram could be globally applicable to decide customized treatment options for patients with IPMN.

Systematic review of the utility of 18-FDG PET in the preoperative evaluation of IPMNs and cystic lesions of the pancreas

The aim of this systematic review is to assess the role of 18-fluorodeoxyglucose positron emission tomography in the preoperative evaluation of intraductal papillary mucinous neoplasms and cystic lesions of the pancreas. A computerized PubMed search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies evaluating positron emission tomography in the preoperative evaluation of pancreatic cystic lesions. A total of 14 studies evaluated the role of 18-fluorodeoxyglucose positron emission tomography/positron emission tomography-computed tomography, 9 of which evaluated only intraductal papillary mucinous neoplasms and 5 evaluated all pancreatic cystic lesions, including intraductal papillary mucinous neoplasms. Pooled analysis was carried out for studies evaluating intraductal papillary mucinous neoplasms only and studies evaluating all cystic lesions. Imaging with 18-fluorodeoxyblucose positron emission tomography had a positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of 90%, 91%, 85%, 95%, and 91% in identifying malignancy (defined as either invasive and/or high-grade dysplasia) in intraductal papillary mucinous neoplasms and a positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of 85%, 81%, 79%, 86%, and 88% in identifying malignancy in other cystic lesions. Pooled analysis reported the positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of Sendai consensus guidelines (SCG) criteria as 69%, 69%, 68%, 55%, and 58%. The Fukuoka consensus guidelines (FCG) only had sensitivity, specificity, and accuracy reported as 61%, 52%, and 52%, respectively. The 18-fluorodeoxyblucose positron emission tomography had a high degree of accuracy of detecting malignancy in intraductal papillary mucinous neoplasm and cystic lesion of the pancreas. Comparison of the utility of positron emission tomography with the Fukuoka consensus guidelines and the Sendai consensus guidelines suggest that positron emission tomography is superior to present guidelines in detecting malignant intraductal papillary mucinous neoplasm and cystic lesion of the pancreas. Further studies in larger patient cohorts may be required to corroborate these findings and to determine the place of positron emission tomography in the management of intraductal papillary mucinous neoplasm and cystic lesions of the pancreas.

New Model for Predicting Malignancy in Patients With Intraductal Papillary Mucinous Neoplasm.

To create a simple, objective model to predict the presence of malignancy in patients with intraductal papillary mucinous neoplasm (IPMN), which can be easily applied in daily practice and, importantly, adopted for any lesion types. No predictive model for malignant IPMN has been widely applied in clinical practice. The clinical details of 466 patients with IPMN who underwent pancreatic resection at 3 hospitals were retrospectively analyzed for model development. Then, the model was validated in 664 surgically resected patients at 8 hospitals in Japan.In the preoperative examination, endoscopic ultrasonography (EUS) was considered to be essential to observe mural nodules in both the model development and external validation sets. Malignant IPMNs were defined as those with high-grade dysplasia and associated invasive carcinoma. Of the 466 patients, 258 (55%) had malignant IPMNs (158 high-grade dysplasia, 100 invasive carcinoma), and 208 (45%) had benign IPMNs. Logistic regression analysis resulted in 3 variables (mural nodule size, main pancreatic duct diameter, and cyst size) being selected to construct the model. The area under the receiver operating characteristic curve (AUC) for the model was 0.763. In external validation sets, the pathological diagnosis was malignant and benign IPMN in 351 (53%) and 313 (47%) cases, respectively. For the external validation, the malignancy prediction ability of the model corresponded to an AUC of 0.725. This predictive model provides important information for physicians and patients in assessing an individual's risk for malignancy and may help to identify patients who need surgery.

Develop Nomogram to Predict Malignancy of Intraductal Papillary Mucinous Neoplasm.

A nomogram is a useful graphical tool for presenting a risk prediction and prognosis prediction in medical research. Intraductal papillary mucinous neoplasm (IPMN) is the premalignant lesions of the pancreas. Among the IPMN, branch duct (BD) IPMN is hard to determine whether progress to an invasive tumor or not. Surgery on the pancreas part is likely to lower the quality of life of the patient, so avoiding surgery to remove IPMN tissue of the patients with low risk should be carefully decided. In this study, we introduce the process of constructing a nomogram and illustrate it with a prediction model to predict malignancy of IPMN.

Endoscopic diagnosis of cystic lesions of the pancreas

Endoscopic methods are increasingly used in the diagnosis of cystic lesions of the pancreas. The two major endoscopic approaches are endoscopic ultrasonography (EUS) and transpapillary diagnosis. EUS-guided fine-needle aspiration cytology and EUS-guided fine needle-based confocal laser endomicroscopy have been used in the differential diagnosis of mucinous and non-mucinous pancreatic cysts. EUS is the most sensitive modality for detecting mural nodules (MN) in intraductal papillary mucinous neoplasms (IPMN). Contrast-enhanced harmonic EUS (CH-EUS), as an add-on to EUS, is useful for identifying and characterizing MN. Recent studies show that CH-EUS has a sensitivity of 60-100% and a specificity of 75-92.9% for diagnosing malignant cysts. Intraductal ultrasonography and peroral pancreatoscopy are especially useful for detecting MN and IPMN. A recent meta-analysis showed that cytological assessment of pancreatic juice using a transpapillary approach had a pooled sensitivity, specificity, and accuracy of 35.1%, 97.2%, and 92.9%, respectively, for diagnosing malignant IPMN. Further studies are warranted to determine the indications for each of these novel techniques in assessing cystic lesions of the pancreas.

Adjuvant chemotherapy after surgery for intraductal papillary mucinous neoplasms of the pancreas: promising observational data call for controlled studies

Introduction: Little is known about the role of adjuvant treatment after surgery for malignant Intraductal Papillary Mucinous Neoplasms (IPMNs).The aim of this study is to assess the potential role of adjuvant chemotherapy in terms of improvement of survival. Methods: Retrospective evaluation of all patients with resected IPMNs with high grade dysplasia (HGD) or invasive carcinoma (iCa) at the Department of General and Pancreatic Surgery - The Pancreas Institute, University of Verona, with univariate and multivariate analysis for determinants of disease specific survival (DSS) were performed.Kaplan-Maier curves were used to compare patients. Results: From 467 resected IPMNs, we identified 195 patients: 110 (56%) with iCa and 85 (44%) with HGD.As expected, none of the patients with HGD received adjuvant therapy, while 22.7% of patients with IPMN-iCa did.The most used chemotherapy regimen was Gemcitabine (72%).Overall, the median DSS for IPMN-iCa was 208 months.The median DSS of IPMN treated with adjuvant therapy was not reached, while it was 94 months for surgery alone (p< 0.01).Predictors of DSS were adjuvant therapy (HR=0.42; CI=0.26-0.67; p< 0.01), tubular invasive component (HR=5.79; CI=2.69-12.45; p< 0.01) and pancreatobiliary epithelial type (HR=2.85; CI=1.3-7.87; p=0.03). At multivariate analysis, adjuvant therapy resulted an independent predictor of DSS (HR=0.45; CI=0.20-0.98; p< 0.04).Stratifying for pathological features,adjuvant therapy was independently associated with DSS only in case of tubular invasive component. Conclusions: Adjuvant therapy for IPMNs with iCa is associated with improved DSS compared with surgery alone, especially in case of tubular invasive component. Future controlled trials are needed to improve the level of evidence.