Malignant Mucinous Cystic Neoplasms Research Articles

Comparison with surgically resected mucinous cystic neoplasm of pancreas and branch-duct type intraductal papillary mucinous neoplasm considering clinico-radiological high-risk features: a reassessment of current guidelines.

To perform a comparative analysis of surgically resected mucinous cystic neoplasm (MCN) of pancreas and branch-duct type intraductal papillary mucinous neoplasms (BD-IPMN) considering clinico-radiological high-risk predictors for malignant tumors using the current management guidelines. 224 patients who underwent surgical resection and had histopathologically confirmed MCNs (benign 73; malignant 17) or BD-IPMNs (benign 110; malignant 24) and had pre-operative CT or MRI were retrospectively reviewed. Tumors classified as either high-grade dysplasia or invasive carcinoma were considered malignant, whereas those with low-grade dysplasia were considered benign. Imaging features were analyzed by two radiologists based on selected high-risk stigmata or worrisome features proposed by prevalent guidelines except tumors with main pancreatic duct dilatation (> 5mm) were excluded. MCNs and BD-IPMNs showed significant differences in aspects like tumor size, location, the presence and size of enhancing mural nodules, the presence of wall or septal thickening, and multiplicity. Multivariate analyses revealed tumor size (OR, 1.336; 95% CI, 1.124-1.660, p = 0.002) and the presence of enhancing mural nodules (OR, 67.383; 95% CI, 4.490-1011.299, p = 0.002) as significant predictors of malignant MCNs. The optimal tumor size differentiating benign from malignant tumor was 8.95cm, with a 70.6% sensitivity, 89% specificity, PPV of 27.6%, and NPV of 96.9%, demonstrating superior specificity than the guideline-suggested threshold of 4.0cm. For malignant BD-IPMNs, the presence of enhancing mural nodules (OR, 15.804; 95% CI, 4.439-56.274, p < 0.001) and CA 19 - 9 elevation (OR, 19.089; 95%CI, 2.868-127.068, p = 0.002) as malignant predictors, with a size of enhancing mural nodule threshold of 5.5mm providing the best malignancy differentiation. While current guidelines may be appropriate for managing BD-IPMNs, our results showed a notably larger optimal threshold size for malignant MCNs than that suggested by current guidelines. This warrants reconsidering existing guideline thresholds for initial risk stratification and management of MCNs.

Pancreatic cystic neoplasms: Still high rates of preoperative misdiagnosis in the guidelines and endoscopic ultrasound era

BackgroundA wrong diagnosis of nature is common in pancreatic cystic neoplasms. The aim of the current study is to reappraise the diagnostic errors for presumed pancreatic cystic neoplasms in patients undergoing surgery. MethodsAll pancreatic resections for presumed pancreatic cystic neoplasms following international guidelines between 2011 and 2020 were analyzed. Misdiagnosis was defined as the discrepancy between preoperative diagnosis of nature and final pathology. Mismatch was defined as the discrepancy between the preoperative suspect of malignancy (or its absence) and final pathology. ResultsA total of 601 patients were included. Endoscopic ultrasound was performed in 301 (50%) patients. Overall misdiagnosis and mismatch were 19% and 34%, respectively, with no significant benefit for those patients who underwent endoscopic ultrasound. The highest rate of misdiagnosis was reached for cystic neuroendocrine tumors (61%) and the lowest for solid pseudopapillary tumors (6%). Several diagnostic errors had clinical relevance, including 7 (13%) presumed serous cystic neoplasms eventually found to be other malignant entities, 50 (24%) intraductal papillary mucinous neoplasms with high-risk stigmata revealed to be non-malignant, and 38 (33%) intraductal papillary mucinous neoplasms without high-risk stigmata revealed to be malignant at final pathology. A preoperative presumption of malignant mucinous cystic neoplasm was correct in only 20 (16%) patients. ConclusionsDespite not always being clinically relevant, diagnostic errors are still common among resected pancreatic cystic neoplasms when applying international guidelines. New diagnostic tools beyond endoscopic ultrasound are needed to refine the diagnosis of those lesions at higher risk for unnecessary surgery or accidentally observed, nevertheless being malignant.

Malignancy risk factors and prognostic variables of pancreatic mucinous cystic neoplasms in Chinese patients.

Pancreatic mucinous cystic neoplasms (MCNs) represent one of the precursor lesions of pancreatic ductal adenocarcinoma, and their detection has been facilitated by advances in preoperative imaging. Due primarily to the rarity of MCNs, however, there is limited knowledge regarding the prognostic variables and high-risk factors for malignant transformation. A more comprehensive and nuanced approach is necessary to fill this gap and provide a basis for improved treatment decisions and patient outcomes. To investigate the high-risk factors associated with malignant MCNs and to explore the prognostic factors of MCN with associated invasive carcinoma (MCN-AIC). All cases of resected MCNs from a single high-volume institution between January 2012 and January 2022 were retrospectively reviewed. Only cases with ovarian-type stroma verified by progesterone receptor staining were included. Preoperative features, histological findings and postoperative course were documented. Multivariate logistic regression was employed to investigate variables related to malignancy. Survival analysis was performed using the Kaplan-Meier curve, and the prognostic factors were assessed to evaluate the postoperative course of patients with MCN-AIC. Among the 48 patients, 36 had benign MCNs, and 12 had malignant MCNs (1 high-grade atypical hyperplasia and 11 MCN-AIC). Age, tumour size, presence of solid components or mural nodules and pancreatic duct dilatation were identified as independent risk factors associated with malignancy. The follow-up period ranged from 12 mo to 120 mo, with a median overall survival of 58.2 mo. Only three patients with MCN-AIC died, and the 5-year survival rate was 70.1%. All 11 cases of MCN-AIC were stage I, and extracapsular invasion was identified as a prognostic factor for poorer outcomes. The risk factors independently associated with malignant transformation of MCNs included age, tumour size, presence of solid components or mural nodules, and pancreatic duct dilatation. Our study also revealed that encapsulated invasion was a favourable prognostic factor in MCN-AIC patients.

Risk factors of malignant mucinous cystic neoplasm of pancreas and its prognosis

Risk factors of malignant mucinous cystic neoplasm of pancreas and its prognosis

MRI is useful to suggest and exclude malignancy in mucinous cystic neoplasms of the pancreas.

To evaluate the value of MRI in differentiating benign (b-MCN) and malignant (m-MCN) MCN. European guidelines suggest that certain mucinous cystic neoplasms (MCN) of the pancreas can be conservatively managed. A retrospective single-center study of consecutive patients with resected MCN. MRIs were independently reviewed by two readers blinded to the pathological results. The authors compared b-MCN (i.e., mucinous-cystadenoma comprising high-grade dysplasia (HGD)) and m-MCN (i.e., cystadenocarcinoma). Sixty-three patients (62 women [98%]) with 63 MCN (6 m-MCN, 2 HGD) were included. m-MCN tumors had a tendency to be larger than b-MCN (median 86 [25-103] vs. 45 [17-130] mm, p = .055). The combination of signal heterogeneity on T2-weighted imaging, wall thickness ≥ 5 mm, the presence of mural nodules ≥ 9 mm, and enhancing septa had an area under the ROC curve of 0.97 (95% CI 0.91-1.00) for the diagnosis of m-MCN. A total of 24 (37%), 20 (32%), 10 (16%), 5 (8%), and 4 (6%) out of 63 MCNs showed 0, 1, 2, 3, and 4 of these features, respectively. The corresponding rate of m-MCN was 0%, 0%, 10%, 20%, and 100%, respectively, with a good-to-excellent inter-reader agreement. Patterns with a high NPV for m-MCN included an absence of enhancing septa or walls (NPV 97% and 100%, respectively), wall thickness < 3 mm (NPV 100%), and no mural nodules (NPV 100%). A combination of 4 imaging features suggests malignant MCN on MRI. On the other hand, visualization of a thin non-enhancing wall with no mural nodules suggests benign MCN. • A heterogenous signal on T2-weighted MRI, a ≥ 5-mm-thick wall, mural nodules ≥ 9 mm, and/or enhancing septa suggest malignant MCNs. • A thin non-enhancing wall with no mural nodules suggests benign MCNs. • MRI should be performed in the pre-therapeutic evaluation of MCN to help determine the therapeutic strategy in these patients.

Actual malignancy risk of either operated or non-operated presumed mucinous cystic neoplasms of the pancreas under surveillance

Despite the low malignant potential of pancreatic mucinous cystic neoplasms (MCNs), surgery is still performed. The aim of this pragmatic study was to assess the outcome of surgery and surveillance for patients presenting with a presumed MCN at the first evaluation. Data for patients with a presumed MCN observed from 2000 to 2016 at the Verona Pancreas Institute and San Raffaele Hospital were extracted from prospective databases. The endpoints were risk of malignancy at pathology and rate of misdiagnosis for the surgical series, expressed as an odds ratio (OR) with 95 per cent confidence interval, and disease-specific survival (DSS) for the surveillance cohort investigated by the Kaplan-Meier method. A total of 424 patients were identified. In the surgical series (229 patients), the rate of misdiagnosis was 19.2 per cent. The rate of malignant MCNs was 10.9 per cent (25 patients). The overall rate of malignancy, including misdiagnoses, was 11.3 per cent (26 patients). Predictors of malignancy were mural nodules (OR 27.75, 95 per cent c.i. 4.44-173.61; P < 0.001), size at least 50 mm (OR 13.39, 2.01 to 89.47; P = 0.007), and carbohydrate antigen 19.9 level (OR 3.98, 1.19 to 13.30; P = 0.025). In the absence of mural nodules and enhancing walls, none of the resected presumed MCNs smaller than 50 mm were malignant. Only patients with high-risk stigmata undergoing surgery experienced a significantly reduced 5-year DSS compared with all other patients (88 versus 100 per cent; P = 0.031). Presumed MCNs with mural nodules, enhancing walls or cysts of 50 mm or larger should be considered for upfront surgical resection owing to the high risk of malignancy. In the absence of these features, the incidence of malignancy is negligible, favouring surveillance in selected patients given the low risk of malignancy and the high rate of misdiagnosis. Malignant degeneration of presumed pancreatic mucinous cystic neoplasms takes several years, if it occurs at all. Mural nodules, enhancing walls or cysts of 50 mm or larger call for surgical resection owing to an increased risk of malignancy; otherwise, surveillance seems a good option.

Multiparameter Analysis Using 18F-FDG PET/CT in the Differential Diagnosis of Pancreatic Cystic Neoplasms.

Purpose To evaluate multiparametric analysis in differential diagnosis between pancreatic serous cystic neoplasms (SCNs) and mucinous cystic neoplasms (MCNs) as well as the differentiation of the benign and malignant MCNs with 18F-FDG (18-fluorodeoxyglucose) PET/CT (positron emission tomography). Methods Forty patients with total of 41 lesions (SCNs: 27/41; MCNs: 14/41), who were preoperatively examined with 18F-FDG PET/CT, were retrospectively analyzed. Multiple quantitative parameters using conventional and texture features were included. The combined model was established with complementary PET/MR parameters. The differential diagnostic efficacy of each independent parameter and the combined model were evaluated with receiver operating characteristic (ROC) analysis. Integrated discriminatory improvement (IDI) and net reclassification improvement (NRI) were used to evaluate improvement of diagnostic efficacy by using combination of multiple parameters. Results Among all independent parameters, the percentile 5th (0.88 ± 0.38 vs 0.47 ± 0.23, P < 0.001) showed the highest discriminative diagnostic value. The combination of multiple parameters can improve the differential diagnostic efficacy of SCNs and MCNs (sensitivity = 71.4%, specificity = 77.8%, and AUC = 0.788), and the addition of texture parameters to the conventional parameters allowed a significant reclassification with IDI = 0.236 (95% CI: 0.095–0.377) and categorical NRI = 0.434 (95% CI: 0.030–0.838). SURmax (tumor to normal pancreas ratio, T/P) and SURmax (tumor to aorta ratio, T/A) both showed the highest discriminative diagnostic value (sensitivity = 100.0%, specificity = 70.0%, AUC = 0.900, and Youden index = 0.700) in the differential diagnosis of benign and malignant MCNs, with the cutoff values of 0.84 and 0.90, respectively. ConclusionCombination of multiple parameters using 18F-FDG PET/CT could further improve differentiation between pancreatic SCNs and MCNs. SURmax (T/P) and SURmax (T/A) could improve differential diagnosis of benign and malignant MCNs.

It's not all about the size-characteristics and risk factors for malignancy of mucinous cystic neoplasms of the pancreas.

BackgroundMucinous cystic neoplasms (MCN) of the pancreas are rare mucin-producing cystic tumors. As they harbor malignant potential, surgical resection is frequently performed. Current guidelines recommend surgery in asymptomatic patients only for MCN exceeding 4 cm. The aim of this study was to identify radiological and clinical risk factors for malignancy in a single-center cohort of MCN.MethodsAll resected MCN from a single high-volume center between 2004 and 2019 were retrospectively analyzed. Patient characteristics, preoperative findings, histopathological results, and data on the postoperative course were recorded. Variables associated with malignancy were evaluated using χ2 and Mann-Whitney U test. Receiver operating characteristic (ROC) curves were used to model predictive capabilities of preoperative tumor marker levels. Furthermore uni- and multivariate logistic regression analysis were performed for binary variables. Survival time was plotted as Kaplan-Meier curves and evaluated by log-rank test.ResultsA total of 63 patients were included. Median age was 62 years; 51 (81.0%) of them were women; median tumor size was 3.5 cm (range, 0.5–18.5); 16 (25.4%) of tumors harbored invasive carcinoma and 13 presented intraepithelial dysplasia (20.6%); 7 (43.8%) invasive carcinomas were smaller than 4 cm. All malignant MCN were radiologically suspected of malignancy (calcifications, mural nodules, or wall thickness) preoperatively. Elevated levels of carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) were strongly associated with malignancy (odd’s ratio 33.600; 7.000–161.270); P<0.001 and odd’s ratio 19.250; 3.370–109.970; P<0.001). Other factors associated with malignancy were preoperative weight loss (P=0.015) and higher age (P=0.048). Tumor size, abdominal or back pain or jaundice showed no significant correlation to malignancy in our cohort.ConclusionsMalignant potential of MCN should not be underestimated and a close clinical and radiological follow-up is mandatory in all suspected cases. This is especially important for small lesions. Risk assessment should not rely only on tumor size but consider all clinical, radiological and laboratory findings of each case. Follow-up should be performed by experienced surgeons and radiologists in high volume centers for pancreatic surgery. Surgery should be performed in all cases in which malignancy is suspected.

Endoscopic ultrasound for differential diagnosis of malignant pancreatic cystic lesions: case report and review of literature

A 63-year-old female patient was admitted to the hospital for an in-depth diagnosis of accidentally found pancreatic cystic lesion. The lesion was detected by computed tomography scan and magnetic resonance imaging of the abdomen and identified as potentially malignant mucinous cystic neoplasm (MCN). Endoscopic ultrasound-guided fine-needle aspiration biopsy with the analysis of the fluid from the cyst was performed as well and it confirmed the malignancy of the cystic lesion. The patient was qualified for surgery and the final diagnosis based on histopathological examination of the surgical material confirmed MCN with the accompanying invasive pancreatic adenocarcinoma.

Promoter DNA Hypermethylation of the Cysteine Dioxygenase 1 (CDO1) Gene in Intraductal Papillary Mucinous Neoplasm (IPMN).

Intraductal papillary mucinous neoplasm (IPMN) involves adenoma (IPMA), a precancerous lesion, cancer (IPMC) including high-grade dysplasia (HGD), and invasive carcinoma (IC). DNA markers of IPMN are required for detection of invasive disease, and cysteine dioxygenase 1 (CDO1) gene promoter hypermethylation is a potential candidate. However, it has never been investigated in the context of IPMN. A total of 107 IPMN tumor tissues, including 41 IPMC and 66 IPMA, were studied. CDO1 promoter methylation was quantified using TaqMan quantitative methylation-specific polymerase chain reaction (qMSP) in patients with IPMN and other pancreatic cystic disorders after pancreatectomy. The methylation values (TaqMeth Vs) of CDO1 increased when noncancerous pancreas tissues were compared with IPMA and HGD (p < 0.0001). Among IPMC, the TaqMeth Vs in IC were not significantly higher than in HGD. The TaqMeth Vs of the solid tumors were higher than those of the cystic tumors (p = 0.0016), which were in turn higher than the corresponding noncancerous tissues (p < 0.0001). Prognostic analysis revealed that high TaqMeth Vs (≥ 14.1) resulted in a poorer prognosis than low TaqMeth Vs (< 14.1) (p < 0.0001). In other pancreatic cystic diseases, only malignant mucinous cystic neoplasm showed DNA hypermethylation of its promoter. A pilot study in pancreatic juice confirmed methylation in all IPMN samples but not in benign pancreatic diseases (p = 0.0277). CDO1 promoter hypermethylation is extremely specific to IPMN and may accumulate with IPMN tumor progression during the adenoma-carcinoma sequence. It might be a promising candidate as a diagnostic marker of pancreatic cystic diseases.

Prediction of the Probability of Malignancy in Mucinous Cystic Neoplasm of the Pancreas With Ovarian-Type Stroma: A Nationwide Multicenter Study in Japan.

The aim of the study was to develop a formula for predicting the probability of malignancy of mucinous cystic neoplasm (MCN) of the pancreas with ovarian-type stroma. A total of 364 patients were enrolled. A total score was calculated as the sum of the approximate integers of the odds ratios of the predictive factors identified by multivariate analysis. The relationship between the total score and pathological results was assessed. A total of 321 patients had benign MCN and 43 had malignant MCN. Five possible predictive factors were analyzed: 56 years or older, high serum carcinoembryonic antigen level, high carbohydrate antigen 19-9 level, tumor size of 51 mm or greater, and the presence of mural nodules. The total score was significantly higher in patients with malignant MCN (median, 24; range, 0-37) compared with benign MCN (median, 5; range, 0-33; P < 0.001). Receiver operating characteristic curve analysis demonstrated that the area under the curve was 0.86, and the sensitivity and specificity of the total score for discriminating malignant MCNs were 72% and 83%, respectively, using a cut-off value of 22. The current simple formula can predict the malignancy of MCN and may thus contribute to the adequate management of patients with MCN.

Mucin-producing hepatic cystic neoplasms: an uncommon but challenging disease often misdiagnosed and mismanaged

Background: Mucin-producing hepatic cystic neoplasms (MHCN) are uncommon and potentially malignant.Methods: Nine MHCN were encountered in our centre for over 32 years. Patients’ clinical, biological, radiological and pathological features were reviewed. Lesions were classified into Mucinous Cystic Neoplasms (MCN) and Intraductal Papillary Neoplasms of the Bile duct (IPNB) (WHO 2010 classification).Results: Five MCN and 4 IPNB were reviewed. Serum and intracystic tumour markers were insufficient to diagnose malignancy. Complications were encountered in five out of nine patients (56%), mean symptom duration was 26 months (range: 1–132). Three patients were mismanaged pre-referral. Radiological features enabled preoperative diagnosis in eight out of nine patients (89%). Greater tumour size, unilocular lesion and mural nodularity indicated malignancy. Radical tumour excision was achieved in eight patients. One IPNB patient was misdiagnosed and underwent unroofing. For 103 months median follow-up, five out of six patients with benign tumours were alive and disease-free, whereas the misdiagnosed IPNB recurred with fatal malignant transformation seven years later. Among the three patients with malignancies (median follow-up: 77 months), two IPNB died, one from cancer recurrence and one from unrelated causes, whereas the malignant MCN was alive and disease-free.Conclusions: Appropriate MHCN diagnosis is crucial, yet it is often misdiagnosed and mismanaged. The prognosis after complete excision is favourable

Clinical utility of the guidelines for intraductal papillary mucinous neoplasm: A case series from a medical center in central Taiwan

Surgical resection is recommended for potential malignant or known malignant mucinous cystic neoplasm and intraductal papillary mucinous neoplasm (IPMN). The 2012 updated consensus guidelines proposed “high‐risk stigmata” and “worrisome features” as clinical predictors of malignancy. We present a series of six patients who were diagnosed with IPMN and evaluate the clinical utility of the 2006 and 2012 consensus guidelines with respect to treatment. By comparing the findings of imaging, dysplastic grade of IPMN, and disease outcomes, the dysplastic grade of the IPMN appears to be the most important predictor of patient outcomes. Disease recurrence with low‐to‐intermediate grade of IPMN is uncommon and affected only one of our patients. In summary, the application of the updated 2012 consensus guidelines and the precise assessment of the dysplastic grade and morphological type of IPMN before surgery could provide useful information for clinical disease management.

Rectal metastases from malignant mucinous cystic neoplasm of the pancreas mimicking a rectal carcinoma

Rectal metastases from malignant mucinous cystic neoplasm of the pancreas mimicking a rectal carcinoma

Analysis of the influence of gender on the clinicopathological features and prognosis of pancreatic cystic neoplasms

Objective: To compare the clinicopathological features and prognosis of pancreatic cystic neoplasms (PCN) between male and female patients. Methods: A total of 325 patients with histological confirmed PCN from January 2010 to October 2015 were enrolled. The clinicopathological features, laboratory examination, imaging features, treatment and prognosis were analyzed. Results: Of the 325 patients diagnosed as PCN, 104 were male and 221 were female. The average age of male patients was significantly higher than that of female patients (55.0±12.7 vs 47.9±13.4 years, P<0.001), however, the average tumor size of male patients was smaller than that of female patients (3.9±2.7 vs 4.9±3.0 cm, P=0.004). The location of PCN in male patients was predominantly located at pancreatic head and neck, and majority of male patients were mucinous cystic neoplasms. 1-year, 3-year and 5-year survival rates of patients with PCN were 98.5%, 92.6%, and 87.5%, respectively. 1-year, 3-year and 5-year survival rates of male patients were 97.8%, 84.9%, and 77.8%, however, those of female patients were 98.8%, 96.5%, and 92.2%, respectively. Female patients had better prognosis than male patients (χ2=5.543, P=0.019). Elevated CA19-9 (χ2=3.843, P=0.050), perineuronal invasion (χ2=6.250, P=0.012) and lymph node metastasis (χ2=4.529, P=0.033) were important prognostic factors for malignant mucinous cystic neoplasm. Conclusions: Male patients had low incidence of PCN, and were more common for mucinous cystic neoplasm. The long-term outcome of malignant PCN was poor. Even with complete resection, male patients still had worse prognosis. Close follow-up is recommended especially for male patients.

Nature and management of pancreatic mucinous cystic neoplasm (MCN): A systematic review of the literature

BackgroundThe current management of pancreatic mucinous cystic neoplasms (MCN) is defined by the consensus European, International Association of Pancreatology and American College of Gastroenterology guidelines. However, the criterion for surgical resection remains uncertain and differs between these guidelines. Therefore through this systematic review of the existing literature we aimed to better define the natural history and prognosis of these lesions, in order to clarify recommendations for future management. MethodsA systematic literature search was performed (PubMed, EMBASE, Cochrane Library) for studies published in the English language between 1970 and 2015. ResultsMCNs occur almost exclusively in women (female:male 20:1) and are mainly located in the pancreatic body or tail (93–95%). They are usually found incidentally at the age of 40–60 years. Cross-sectional imaging and endoscopic ultrasound are the most frequently used diagnostic tools, but often it is impossible to differentiate MCNs from branch duct intraductal papillary mucinous neoplasms (BD-IPMN) or oligocystic serous adenomas pre-operatively. In resected MCNs, 0–34% are malignant, but in those less than 4 cm only 0.03% were associated with invasive adenocarcinoma. No surgically resected benign MCNs were associated with a synchronous lesion or recurrence; therefore further follow-up is not required after resection. Five-year survival after surgical resection of a malignant MCN is approximately 60%. ConclusionsCompared to other pancreatic tumors, MCNs have a low aggressive behavior, with exceptionally low rates of malignant transformation when less than 4 cm in size, are asymptomatic and lack worrisome features on pre-operative imaging. This differs significantly from the natural history of small BD-IPMNs, supporting the need to differentiate mucinous cyst subtypes pre-operatively, where possible. The findings support the recommendations from the recent European Consensus Guidelines, for the more conservative management of MCNs.

Diagnosis and treatment of pancreatic cystic neoplasms

Objective To investigate the clinical features, diagnosis and treatment of pancreatic cystic neoplasms. Methods The clinical data of 62 patients with pancreatic cystic neoplasms who were admitted to the First Affiliated Hospital of Anhui Medical University from January 2010 to December 2014 were retrospectively analyzed. Benign neoplasms included benign mucinous cystic neoplasm (MCN) , serous cystic neoplasm (SCN) , solid pesudopapillary neoplasm (SPN) and intraductal papillary mucinous neoplasm (IPMN) and malignant neoplasms included borderline or malignant MCN and borderline or malignant IPMN. The sex, age, clinical symptoms, imaging features, laboratory results, surgical method, operation time, volume of intraoperative blood loss, perioperative complications, result of pathological examination and follow-up were analyzed. Patients were followed up by telephone interview and outpatient examination up to 31, December 2014 or death．Measurement data with normal distribution were presented by±s, while measurement data with non-normal distribution were presented by M (range). Univariate analysis of count data was done by chi-square test or Fisher exact probability. Multivariate analysis was done by Logistic regression model. Results Of the 62 patients with pancreatic cystic neoplasms, 31 were retreated due to upper digestive discomfort, 10 without specific features were found during the health examinations, 10 due to weight loss in near 2-3 months, 9 due to abdominal masses and 2 due to obstructive jaundice.Results of radiographic examinations showed that the diameter of the tumor is (60 ±35) mm, 11 of tumors located in the head and neck of pancreas and 51 located in the body and tail of pancreas.The cystic nodule or solid ingredients were detected in 33 patients and main pancreatic duct dilation in 6 patients.The positive diagnostic rates of B ultrasound, computed tomography (CT) , magnetic resonance imaging (MRI) , and endoscopic ultrasonography (EUS) and positron emission tomography-computed tomography (PET/ CT) were 85.5% (53/ 62) , 93.2% (55/ 59) , 94.1% (16/ 17) , 100.0% (3/ 3) and 100.0% (2/ 2) .Preoperative serum CEA and serum CA19-9 were 1.22 μg/ L(0.20-12.98 μg/ L) and 10.85 U/ mL (0.60-1 000.00 U/ mL) , while the percentage of patients with increasing CEA and CA19-9 were 4.8% (3/ 62) and 14.5% (9/ 62) , respectively.All the 62 patients received surgery, distal pancreatectomy (DP) combined with splenectomy were performed on 36 patients, pancreatoduodenectomy on 10 patients, partial pancreatic resection on 7 patients, spleen-preserving DP on 6 patients, cyst-resection on 2 patients and palliative Roux-en-Y anastomosis on 1 patient.The rate of surgical resection, operation time and volume of blood loss were 98.4% (61/ 62) , (219 ± 79) minutes and (299 ± 296) mL.After operation, 13 patients had different degrees of complication, and were improved by symptomatic treatment such as jejunitas, hemostasis and anti-infection.The results of pathological examination showed that 27 patients were with MCN (11 with malignant or borderline MCN) , 18 with SCN, 11 with SPN and 6 with IPMN (3 with malignant or borderline IPMN) .All the patients were followed up for 3-63 months with good prognoses, except for the death of 2 patients.The results of univariate analysis showed that age of onset, tumor diameter, preoperative serum CEA and preoperative serum CA19-9 were related factors affecting diagnosis of malignant tumor (χ2=18.798, 12.335, 7.281, 10.073, P <0.05 ) .The results of multivariate analysis showed that age≥65 years and preoperative serum CA19-9≥34.00 U/ mL were independent risk factors affecting diagnosis of malignant tumor ( RR =0.923, 0.994; 95% confidence interval : 0.863-0.987, 0.988-0.999; P <0.05). Conclusions B ultrasound, CT and MRI are the main diagnostic methods for pancreatic cystic neoplasms without specific clinical features.Patients with pancreatic cystic neoplasms have overall good prognosis.The results of multivariate analysis showed that age≥ 65 years and preoperative serum CA19-9≥34.00 U/ mL are independent risk factors affecting tumor malignancy. Key words: Pancreatic cystic neoplasms; Diagnosis; Therapy

Clinicopathological and CT features of mucinous cystic neoplasms of the pancreas

To evaluate the clinicopathological and CT features of mucinous cystic neoplasms (MCNs) of the pancreas and analyze the correlative risk factors for malignant pancreatic mucinous cystic neoplasms. Ninety-eight patients who underwent curative resection for mucinous cystic neoplasms of the pancreas at PLA General Hospital from April 1994 to January 2013 were included in this study. All clinicopathological data available were retrospectively analyzed. All patients were divided into benign tumors + premalignant lesion group (70 patients) and malignant tumor group (28 patients). Clinicopathological and CT features of the mucinous cystic neoplasms of the pancreas and risk factors of malignant pancreatic mucinous cystic neoplasms were analyzed. Mucinous cystic neoplasms were seen mostly in perimenopausal women (71.4%, 70/98 cases,), and 51.0% (50/98 cases) of the patients had obvious clinical signs, mostly non-specific abdominal pain, but jaundice was present only in cases of malignant mucinous cystic neoplasms. Benign mucinous cystic neoplasms were mostly located in the distal pancreas (74.3%) and characterized with septa and thin cystic wall, while more malignant mucinous cystic neoplasms were located at the proximal pancreas (57.1%) and characterized with thick cystic wall and solid components. Univariate analysis showed that findings associated with malignancy gender, age ≥ 60, presence of symptoms, jaundice, weight loss, tumor location, margin, wall thickness, solid components and dilation of the main pancreatic duct were significantly correlated with malignant tumor development (P < 0.05 for all). The results of multiple logistic regression analysis showed that thick wall and solid components were independent prognostic factors for malignancy (OR = 31.417 and 34.976, P < 0.05 for both). Gender, age ≥ 60, presence of symptoms, jaundice, weight loss, tumor location, margin, wall thickness, solid components and dilation of the main pancreatic duct are important diagnostic indices of malignant mucinous cystic tumors of the pancreas, while thick wall and solid components are independent risk factors of malignant pancreatic mucinous cystic neoplasms.

Mucinous cystic neoplasm of the pancreas: Is surgical resection recommended for all surgically fit patients?

BackgroundSurgical removal of mucinous cystic neoplasms (MCNs) is usually recommended because of the risk of malignancy. However, increased experience of MCNs suggests that the incidence of invasion is lower than had been thought. This study was designed to establish more reasonable surgical indications for MCN through re-assessment using strict pathologic diagnostic criteria. MethodsNinety-four patients who underwent surgical removal of MCNs at Seoul National University Hospital from 1991 to 2012 were retrospectively analyzed. Pathologic results were re-evaluated by an experienced pathologist. Medical records and radiologic images were reviewed to determine factors predicting malignancy. ResultsOf the 94 patients, 4 were found to have intraductal papillary mucinous neoplasms (IPMNs). Of the 90 MCNs, 60 (66.7%) were low-grade, 21 (23.3%) were intermediate-grade, and 5 (5.5%) were high-grade dysplasias; and 4 (4.4%) were invasive carcinoma. Mural nodules on CT scan (p = 0.005) and abnormal serum CA19-9 concentration (p = 0.029) were significant predictors of malignancy. All MCNs less than 3 cm in size with normal serum tumor markers were benign and all malignant MCNs had cyst fluid CA19-9 over 10,000 units/ml. The five year disease specific survival rates were 98.8% for all patients and 75.0% for those with invasive MCNs. ConclusionMCNs had a low prevalence of malignancy. Regardless of the histological grade, long-term outcome was excellent. Therefore, in the absence of specific symptoms, surgery may not be indicated for MCNs <3 cm without mural nodules or elevated serum tumor markers. Validation by a prospective study with very careful design is needed.

EUS for Pancreas Cysts: What Should We Be Sampling?

The growing resolution and more frequent use of imagingmethods has increasingly identified pancreatic cysts,ranging from benign serous and pseudocysts to premalig-nant or malignant mucinous cystic neoplasm (MCN). Dueto the disparate course and management of benign cystsversus cystic neoplasms or pre-neoplasms, unambiguouslesion identification is essential, which is not always pos-sible with conventional cross-sectional imaging [1]. Thus,an increasing number of centers are utilizing endoscopicultrasound (EUS) for further characterization of pancreaticcysts with high resolution images of cyst morphology, size,presence and type of septations, presence of solid compo-nents, and the ability to sample cyst contents using fineneedle aspiration (FNA) and to perform biopsies. Charac-teristics such as diameter[3 cm and the presence of muralnodules may be the best predictors of malignant transfor-mation of MCN or side-branch type intraductal papillaryneoplasms (SB-IPMN) [2]. In some cases, however, biopsyof solid material or aspiration of cyst fluid is essential toconfirm the diagnosis. Thus, when a pancreas cyst isdetected on CT or MRI, the clinical question often arises asto whether EUS should be performed and, furthermore, ifadditional FNA or biopsy is helpful.In this month’s issue of Digestive Diseases and Sci-ences, Lim et al. [3] report their findings in ‘‘Factorsdetermining diagnostic yield of EUS guided fine-needleaspiration for pancreatic cystic lesions: a multicenter Asianstudy.’’ The authors include a multicenter analysis of 298patients with diverse pancreatic cystic lesions who under-went EUS of whom 132 (44 %) underwent EUS–FNA.FNA cytology with a single pass was only 29 % when solidcomponents are not present. Furthermore, their studydemonstrated a higher yield (44 %) when solid componentswere biopsied during a single pass, which increased to78 % with multiple passes. Although biochemical markerssuch as carcinogenic embryonic antigen (CEA) and amy-lase measured in cyst fluid aspirates are frequently used toaid in diagnosis of pancreatic cysts, the authors focused oncytologic yield from EUS–FNA. In the literature, theoverall yield of EUS–FNA for cytologic analysis of inde-terminate pancreatic cystic lesions is 31–37 % [2, 4].Morphologic features noted by high resolution EUSimages of small pancreatic cysts can help differentiatemucinous-type cysts from others. Nevertheless, in a recentstudy, expert endosonographers were evaluated for theirability to make a diagnosis of pancreatic MCN based onEUS appearance alone without FNA. The accuracy wasonly 23–46 % despite the use septations, mural nodules,solid components, and communication with the pancreaticduct as criteria [5]. Therefore, FNA for fluid analysis orbiopsy of solid materials may add to diagnostic yield,particularly for indeterminate cysts. Solid material within acyst may represent debris but could also arise frommalignancy.Several studies have addressed the acquisition of pan-creatic cyst specimens and types of analysis that providethe highest diagnostic yield. Cytologic analysis of aspiratedfluid is usually of low yield due to the unlikelihood thatpancreatic cysts shed adequate cells for evaluation.Accordingly, a recent study demonstrated that FNA of thecyst wall rather than fluid aspiration alone can improvediagnostic yield up to 81 %, with the majority of casesdemonstrating mucinous epithelium [6]. Other investiga-tors have examined the use of a cytology brush passedthrough a 19-gauge FNA needle to gather more cellular