Management Of Pancreatic Cysts Research Articles

Mo1503 Impact of Endoscopic Ultrasound (EUS) on Management of Pancreatic Cysts in an Integrated Healthcare System

Mo1503 Impact of Endoscopic Ultrasound (EUS) on Management of Pancreatic Cysts in an Integrated Healthcare System

Mo1516 Does Molecular Analysis Alter Pancreatic Cyst Management?

Pancreatic cyst management is determined by the malignant potential of the cystic lesion. The use of cross-sectional imaging, endoscopic ultrasound (EUS), cyst fluid characteristics (CEA and amylase) and cytology are often used to stratify lesions. It has been proposed that molecular analysis be used as an adjunctive diagnostic tool to identify lesions with malignant potential. This study was designed to evaluate whether additional data provided by molecular analysis alters the clinical management recommendations of pancreatic cysts.

Allelic Imbalance and KRAS Mutational Analyses Predict Biological Behavior of Pancreatic Cysts

Purpose: The widespread use of cross-sectional imaging has led to increased detection of pancreatic cysts. Current management of pancreatic cysts includes endosonographic imaging and cyst fluid analysis; however, the malignant potential of these lesions often remains undetermined. Our study aimed to evaluate whether combining routine cytology and cyst fluid CEA with cyst fluid genetic analyses for allelic imbalance and KRAS mutations can be used to better predict the malignant potential of pancreatic cysts. Methods: Thirty-six patients with pancreatic cysts had EUS-guided fine needle aspiration. Cyst fluid was analyzed for CEA, amylase, KRAS mutations, allelic imbalance, DNA quantity (RedPath Integrated Pathology, Inc), and sent for cytology. Cysts were labeled as serous (CEA <5 ng/ml, amylase <800 U/L, clear aspirate), mucinous (CEA >192 ng/ml, amylase <800 U/L, viscous aspirate), branch duct (BD) IPMN (CEA >192 ng/ml, amylase >800 U/L, viscous aspirate) or indeterminate (CEA 5-192 ng/ml, clear aspirate). Based on KRAS point mutations, allelic imbalance and DNA quantity, cyst fluid genetic analyses were reported as benign, statistically indolent or aggressive. Mean follow-up time was 2.4 years. Results: Of the 36 patients evaluated, 22 were female, 14 male. Based on the above criteria (prior to genetic analysis), there were 6 serous, 8 mucinous, 21 BD-IPMN, and 1 indeterminate cysts (Table). Genetic analysis identified 4 cysts as aggressive and 32 as benign/indolent. Out of four aggressive cysts, one BD-IPMN cyst with adjacent nodule seen on EUS had four LOH mutations, and its surgical pathology revealed adenocarcinoma. The other three aggressive cysts (one BD-IPMN and two mucinous) showed LOH and KRAS mutations, and are pending surgery. Ten out of 32 benign/indolent cases had follow-up imaging, all of which demonstrated no disease progression.Table: No Caption available.Conclusion: When genetic analysis, endosonographic imaging and cytology are all consistent with indolent behavior, close observation in lieu of immediate surgical resection may be appropriate for small (<3 cm) mucinous cysts and BD-IPMNs.

MiRNA Biomarkers in Cyst Fluid Augment the Diagnosis and Management of Pancreatic Cysts

The diagnosis of pancreatic cystic lesions has increased dramatically. Most are benign, whereas some, such as intraductal papillary mucinous neoplasms (IPMN), represent precursors of pancreatic adenocarcinoma. Therapeutic stratification of IPMNs is challenging without precise information on dysplasia grade and presence of invasion. We assessed the diagnostic benefit of using miRNAs as biomarkers in pancreatic cyst fluid, focusing on IPMNs because of their frequency and malignant potential. RNA was extracted from 55 microdissected formalin-fixed, paraffin-embedded (FFPE) IPMN specimens, and 65 cyst fluid specimens aspirated following surgical resection. Expression of 750 miRNAs was evaluated with TaqMan miRNA Arrays using 22 FFPE and 15 cyst fluid specimens. Differential expression of selected miRNA candidates was validated in 33 FFPE and 50 cyst fluid specimens using TaqMan miRNA Assays. We identified 26 and 37 candidate miRNAs that distinguish low-grade from high-grade IPMNs using FFPE and cyst fluid specimens, respectively. A subset of 18 miRNAs, selected from FFPE and cyst fluid data, separated high-grade IPMNs from low-grade IPMNs, serous cystadenomas (SCA) and uncommon cysts, such as solid pseudopapillary neoplasms (SPN) and cystic pancreatic neuroendocrine tumors (PanNET). A logistic regression model using nine miRNAs allowed prediction of cyst pathology implying resection (high-grade IPMNs, PanNETs, and SPNs) versus conservative management (low-grade IPMNs, SCAs), with a sensitivity of 89%, a specificity of 100%, and area under the curve of 1. We found candidate miRNAs that helped identify patients with high-grade IPMN and exclude nonmucinous cysts. These classifiers will require validation in a prospective setting to ultimately confirm their clinical usefulness.

Molecular Analysis of Cyst Fluid Aspiration in the Diagnosis and Risk Assessment of Cystic Lesions of the Pancreas

Pancreatic cyst detection is increasing largely due to increasing use of cross-sectional imaging. The management of pancreatic cysts differs for true cysts, pseudocysts, mucinous cysts, nonmucinous cysts, and malignant lesions. Depending on the setting, diagnostic tests, such as cross-sectional imaging, endoscopic ultrasound, cyst fluid chemistry, and cytology, have moderate accuracy in characterizing the cyst subtype. Molecular analysis of cyst fluid aspirates has shown promise in preliminary studies and may require smaller fluid volumes than is needed for carcinoembryonic antigen level and cytology. This article reviews published studies in which molecular analysis was performed in the evaluation of pancreatic cysts. The molecular studies are compared with the conventional tests. Most studies have had moderate sample sizes (16-124) and have characterized a high proportion of patients with malignant cysts. Evaluation of molecular analysis as a diagnostic tool merits larger prospective trials with long-term follow-up of patients who are not sent to surgery. Larger cysts may meet size criteria for resection, and it is the smaller cysts for which molecular analysis may be of benefit if additional molecular testing results in a change in management.

Current status on the diagnosis and management of pancreatic cysts in the Asia–Pacific region: Role of endoscopic ultrasound

Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) play increasingly prominent roles in the diagnosis and management of pancreatic cysts. The Asian Consortium of Endoscopic Ultrasound was recently formed to conduct collaborative research in this area. This is a review of literature on true pancreatic cysts. Due to the lack of systematic studies, there are no robust data on the true incidence of pancreatic cystic lesions in Asia and any change in over the recent decades. Certain EUS morphological features have been used to predict particular types of pancreatic cysts. Pancreatic cyst fluid viscosity, cytology, pancreatic enzymes, and tumor markers, in particular carcinoembryonic antigen, can aid in the diagnosis of pancreatic cysts. Hemorrhage and infection are the most common complications of EUS-FNA of pancreatic cysts. Pancreatic cysts can either be observed or resected depending on the benign or malignant nature, or malignant potential of the lesions. Guidelines from an international consensus did not require positive cytological findings to be present in their recommendation for resection, which included all mucinous cystic neoplasms, all main-duct intraductal papillary mucinous neoplasms (IPMN), all mixed IPMN, symptomatic side-branch IPMN, and side-branch IPMN larger than 3 cm. In patients with poor surgical risks, EUS-guided cyst ablation of mucinous pancreatic cysts is an alternative. As long-term prospective data on pancreatic cysts are still not available in Asia, management strategies are largely based on risk stratification by surgical risk and malignant potential. Gene expression profiling of pancreatic cyst fluid and confocal laser endomicroscopic examination of pancreatic cysts are novel techniques currently being studied.

Asymptomatic curable pancreatic ductal carcinoma detected during the follow-up of pancreatic cysts distinct from carcinoma.

Recent studies have reported that pancreatic ductal carcinomas are frequently found during the follow-up of pancreatic cysts distinct from carcinoma; however, the majority of them are detected in advanced stages. Therefore, the early detection of metachronous ductal carcinomas is one of the issues in the management of pancreatic cysts. A 25-mm pancreatic cyst in the pancreatic head was found during an annual check-up in a 70-year-old woman. She was followed up every 6months by abdominal ultrasound (US) and blood tests, and every 12months by an additional magnetic resonance imaging scan. Twelve months later, abdominal US revealed a suspicious low-echoic area of 17mm diameter in the pancreatic body. Eighteen months later, her serum carbohydrate antigen 19-9 level rose to 92U/ml. Endoscopic retrograde pancreatography demonstrated a strictured main pancreatic duct (MPD) of 15mm in length in the pancreatic body. A cytological examination of the brushed MPD revealed adenocarcinoma. The patient underwent distal pancreatectomy and splenectomy after chemoradiotherapy. An histological examination revealed a ductal carcinoma of 26mm diameter in the pancreatic body, which was successfully resected. This case might help to establish an optimal surveillance method to detect metachronous ductal carcinomas arising from the pancreas harboring cystic lesions.

T1475: Prospective Study to Assess the Impact of EUS in the Management of Patients With Pancreatic Cystic Lesions

Pancreatic cystic lesions are increasingly detected incidentally with cross-sectional imaging. A significant proportion (10-15 percent) of these cysts are neoplastic (both pre-malignant and malignant). Endoscopic (EUS) has become an increasingly available modality in the diagnosis of pancreatic cyst neoplasms. However little is known as to whether EUS actually changes management in these patients. The aim of this study was to determine prospectively the impact of EUS in the management of pancreatic cysts.

Variability in measurements of pancreatic cyst size among EUS, CT, and magnetic resonance imaging modalities

Cyst size is an important factor in the management of pancreatic cysts, both in predicting the need for surgery and the frequency of follow-up. To determine agreement and precision of EUS, CT, and magnetic resonance imaging (MRI) modalities in the evaluation of pancreatic cyst diameter. Retrospective chart review. Tertiary-care center, January 2000 to June 2009. This study involved 175 patients presenting for EUS evaluation of pancreatic cysts, with size measured by at least two of the aforementioned imaging studies within a 90-day period. Largest cyst diameter from EUS, CT, MRI/MRCP, and surgical pathology. A total of 175 patients underwent EUS. Seventy-three had CT plus EUS, 33 had MRI/MRCP plus EUS, 23 had MRI/MRCP plus CT, and 15 had all imaging studies, occurring within 90 days of each other. Median size differences between studies: EUS and CT (ie, absolute value of size determined by EUS minus size determined by CT) = 4 mm (range 0-25 mm), EUS and MRI = 4 mm (range 0-17 mm), CT and MRI = 3 mm (range 2-20 mm). Median size differences for surgical pathology specimens compared with results of 12 EUS, 13 CT, and 8 MRI/MRCP studies were as follows: EUS and pathology = 9.5 mm (range 0-20 mm), CT and pathology = 5 mm (range 0-21 mm), MRI and pathology = 5.5 mm (range 2-44 mm). Interobserver variability and small sample of surgical pathology cysts. There is considerable variation in size estimates of pancreatic cysts by different imaging modalities, which practitioners should take into account when making management decisions. Use of a single imaging modality is recommended during follow-up. The precision of imaging studies for measuring pancreatic cysts must be prospectively defined if change in size is to be reliably used for clinical management.

Asymptomatic Pancreatic Cystic Neoplasms: Maximizing Survival and Quality of Life Using Markov-Based Clinical Nomograms

The natural history and management of pancreatic cysts, especially for branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), remain uncertain. We developed evidence-based nomograms to assist with clinical decision making. We used decision analysis with Markov modeling to compare competing management strategies in a patient with a pancreatic head cyst radiographically suggestive of BD-IPMN, including the following: (1) initial pancreaticoduodenectomy (PD), (2) yearly noninvasive radiographic surveillance, (3) yearly invasive surveillance with endoscopic ultrasound, and (4) "do nothing." We derived probability estimates from a systematic literature review. The primary outcomes were overall and quality-adjusted survival. We depicted the results in a series of nomograms accounting for age, comorbidities, and cyst size. Initial PD was the dominant strategy to maximize overall survival for any cyst greater than 2 cm, regardless of age or comorbidities. In contrast, surveillance was the dominant strategy for any lesion less than 1 cm. However, when measuring quality-adjusted survival, the do-nothing approach maximized quality of life for all cysts less than 3 cm in patients younger than age 75. Once age exceeded 85 years, noninvasive surveillance dominated. Initial PD did not maximize quality of life in any age group or cyst size. Management of pancreatic cysts can be guided using novel Markov-based clinical nomograms, and depends on age, cyst size, comorbidities, and whether patients value overall survival vs quality-adjusted survival. For patients focused on overall survival, regardless of quality of life, surgery is optimal for lesions greater than 2 cm. For patients focused on quality-adjusted survival, a 3-cm threshold is more appropriate for surgery except for the extreme elderly.

Cystic lesions and intraductal neoplasms of the pancreas

Pancreatic cystic lesions are being detected more frequently given increased use of cross-sectional imaging modalities. The most common cysts encountered are mucinous cysts, which have malignant potential. As many of these lesions are incidental findings, it is important to further evaluate them with endoscopic ultrasound-guided fine needle aspiration for diagnostic purposes and risk stratification. These cysts either require surgical resection or surveillance given the malignant risk. Mucinous cystic neoplasms should be resected. Intraductal papillary mucinous neoplasia (IPMN) has consensus-guideline indications for resection. These include main duct diameter > or = 10 mm, a branch duct size > or = 3 cm, presence of a mural nodule, or cytology suspicious for malignancy. Additionally, all symptomatic cysts, regardless of etiology, should undergo resection. Branch duct IPMN is less aggressive that the main duct variety, and may be conservatively followed. However, the development of an established indication for resection should prompt surgery. Despite generalized guidelines, decisions regarding management of pancreatic cysts should be individualized, accounting for the malignant risk of the lesion and the surgical risk of the patient.

Combined EUS and ERCP for Distal Biliary Obstruction: Technical Feasibility, Success Rates of Biliary Decompression and Tissue Sampling

Background: While endoscopic ultrasound (EUS) and ERCP are commonly performed procedures in the evaluation and management of presumed malignant biliary obstruction, there is a paucity of literature describing the use of combined procedures. Methods: We retrospectively reviewed all EUS and ERCP performed on the same day between 7/02-7/06. EUS with a pre-procedure indication of a biliary stricture or suspected mass in the head of the pancreas were evaluated. The indication of the ERCP was jaundice or increased liver enzymes. Exclusion criteria included: choledocholithiasis, pancreatic cyst management, prior sphincterotomy, prior biliary or pancreatic stents, non-visualized papilla due to tumor in-growth, hilar strictures, known or presumed PSC, and surgically altered anatomy. For a comparison, ERCP done alone over the same time period with the same indications and exclusion criteria were reviewed. Data extracted included medication use, technical success of placing a biliary stent, and the results of all tissue sampling. All pathology specimens were reported as malignant, suspicious, atypical, or benign. Results: Fifty-three combination procedures (EUS/ERCP) and 124 ERCP met the study criteria. The mean midazolam dose was higher in the EUS/ERCP group than in the ERCP alone group (6.36 mg vs. 5.53 mg, p = 0.0086). The mean fentanyl equivalent dose (fentanyl 100 mcg = merperidine 75 mg) was also higher in the EUS/ERCP group (219.1 mcg vs. 192.9 mcg, p = 0.029). There was no difference in the use of an adjuvant medication (i.e. droperidol, promethazine, diphenhydramine) between the groups (42.7% vs. 50.9%, p = 0.3). Successful cannulation and stent placement was achieved in 52/53 in the EUS/ERCP group and 118/124 in the ERCP group (98.1% vs. 95.2%, p = 0.3). Tissue sampling was performed more often in the EUS/ERCP group than the ERCP group (94.3% vs. 63.7%, p < 0.001). There were no significant differences in the percentage of studies in which biliary brushings (56.6% vs. 62.9%, p = 0.4) or forceps biopsies were obtained (17.0% vs. 12.1%, p = 0.3). EUS/FNA was performed in 56.6%. Combining all tissue sampling techniques, the EUS/ERCP group more often achieved a definitively malignant pathology result as compared to the ERCP group (70% vs 32.9%, p < 0.001). Conclusion: Same day EUS/ERCP with moderate sedation for presumed malignant distal bile duct obstruction appears technically feasible. If pathologic specimens are taken, a combined procedure results in a higher yield of definitively positive results, specifically due to the ability to perform FNA. Combined procedures require minimal added sedation and do not limit the ability to drain an obstructed biliary system.

Pancreatic cysts: a report of 10 cases.

Abstract Ten cases of pancreatic cysts seen in 12 years in the University College Hospital, Ibadan, are reported. The clinical features and diagnoses are reviewed and found to be similar to those reported elsewhere. Pancreatic cysts occur in a younger age-group in this series than in other reports and this is related to malnutritional fibrocalcific pancreatic disease. The classification of pancreatic cysts is discussed and modified according to the experience of this series. The operative management of pancreatic cysts is briefly discussed.

Surgical Management of Pancreatic Cysts

Surgical Management of Pancreatic Cysts

Factors Influencing the Management of Pancreatic Cysts

Factors Influencing the Management of Pancreatic Cysts