Mural Nodule Size Research Articles

CT findings and clinical effects of high grade pancreatic intraepithelial neoplasia in patients with intraductal papillary mucinous neoplasms.

To investigate the common CT findings of high-grade (HG) PanIN and clinical effects in the remnant pancreas in patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas. Two hundred fifty-one patients with surgically confirmed IPMNs (118 malignant [invasive carcinoma/high-grade dysplasia] and 133 benign [low-grade dysplasia]) were retrospectively enrolled. The grade of PanIN (233 absent/low-grade and 18 high-grade) was recorded, and all patients underwent serial CT follow-up before and after surgery. Two radiologists analyzed CT findings of high-risk stigmata or worrisome features according to 2017 international consensus guidelines. They also analyzed tumor recurrence on serial follow-up CT after surgery. Statistical analyses were performed to identify significant predictors and clinical impact on postoperative outcomes of HG PanIN. PanIN grade showed a significant association with IPMN grade (p = 0.012). Enhancing mural nodules ≥5 mm, abrupt main pancreatic duct (MPD) changes with distal pancreatic atrophy, increased mural nodule size and MPD diameter were common findings in HG PanIN (P<0.05). In multivariate analysis, abrupt MPD change with distal pancreatic atrophy (odds ratio (OR) 6.59, 95% CI: 2.32-18.72, <0.001) and mural nodule size (OR, 1.05; 95% CI, 1.02-1.08, 0.004) were important predictors for HG PanIN. During postoperative follow-up, HG PanIN (OR, 4.98; 95% CI, 1.22-20.33, 0.025) was significantly associated with cancer recurrence in the remnant pancreas. CT can be useful for predicting HG PanIN using common features, such as abrupt MPD changes and mural nodules. In HG PanIN, extra caution is needed to monitor postoperative recurrence during follow-up.

MR diagnosis of SCC arising within ovarian cystic teratomas: analysis of mural nodule characteristics

PurposeThis study aims to evaluate and identify magnetic resonance (MR) findings of mural nodules to detect squamous cell carcinoma arising from ovarian mature cystic teratoma (SCC-MCT).MethodsThis retrospective study examined 135 patients (SCC-MCTs, n = 12; and benign MCTs, n = 123) with confirmed diagnoses across five different institutions between January 2010 and June 2022. Preoperative MR images for each patient were independently assessed by two experienced radiologists and analyzed following previously reported findings (PRFs): age, tumor size, presence of mural nodules, size of mural nodule, and the angle between mural nodule and cyst wall (acute or obtuse). Furthermore, this study evaluated four mural nodule features—diffusion restriction, fat intensity, Palm tree appearance, and calcification—and the presence of transmural extension.ResultsThere were significant differences between the SCC-MCT and benign MCT groups in terms of all PRFs and all mural nodule findings (p < 0.01). Among the PRFs, “tumor size” demonstrated the highest diagnostic performance, with a sensitivity of 83.3% and a specificity of 88.6%. A combination of the aforementioned four mural nodule findings showed a sensitivity and specificity of 83.3% and 97.6%, respectively, for the diagnosis of SCC-MCT. Regarding diagnosis based on a combination of four mural nodule findings, the specificity was significantly higher than the diagnosis based on tumor size (p = 0.021). Based on these mural nodule findings, three SCC-MCT patients without transmural invasion could be diagnosed.ConclusionMural nodule MR findings had a higher diagnostic performance than PRFs for SCC-MCT and can potentially allow early detection of SCC-MCTs.Graphical abstract

A model for predicting degree of malignancy in patients with intraductal papillary mucinous neoplasm.

There is no predictive model available to address early stage malignant intraductal papillary mucinous neoplasm (IPMN) including high grade dysplasia (HGD) and pT1a (invasive component≤0.5 cm). The aim of this study was to establish an objective and sufficient model to predict the degree of malignancy in patients with IPMN, which can be easily applied in daily practice and adopted for any type of lesion. A retrospective cohort study of 309 patients who underwent surgical resection for IPMN was performed. Members of the cohort were randomly allocated to the training or testing set. A detection tree model and random forest model were used for a 3-class classification to distinguish low grade dysplasia (LGD), HGD/pT1a IPMN, and invasive intraductal papillary mucinous cancer (I-IPMC) beyond pT1a. Of the 309 patients, 54 (17.4%) had early stage malignancy (19 HGD, 35 pT1a), 49 (15.9%) had I-IPMC beyond pT1a, and 206 (66.7%) had LGD IPMN. We proposed a 3-class classification model using a random forest algorithm, and the model had an accuracy of 99.5% with the training set, and displayed an accuracy of 96.0% with the testing set. We used SHAP for interpretation of the model and showed the top five factors (mural nodule size, main pancreatic duct diameter, CA19-9 levels, lesion edge and common bile duct dilation) were most likely to influence the 3-class classification results in terms of interpretation of the random forest model. This predictive model will help assess an individual's risk for different stages of IPMN malignancy and may help identify patients with IPMN who require surgery.

Nomogram to predict malignancy in branch duct type intraductal papillary mucinous neoplasms.

Prediction of malignancy in branch duct (BD)-type intraductal papillary mucinous neoplasms (BD-IPMNs) is difficult. In this retrospective study, we showed the performance of imaging biomarker and biochemical biomarker in identifying the malignant BD-IPMNs. A total of 97 patients with pathological proved BD-IPMNs were included in this study. Imaging data were collected from magnetic resonance imaging (MRI). Malignant BD-IPMNs were defined as those with high grade dysplasia and invasive carcinoma. There were 10 patients with malignant BD-IPMNs (10.3%). Significant difference was found in prevalence of mural nodule and tumor size >3.0 cm between patients with and without malignant BD-IPMNs (44.4% vs 3.1%, P < .01; 80.0% vs 33.3%, P < .01). Significant differences were observed in mural nodule and elevated carbohydrate antigen 19-9 (CA19-9) between patients with and without invasive carcinoma (40.0% vs 7.6, P = .05; 60% vs 15.3%, P = .04). Mural nodule and tumor size >3.0 cm were the independent associated factor for malignant BD-IPMNs. The odds ratio (OR) was 5.22 (95% confidence interval [CI]: 1.04–31.16) for mural nodule and was 6.80 (95% CI: 1.16–39.71) for cyst size >3.0 cm. The combined model of mural nodule and tumor size showed good performance in identifying malignant BD-IPMNs (area under the curve [AUC] = 0.82, 95%CI: 0.67–0.97). Our data show that mural nodule and cystic size can be used as predictor of malignancy in BD-IPMN. The predictive performance is acceptable.

Predictors of malignancy in main duct intraductal papillary mucinous neoplasm of the pancreas

The International Consensus Guidelines updated in 2017 recommended surgery to all main duct intraductal papillary mucinous neoplasms (MD-IPMNs) with the main pancreatic duct (MPD) of 10mm or more and those with mural nodules regardless of size. The aim of the present study was to identify predictors of malignancy in MD-IPMN among preoperative factors including MPD and mural nodule size. Twenty-six benign MD-IPMNs (7 resected and 19 nonresected) and 32 malignant MD-IPMNs (31 resected and 1 nonresected) were included in the study. MRCP, CT, EUS, and cytology were performed using pancreatic juice collected by endoscopic retrograde pancrestography (ERP). Resected IPMNs were classified as benign or malignant by histologic examination and nonresected MD-IPMNs by imaging, cytology, and observation. Cutoff values of candidate parameters were determined by receiver operating characteristic curves. Univariate and multivariate analyses by regression model were performed. MPD and mural nodule size and cytology results differed significantly between benign and malignant groups.Cutoff values of MPD and mural nodule sizes were 15mm and 10mm with areas under the curve of .66and .86, respectively. Mural nodules of 10mm or more (odds ratio, 8.32; 95% confidence interval, 1.13-61.2; P= .038) and positive cytology (odds ratio, 42.5; 95% confidence interval, 4.10-439; P= .002) were shown to be independent predictors of malignancy by multivariate analysis. When MD-IPMNs with either predictor were diagnosed to be malignant, sensitivities, specificities, and overall accuracy for malignancy were 94%, 85%, and 90%, respectively. Mural nodules of 10mm or more and positive cytology were independent predictors of malignancy in MD-IPMN.

Computed tomography nomogram to predict a high-risk intraductal papillary mucinous neoplasm of the pancreas.

The intraductal papillary mucinous neoplasm (IPMN) of the pancreas is regarded as a precursor to pancreatic cancer; this study aimed to develop and validate a model based on CT characteristics for the non-invasive prediction of the high-risk IPMN of the pancreas. In this retrospective study, all patients underwent multidetector CT and surgical resection. A prediction model was developed based on a training set consisting of 136 patients with low-risk IPMN and 85 patients with high-risk IPMN between October 2012 and April 2019, and a multivariable logistic regression model was adopted to establish a nomogram. The nomogram performance was determined by its discrimination, calibration, and clinical usefulness. The model was validated in 80 consecutive patients between May 2019 and April 2020, of which 47 and 33 patients had low-risk and high-risk IPMNs, respectively. The multivariable logistic regression model of CT characteristics included the enhancing mural nodule size, the main pancreatic duct (MPD) diameter, the abrupt change in caliber of the MPD with distal pancreatic atrophy, cyst size, thickened enhancing cyst wall, and the presence of lymphadenopathy. The individualized prediction nomogram using these predictors of the high-risk IPMN achieved an area under the curve (AUC) of 0.92 (95% CI 0.88-0.95) in the training set and 0.87 (95% CI 0.79-0.95) in the validation set. The decision curve analysis demonstrated that the nomogram was clinically useful. The CT nomogram, which is a non-invasive predictive tool, can preoperatively predict the risk of malignant IPMN and help identify patients who require a surgical procedure.

Magnetic resonance imaging-derived fat fraction predicts risk of malignancy in intraductal papillary mucinous neoplasm.

Assess the relationship between MRI-derived pancreatic fat fraction and risk of malignancy in intraductal papillary mucinous neoplasm (IPMN). MRIs of patients with IPMN who underwent pancreaticoduodenectomy were analyzed. IPMN with low-grade dysplasia (n = 29) were categorized as low-risk while IPMN at high risk of malignancy consisted of those with high-grade dysplasia/invasive carcinoma (n = 33). Pancreatic fat-fraction (FFmean) was measured using the 2-point Dixon-method. Images were evaluated for the high-risk stigmata and worrisome features according to the revised 2017 Fukuoka consensus criteria. Data on serum CA19-9, Diabetes Mellitus (DM) status, body mass index (BMI), and histological chronic pancreatitis were obtained. A significant difference in FFmean was found between the high-risk IPMN (11.45%) and low-risk IPMN (9.95%) groups (p = 0.027). Serum CA19-9 level (p = 0.021), presence of cyst wall enhancement (p = 0.029), and solid mass (p = 0.008) were significantly associated with high-risk IPMN. There was a significant correlation between FFmean and mural nodule size (r = 0.36, p˂0.01), type 2 DM (r = 0.34, p˂0.01), age (r = 0.31, p˂0.05), serum CA 19-9 (r = 0.30, p˂0.05), cyst diameter (r = 0.30, p˂0.05), and main pancreatic duct diameter (r = 0.26, p˂0.05). Regression analysis revealed FFmean (OR 1.103, p = 0.035) as an independent predictive variable of high-risk IPMN. FFmean is significantly associated with high-risk IPMN and an independent predictor of IPMN malignant risk. FFmean may have clinical utility as a biomarker to complement the current IPMN treatment algorithm and improve clinical decision making regarding the need for surgical resection or surveillance.

Nomogram for the Prediction of High-Grade Dysplasia and Invasive Carcinoma in Patients With Intraductal Papillary Mucinous Neoplasms of the Pancreas Based on Variables of Noninvasive Examination.

Intraductal papillary mucinous neoplasms (IPMNs) are a heterogeneous group of neoplasms and represent the most common identifiable precursor lesions of pancreatic cancer. Clinical decision-making of the risk for malignant disease, including high-grade dysplasia and invasive carcinoma, is challenging. Moreover, discordance on the indication for resection exists between the contemporary guidelines. Furthermore, most of the current nomogram models for predicting malignant disease depend on endoscopic ultrasonography to evaluate the precise size of mural nodules. Thus, this study aimed to propose a model to predict malignant disease using variables from a noninvasive examination. We evaluated patients who underwent resection of pathologically confirmed IPMNs between November 2010 and December 2018 and had preoperative clinical data available for review. Based on binary multivariable logistic regression analysis, we devised a nomogram model to predict malignant IPMNs. The area under the receiver operating characteristics curve (AUC) was used to evaluate the discrimination power of the model. Of the 333 patients who underwent resection of IPMNs, 198 (59.5%) had benign and 135 (40.5%) had malignant IPMNs. Multivariable logistic regression analysis showed that cyst size, cyst location, cyst wall enhancement, multicystic lesion, diameter of main pancreatic duct, neutrophil-to-lymphocyte ratio, serum carbohydrate antigen 19-9, and carcinoembryonic antigen were significantly associated with malignancy. The nomogram, constructed based on these variables, showed excellent discrimination power with an AUC of 0.859 (95% CI: 0.818–0.900, P < 0.001). In conclusion, we have developed a nomogram consisting of a combination of cross-sectional imaging features and blood markers, variables that can readily be obtained by noninvasive examinations during the surveillance period, which can distinguish benign from malignant IPMNs. Nevertheless, external validation is warranted.

Magnetic resonance (MR) for mural nodule detection studying Intraductal papillary mucinous neoplasms (IPMN) of pancreas: Imaging-pathologic correlation

PurposeMagnetic Resonance (MR) is recommended to diagnose Intraductal Papillary Mucinous Neoplasms (IPMN) and in the follow-up of borderline lesions. The purpose of this work is to evaluate the diagnostic accuracy of dynamic MR with Diffusion Weighted Imaging (DWI) in the identification of mural nodules of pancreatic IPMN by using pathological analysis as gold standard. Materials and methodsNinety-one preoperative MR with histopathological diagnosis of IPMN were reviewed by two radiologists. Presence, number and size of mural nodule, signal intensity of the nodule on T1-weighted imaging (T1-WI) after contrast medium administration and on DWI. Inter-observer agreement was evaluated. ResultsSignificant correlation (p < 0.0001) were found for presence of nodules > 5 mm on MR and pathological specimen, size and number of mural nodules evaluated on pathological review and degree of dysplasia, size and number of mural nodules evaluated on MR and tumoral dysplasia, presence of nodule > 5 mm with enhancement after contrast medium administration and hyperintensity on DWI and degree of dysplasia. Interobserver agreement was moderate for the presence of mural nodule (K = 0.56), for the presence of high signal intensity on DWI (K = 0.57) and enhancement of mural nodule (K = 0.58). Apparent Diffusion Coefficient (ADC) map histogram analysis showed a correlation between Entropy of the entire cystic lesion and the degree of dysplasia (p < 0.034). ConclusionsMR with dynamic and DWI sequences was an accurate method for the identification of ≥ 5 mm solid nodules of the IPMNs and correlate with the lesion malignancy. Entropy, calculated from the histogram analysis of the IPMN ADC map, correlated with the lesion dysplasia.

Assessment of malignant potential in intraductal papillary mucinous neoplasms of the pancreas using MR findings and texture analysis.

To investigate the utility of MR findings and texture analysis for predicting the malignant potential of pancreatic intraductal papillary mucinous neoplasms (IPMNs). Two hundred forty-eight patients with surgically confirmed IPMNs (106 malignant [invasive carcinoma/high-grade dysplasia] and 142 benign [low/intermediate-grade dysplasia]) and who underwent magnetic resonance imaging (MRI) with MR cholangiopancreatography (MRCP) were included. Two reviewers independently analyzed MR findings as proposed by the 2017 international consensus guidelines. Texture analysis of MRCP was also performed. A multivariate logistic regression analysis was used to identify predictors for malignant IPMNs. Diagnostic performance was also analyzed using receiver operating curve analysis. Among MR findings, enhancing mural nodule size ≥ 5mm, main pancreatic duct (MPD) ≥ 10mm or MPD of 5 to 9mm, and abrupt change of MPD were significant predictors for malignant IPMNs (p< 0.05). Among texture variables, significant predictors were effective diameter, surface area, sphericity, compactness, entropy, and gray-level co-occurrence matrix entropy (p< 0.05). At multivariate analysis, enhancing mural nodule ≥ 5mm (odds ratios (ORs), 6.697 and 6.968, for reviewers 1 and 2, respectively), MPD ≥ 10mm or MPD of 5 to 9mm (ORs, 4.098 and 4.215, and 2.517 and 3.055, respectively), larger entropy (ORs, 1.485 and 1.515), and smaller compactness (ORs, 0.981 and 0.977) were significant predictors for malignant IPMNs (p< 0.05). When adding texture variable to MR findings, diagnostic performance for predicting malignant IPMNs improved from 0.80 and 0.78 to 0.85 and 0.85 in both reviewers (p< 0.05), respectively. MRCP-derived texture features are useful for predicting malignant IPMNs, and the addition of texture analysis to MR features may improve diagnostic performance for predicting malignant IPMNs. • Among the MR imaging findings, an enhancing mural nodule size ≥ 5mm and dilated main pancreatic ducts are independent predictors for malignant IPMNs. • Greater entropy and smaller compactness on MR texture analysis are independent predictors for malignant IPMNs. • The addition of MR texture analysis improved the diagnostic performance for predicting malignant IPMNs from 0.80 and 0.78 to 0.85 and 0.85, respectively.

Prognosis of resected intraductal papillary mucinous neoplasm of the pancreas: using revised 2017 international consensus guidelines.

Although there has been considerable effort to define pre-operative features to predict the malignant potential of intraductal papillary mucinous neoplasms (IPMNs), the prognostic value of pre-operative clinical and MRI features has not been assessed. The aim of this study was to determine pre-operative clinical and MRI features that are predictive of disease-specific death or recurrence in patients undergoing pancreatic resection for IPMNs. We performed a retrospective analysis of 167 patients (mean age, 65years; 114 men and 53 women) who underwent pre-operative MRI and surgical resection of IPMN of pancreas between 2009 and 2019. We evaluated disease-specific survival (DSS) and recurrence-free survival (RFS). Prognostic factor analysis was performed using clinical and MRI features according to the 2017 international consensus guidelines. Of 167 patients, 86 (51.5%) had benign IPMNs and 81 (48.5%) had malignant IPMNs (48 [28.7%] invasive carcinoma and 33 [19.8%] high grade). On multivariable analysis, mural nodule size (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.04-1.18 and HR 1.07; 95% CI 1.03-1.12) and obstructive jaundice (HR 5.01; 95% CI 1.44-17.46 and HR 5.60; 95% CI 2.42-12.99) were the significant variables that were associated with DSS and RFS. The presence of lymphadenopathy (HR 50.7; 95% CI 4.0-643.0; P = 0.002) was the significant factor for DSS. IPMNs with mural nodule showed a significantly lower 5-year DSS (83.7% vs. 100%, P value < 0.01) and RFS (73.1% vs. 95.0%, P value < 0.01) compared with IPMNs with no mural nodule. Mural nodule size on MRI and obstructive jaundice were prognostic markers in the pre-operative evaluation of patients with IPMN of pancreas.

Validation of a nomogram to predict the risk of cancer in patients with intraductal papillary mucinous neoplasm and main duct dilatation of 10 mm or less

Intraductal papillary mucinous neoplasm (IPMN) is premalignant pancreatic lesion. International guidelines offer limited predictors of individual risk. A nomogram to predict individual IPMN malignancy risk was released, with good diagnostic performance based on a large cohort of Asian patients with IPMN. The present study validated a nomogram to predict malignancy risk and invasiveness of IPMN using both Eastern and Western cohorts. Clinicopathological and radiological data from patients who underwent pancreatic resection for IPMN at four centres each in Eastern and Western countries were collected. After excluding patients with missing data for at least one malignancy predictor in the nomogram (main pancreatic duct diameter, cyst size, presence of mural nodule, serum carcinoembryonic antigen and carbohydrate antigen (CA) 19-9 levels, and age). In total, data from 393 patients who fit the criteria were analysed, of whom 265 were from Eastern and 128 from Western institutions. Although mean age, sex, log value of serum CA19-9 level, tumour location, main duct diameter, cyst size and presence of mural nodule differed between the Korean/Japanese, Eastern and Western cohorts, rates of malignancy and invasive cancer did not differ significantly. Areas under the receiver operating characteristic (ROC) curve values for the nomogram predicting malignancy were 0·745 for Eastern, 0·856 for Western and 0·776 for combined cohorts; respective values for the nomogram predicting invasiveness were 0·736, 0·891 and 0·788. External validation of the nomogram showed good performance in predicting cancer in both Eastern and Western patients with IPMN lesions.

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.

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.

Surgical indication for BD-IPMN – mural nodule in algorithm of 2012 & 2017 International Consensus Guidelines

Introduction: To identify high risk of malignancy, mural nodule (MN) size 5mm was added in algorithm of 2017 Guidelines for the management of BD-IPMN. Methods: The present study was a retrospective investigation of predictors of malignancy in BD-IPMN, paying special attention to MN. 466 patients with IPMN underwent pancreatic resection at 3 hospitals between 1996 and 2014. 156 patients with BD-IPMN were enrolled in this study. Preoperative findings and pathological diagnosis were analyzed. Endoscopic ultrasonography (EUS) measurements were essential for MN size, and computed tomography (CT) for MPD diameter and BPD cyst size. BD-IPMN was defined cystic dilatation of BPD and MPD diameter was considered < 5 mm (2012 Guidelines). According to WHO 2010 classification, diagnoses are classified as low-grade dysplasia (LGD), intermediate-grade dysplasia (IGD), high-grade dysplasia (HGD), or invasive carcinoma (IPMC). Patients were categorized as benign (LGD and IGD) or malignant (HGD and IPMC). Results: Pathological diagnoses were benign in 91 cases and malignant 65. In multivariate analyses, MN size (p< 0.0001) and BPD cyst size (p=0.0004) were independent predictors of malignancy, and in ROC analysis AUC was 0.74 and 0.72. With 5 mm taken as the cutoff value for MN size, diagnosis of malignant IPMN had sensitivity of 72%, specificity 65% and accuracy 68%. Carcinoma without MN was present in 15patients (15/65=23%). Pathological findings were HGD in 12 (12/65=18%) and IPMC 3 (3/65=5%). Conclusions: MN size measured with EUS showed high predictive ability. However, about 20% of malignant patients have no nodules, that is a problem for future.

MRI features of pancreatic intraductal papillary mucinous neoplasms associated with invasive carcinoma

Aim To assess the correlation between the magnetic resonance imaging (MRI) characteristics and histopathology in pancreatic intraductal papillary mucinous neoplasms (IPMNs) associated with invasive carcinoma. Materials and methods Thirty-two patients with pancreatic IPMN associated with invasive carcinoma treated at a regional hospital in Dezhou were enrolled and the MRI findings were analysed retrospectively. The patients were assigned to one of two groups based on the invasive component: invasive component of Results The groups did not significantly differ in lesion location, radiological type, apparent diffusion coefficient (ADC) value, main pancreatic duct diameter, mural nodule size, early arterial phase signal enhancement ratio (SEREAP), lymphatic metastasis, etc.; however, lesion size and tumour classifications significantly differed between the groups (p Conclusion Thus, the MRI features differed between IPMC-I and PDAC-IPMN. In particular, dynamic enhancement on preoperative MRI could be used for diagnosis and clinicopathological classification of pancreatic IPMN associated with invasive carcinoma.

Circulating serum oncologic miRNA in pediatric juvenile pilocytic astrocytoma patients predicts mural nodule volume.

Juvenile pilocytic astrocytomas represent the largest group of pediatric brain tumors. The ideal management for these tumors is early, total surgical resection. To detect and track treatment response, a screening tool is needed to identify patients for surgical evaluation and assess the quality of treatment. The identification of aberrant miRNA profiles in the sera of juvenile pilocytic astrocytoma patients could provide such a screening tool. The authors reviewed the serum profiles of 84 oncologically relevant miRNAs in pediatric juvenile pilocytic astrocytoma patients via qPCR screening. miR-21, miR-15b, miR-23a, and miR-146b were significantly elevated in the sera of JPA patients as compared to non-oncologic controls, oncologic controls, and post-JPA resection samples (p < 0.001, 0.022, 0.034, 0.044). miR-21 had the highest AUC on ROC analysis (AUC > 0.99, sensitivity 75%, specificity 100%). All four miRNAs also correlated well with tumor mural nodule size, though they only poorly correlated with total tumor size, including cystic components (Spearman's R2: miR-21 91.7 vs 6.9%, miR-15b 86.3 vs 23.1%, miR-23a 85.8 vs 23.0%, miR-146b 59.8 vs 11.9%). In this small pilot study, pediatric juvenile pilocytic astrocytoma patients had significant elevations in serum miR-21, miR-15b, miR-23a, and miR-146b levels that do not appear to be driven by hydrocephalus or local distortion of the intracranial contents. These alterations correlate with solid tumor component volume and reverse with complete tumor resection, suggesting that this serum miRNA profile may delineate biomarkers for screening and tracking juvenile pilocytic astrocytoma patients. Additional studies, with a larger cohort, are needed to verify these results.

Intraductal Papillary Mucinous Neoplasms of the Pancreas: Correlation of Helical Computed Tomography (CT) Features With Pathologic Findings

Intraductal papillary mucinous neoplasms (IPMNs) are precancerous lesions of the pancreas. Computed tomography (CT) has been recommended to screen the malignant potential of IPMNs. However, data evaluating the use of CT to differentiate categories of IPMN based on disease progression are limited. This study aimed to explore the correlation between CT characteristics and pathology in IPMN associated with invasive carcinoma. A total of 31 patients with intraductal papillary mucinous carcinoma (IPMC) treated at one local regional hospital in Shanghai, China, were enrolled in this study. Patients were divided into two groups based on invasion component and characterized as follows: group A, an invasive component of less than 50% (IPMC-I); and group B, with invasion of 50% or greater and defined as pancreatic ductal adenocarcinoma associated with IPMN (PDAC-IPMN). First, we analyzed the imaging information of the 31 patients retrospectively. Then, we compared the imaging differences between the two groups. Fifteen patients with IPMC-1 and 16 patients with PDAC-IPMN were identified. There was no statistically significant difference in sex, age, lesion location, radiologic type, tumor size, mural nodule size, and lymphatic metastasis between the two groups. However, the arterial increased CT values were significantly different between the two groups (P < .01), with values of 29.2 ± 12.4 HU for group A and 14.2 ± 8.8 HU for group B. The venous increased CT values were 44.6 ± 12.0 HU for group A and 28.4 ± 12.3 HU for group B, and these were significantly different between the two groups (P < .01). In group A, 13 cases (86.7%) were classified as T1 or T2 stage, and in group B, eight cases (50.0%) were classified as T1 and T2 stage. There was a statistically significant difference in tumor classification between group A and group B patients (P < .05). IPMC-I and PDAC-IPMN have different characteristics in CT imaging, and we demonstrated that CT scans based on blood supply and lymphatic metastasis could be used to evaluate and potentially screen for variation in IPMC disease outcomes.

Factors Associated With Invasive Intraductal Papillary Mucinous Carcinoma of the Pancreas

Invasive intraductal papillary mucinous carcinoma has aggressive malignant behavior, including lymph node metastasis. It is important to identify factors associated with invasive intraductal papillary mucinous carcinoma to determine operative procedures, but they remain unclear. To identify the specific factors associated with invasive intraductal papillary mucinous neoplasms for branch duct, main duct, and mixed type carcinomas. Retrospective cohort study of 286 consecutive patients who underwent surgical resection for intraductal papillary mucinous neoplasm from July 1999 to December 2015 at a tertiary institute. We compared clinical features between 96 patients (33.6%) with invasive intraductal papillary mucinous carcinoma and 190 patients (66.4%) with noninvasive intraductal papillary mucinous neoplasm for each morphological type. Factors associated with invasive intraductal papillary mucinous carcinoma. Mural nodule size was measured by endoscopic ultrasonography. Of the 286 patients included in the cohort, the median (range) age was 71 (28-86) years, and 162 (56.6%) were male. High mural nodule size was independently associated with invasive intraductal papillary mucinous carcinoma in all types (branch duct: odds ratio [OR], 1.992; 95% CI, 1.177-3.367; P = .01; main duct: OR, 1.443; 95% CI, 1.094-1.905; P = .01; and mixed: OR, 1.178; 95% CI, 1.057-1.312; P = .04). The cutoff values for intraductal papillary mucinous neoplasms, determined by a receiver operating characteristic, were 9 mm for branch duct and 6 mm for mixed and main duct carcinoma. A high carcinoembryonic antigen level in the pancreatic juice was independently associated with mixed (OR, 1.002; 95% CI, 1.000-1.003; P = .01) and main duct (OR, 1.002; 95% CI, 1.000-1.003; P = .048) carcinomas, and the cutoff values were determined to be 150 and 300 ng/mL, respectively (to convert to micrograms per liter, multiply by 1). In addition, both being female and having an elevated serum carbohydrate antigen 19-9 level were also found to be independently associated with mixed type invasive intraductal papillary mucinous carcinoma, and using any 2 among 4 identified factors yielded the highest accuracy (79.0%) for mixed type carcinomas. For all types, the accuracy for these factors was 86.0% for differentiating between invasive and noninvasive intraductal papillary mucinous neoplasms, which was superior to the accuracies using the "high-risk stigmata" factors or "worrisome features" suggested by the international consensus guideline in 2012 (66.1% and 39.9%, respectively). The measurement of mural nodule size in all types of carcinomas and carcinoembryonic antigen level in the pancreatic juice in mixed and main duct carcinomas might play important roles in predicting invasive intraductal papillary mucinous carcinoma, but further large studies are needed to confirm these results.

Validation of the 2012 International Consensus Guidelines Using Computed Tomography and Magnetic Resonance Imaging: Branch Duct and Main Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas.

To validate the 2012 guidelines for intraductal papillary mucinous neoplasm (IPMN) of the pancreas and to compare diagnostic performances of computed tomography (CT) and magnetic resonance imaging (MRI) for differentiating malignant from benign IPMN. As IPMN has variable risks of malignancy and management of this entity is closely related to its malignant potential, it is important to predict risks of IPMN malignancy. This retrospective study included 158 patients with surgically confirmed IPMN of the pancreas who underwent both preoperative CT and MRI. Two radiologists evaluated the "high-risk stigmata" and "worrisome features" of the 2012 guidelines for branch duct (BD)-IPMN and main duct (MD)-IPMN. Univariate and multivariable analyses were used to identify significant predictors of malignancy in IPMN. The diagnostic performance was compared between CT and MRI. Malignant IPMN was seen in 8 of 60 patients (13.3%) with BD-IPMN and 44 of 98 patients (44.9%) with MD-IPMN. Presence of mural nodule was the most important predictor in BD-IPMN and MD-IPMN (odds ratios, 9.2 and 7.6, respectively, P = 0.01 on CT; and odds ratios, 5.7 and 13.3, respectively, P ≤ 0.04 on MRI), whereas mural nodule size and lymphadenopathy were significant only in MD-IPMN (P < 0.05). The diagnostic performance of CT and MRI for significant findings was not statistically different in both types of IPMN (P > 0.34). The presence of mural nodule was the most important predictor of malignancy in both types of IPMN. Mural nodule size and lymphadenopathy were also significant predictors in MD-IPMN. Computed tomography and MRI showed similar diagnostic performances for differentiating malignant from benign IPMN.