Imaging Pearls ❯ Pancreas ❯ IPMN
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- “IPMNs can be challenging to diagnose accurately because several benign lesions can mimic their characteristics. Unfortunately, CT and MRI have mixed accuracy. In one study, the accuracy of CT or MRI for the overall characterization of a PCL is relatively high though with limited diagnostic accuracy for specific cystic pancreatic masses based on CT or MRI appearance. In the study, reviewers were correct in only 57% of cases in which they were confident in the leading diagnosis. Nevertheless, MRI has higher soft-tissue contrast and multiplanar capability result in superior differentiation of cystic neoplasms while others have found that MRI adds little to CT.”
Misdiagnosis of pancreatic intraductal papillary mucinous neoplasms and the challenge of mimicking lesions: imaging diagnosis and differentiation strategies
Mohammad Yasrab· Stephen J. Kwak · Parissa Khoshpouri· Elliot K. Fishman · Atif Zaheer
Abdominal Radiology (2024, in press) https://doi.org/10.1007/s00261-024-04551-x 
Misdiagnosis of pancreatic intraductal papillary mucinous neoplasms and the challenge of mimicking lesions: imaging diagnosis and differentiation strategies
Mohammad Yasrab· Stephen J. Kwak · Parissa Khoshpouri· Elliot K. Fishman · Atif Zaheer
Abdominal Radiology (2024, in press) https://doi.org/10.1007/s00261-024-04551-x- “The rising prevalence of pancreatic cystic lesions (PCLs), particularly intraductal papillary neoplasms (IPMNs), has been attributed to increased utilization of advanced imaging techniques. Incidental detection of PCLs is frequent in abdominal CT and MRI scans, with IPMNs representing a significant portion of these lesions. Surveillance of IPMNs is recommended due to their malignant potential; however, their overlapping imaging features with benign entities can lead to misdiagnosis, overtreatment, and overutilization of healthcare resources. This paper aims to highlight and differentiate lesions often mistaken for IPMNs, providing insight into their imaging characteristics, diagnostic challenges, and distinctive features while highlighting the incidence of wrong diagnosis for these lesions. These lesions include serous cystadenomas, cystic pancreatic neuroendocrine tumors, mucinous cystic neoplasms, lymphoepithelial cysts, duodenal diverticula, pancreatic schwannomas, chronic pancreatitis, retention cysts, intrapancreatic accessory spleens, pancreatic lipomas, choledochal cysts, and others. Utilizing various imaging modalities, including contrast-enhanced CT, MRI, and EUS, alongside histological and molecular analyses, can aid in accurate diagnosis and appropriate management.”
Misdiagnosis of pancreatic intraductal papillary mucinous neoplasms and the challenge of mimicking lesions: imaging diagnosis and differentiation strategies
Mohammad Yasrab· Stephen J. Kwak · Parissa Khoshpouri· Elliot K. Fishman · Atif Zaheer
Abdominal Radiology (2024, in press) https://doi.org/10.1007/s00261-024-04551-x
- OBJECTIVE To fill knowledge gaps in epidemiology of IPMNs and associated PC risk by estimating population prevalence of IPMNs, associated PC risk, and proportion of IPMN-PC.
CONCLUSIONS AND RELEVANCE In this study, CTs identified IPMNs in approximately 10% of patients aged 50 years or older. PC risk in patients with F-N IPMNs was low and not different compared with patients without IPMNs; approximately 10% of patients with PC had IPMN-PC, and they had better survival compared with patients with non-IPMN PC.
Long-Term Outcomes and Risk of Pancreatic Cancer in Intraductal Papillary Mucinous Neoplasms
Jaime de la Fuente et al.
JAMA Network Open. 2023;6(10):e2337799. - Key Points
Question What is the estimated population prevalence of intraductal papillary mucinous neoplasms (IPMNs), associated pancreatic cancer (PC) risk, and proportion of malignant transformation of IPMNs to PC?
Findings In this cohort study of 2114 patients aged 50 years or older, the prevalence of IPMNs on contrastenhanced computed tomography imaging was 10.9%, more than 80% of which were branch-duct IPMNs with no worrisome or high-risk features, and the risk of PC and overall survival in patients with IPMNs without worrisome or high-risk features was similar to that of patients without IPMNs. Approximately 10% of PCs arose from IPMNs, and patients with these cancers had better outcomes.
Meaning This study found that PC risk was low in patients with Fukuoka negative IPMNs and similar to that of patients without IPMNs and that while IPMN-associated PC accounted for a small proportion of all PC cases, these patients had better survival.
Long-Term Outcomes and Risk of Pancreatic Cancer in Intraductal Papillary Mucinous Neoplasms
Jaime de la Fuente et al.
JAMA Network Open. 2023;6(10):e2337799. - Once considered a rare disease, IPMNs are now very common findings due to tremendous technological advances that have improved diagnostics. In keeping with data from surveillance studies, this population-based study found that most IPMNs lacking WFs or HRS at diagnosis did not progress to PC, suggesting that somewh ere likely an example of overdiagnosis and excessive medicalization. Obviously, it is not possible to generalize given that some IPMNs have the potential to progress to cancer over time. Although results of this study should be validated in larger cohorts, they represent useful clinical data from an unselected population-based cohort that helps challenge current IPMN surveillance policies that recommend lifetime active surveillance for all fit individuals. In the future, a multiomics approach with clinical-radiological, metabolic, and molecular and genomic data may increase the probability of finding accurate biomarkers associated with risk stratification of IPMNs and their management in view of personalized medicine. Currently, we can use follow-up data from studies like this one to identify patients with IPMNs who are not at risk of progression based on clinical-radiological parameters. We can furthermore start selecting subgroups of patients with limited life expectancy due to age or comorbidities to be considered for surveillance discontinuation. .
IPMNs of the Pancreas: More Epidemiologically Than Clinically Relevant.
Crippa S, Capurso G, Falconi M
JAMA Netw Open. 2023 Oct 2;6(10):e23386966 - Once considered a rare disease, IPMNs are now very common findings due to tremendous technological advances that have improved diagnostics. In keeping with data from surveillance studies, this population-based study found that most IPMNs lacking WFs or HRS at diagnosis did not progress to PC, suggesting that some where likely an example of overdiagnosis and excessive medicalization. Obviously, it is not possible to generalize given that some IPMNs have the potential to progress to cancer over time. Although results of this study should be validated in larger cohorts, they represent useful clinical data from an unselected population-based cohort that helps challenge current IPMN surveillance policies that recommend lifetime active surveillance for all fit individuals.
IPMNs of the Pancreas: More Epidemiologically Than Clinically Relevant.
Crippa S, Capurso G, Falconi M
JAMA Netw Open. 2023 Oct 2;6(10):e23386966 - In the future, a multiomics approach with clinical-radiological, metabolic, and molecular and genomic data may increase the probability of finding accurate biomarkers associated with risk stratification of IPMNs and their management in view of personalized medicine. Currently, we can use follow-up data from studies like this one to identify patients with IPMNs who are not at risk of progression based on clinical-radiological parameters. We can furthermore start selecting subgroups of patients with limited life expectancy due to age or comorbidities to be considered for surveillance discontinuation. .
IPMNs of the Pancreas: More Epidemiologically Than Clinically Relevant.
Crippa S, Capurso G, Falconi M
JAMA Netw Open. 2023 Oct 2;6(10):e23386966
- IPMN and Cystic Pancreatic Lesions: Guidelines
- Do people actually follow the guidelines?
- Are they numerous interpretations of the guidelines?
- Do the guidelines actually work and whats its success?
- Is there a better way than current practice? - AI and Pancreatic Cystic Lesions
- Radiomics
- Deep Learning algorithmns
- Combine Radiomics and Deep Learning algorithmns - Background: Society consensus guidelines are commonly used to guide management of pancreatic cystic neoplasms( PCNs). However, downsides of these guidelines include unnecessary surgery and missed malignancy. The aim of this study was to use computed tomography (CT)-guided deep learning techniques to predict malignancy of PCNs.
Materials and Methods: Patients with PCNs who underwent resection were retrospectively reviewed. Axial images of the mucinous cystic neoplasms were collected and based on final pathology were assigned a binary outcome of advanced neoplasia or benign. Advanced neoplasia was defined as adenocarcinoma or intraductal papillary mucinous neoplasm with high-grade dysplasia. A convolutional neural network (CNN) deep learning model was trained on 66% of images, and this trained model was used to test 33% of images. Predictions from the deep learning model were compared to Fukuoka guidelines.
Results: Twenty-seven patients met the inclusion criteria, with 18 used for training and 9 for model testing. The trained deep learning model correctly predicted 3 of 3 malignant lesions and 5 of 6 benign lesions. Fukuoka guidelines correctly classified 2 of 3 malignant lesions as high risk and 4 of 6 benign lesions as worrisome. Following deep learning model predictions would have avoided 1 missed malignancy and 1 unnecessary operation.
Discussion: In this pilot study, a deep learning model correctly classified 8 of 9 PCNs and performed better than consensus guidelines. Deep learning can be used to predict malignancy of PCNs; however, further model improvements are necessary before clinical use.
Use of Artificial Intelligence Deep Learning to Determine the Malignant Potential of Pancreatic Cystic Neoplasms With Preoperative Computed Tomography Imaging
Michael D. Watson et al.
The American Surgeon 2021, Vol. 87(4) 602–607 - “The guidelines describe high-risk and worrisome criteria of PCNs based on preoperative imaging and clinical symptoms. Retrospective studies have demonstrate high specificity; however, these guidelines havepoor sensitivity, and using guidelines alone would haveled to missing approximately 50% of advanced neoplasia in 1 series. This results in nearly 20% of patients with a benign lesion undergoing operations with high morbidity. Given that existing guidelines are insufficient for identification of high-risk features of PCNs, an opportunity exists to leverage innovative new technologies toaid in diagnosis of potentially malignant lesions.”
Use of Artificial Intelligence Deep Learning to Determine the Malignant Potential of Pancreatic Cystic Neoplasms With Preoperative Computed Tomography Imaging
Michael D. Watson et al.
The American Surgeon 2021, Vol. 87(4) 602–607 - “In conclusion, this pilot study with a small group ofpatients (n = 27) demonstrated that a deep learning model based only on preoperative CT imaging was better able to predict advanced neoplasia than generally accepted consensus guidelines. Further study should be directed toward creation of a larger, more sophisticated model and ultimately prospective validation of a model for predictionof malignant behavior of PCNs.”
Use of Artificial Intelligence Deep Learning to Determine the Malignant Potential of Pancreatic Cystic Neoplasms With Preoperative Computed Tomography Imaging
Michael D. Watson et al.
The American Surgeon 2021, Vol. 87(4) 602–607 - “In this pilot study for prediction of advanced neoplasia from preoperative CT imaging, a deep learning model was superior to consensus guidelines. The deep learning model was able to correctly classify 8 of 9 high-risk PCNs,while consensus guidelines were correct 6 of 9 times. In terms of possible patient outcomes, following predictions from the deep learning model would have resulted in 1unnecessary operation, while following consensusguidelines would have resulted in 2 unnecessary operationsand 1 missed neoplasm.”
Use of Artificial Intelligence Deep Learning to Determine the Malignant Potential of Pancreatic Cystic Neoplasms With Preoperative Computed Tomography Imaging
Michael D. Watson et al.
The American Surgeon 2021, Vol. 87(4) 602–607 - “We view the use of AI running in the background as a QA tool to be a win/win situation. The process should make radiologists comfortable, not impeding their workflow at all, while also convincing them of its value through consistent demonstration. The QA system we have outlined offers a novel way of approaching the reading of CT scans and represents what might be an easy starting point for those hesitant but interested in exploring AI opportunities. Can AI become the ultimate QA? It is not there yet, clearly, but the prospect of such a role for AI in radiology seems closer than ever.”
Is AI the Ultimate QA?
Edmund M. Weisberg, Linda C. Chu, Benjamin D. Nguyen, Pelu Tran, Elliot K. Fishman
J Digit Imaging. 2022 Feb 15. doi: 10.1007/s10278-022-00598-8. - “The gradual inclusion, or incursion as some see it, of artificial intelligence (AI) into various branches of medicine has ignited fierce debate in recent years, building bases of proponents and opponents in the process. We are firmly among those that believe AI will not replace practitioners and is most valuable as an adjunct in diagnostic radiology. We suggest a different approach to utilizing the technology, which may help even radiologists who may be averse to adopting AI. Here we consider early indications of AI’s potential as the ultimate quality assurance (QA) for radiologists..”
Is AI the Ultimate QA?
Edmund M. Weisberg, Linda C. Chu, Benjamin D. Nguyen, Pelu Tran, Elliot K. Fishman
J Digit Imaging. 2022 Feb 15. doi: 10.1007/s10278-022-00598-8. - “Fifteen studies (25%) addressed prediction of malignancy based on imaging findings, or differentiation of benign from malignant pancreatic conditions[280,301-315]. Marya et al[280] developed an EUS-based CNN model that distinguished AIP from normal pancreas with 99% sensitivity and 98% specificity, AIP from CP with 94% sensitivity and 71% specificity, and AIP from PDAC with 90% sensitivity and 93% specificity. Chu et al[301] conducted a study utilizing CT radiomics features to differentiate PDAC from normal pancreas tissue. The accuracy of the RF binary classification was 99.2%, with an AUC of 99.9%. All cases of PDAC were correctly identified, with a sensitivity of 100% and specificity of 98.5%.”
Artificial intelligence in gastroenterology: A state-of-the-art review
Kröner, Paul T et al.
World journal of gastroenterology vol. 27,40 (2021): 6794-6824.
- "This has led to an increased interest in radiomics, a high-throughput extraction of comprehensible data from standard of care images. Radiomics can be used as a diagnostic and prognostic tool in personalized medicine. It utilizes quantitative image analysis to extract features in conjunction with machine learning and artificial intelligence (AI) methods like support vector machines, random forest, and convolutional neural network for feature se- lection and classification. Selected features can then serve as imaging biomarkers to predict high-risk PCLs. Radiomics studies conducted heretofore on PCLs have shown promising results.”
Radiomics in stratification of pancreatic cystic lesions: Machine learning in action
Vipin Dalala et al.
Cancer Letters,Volume 469,2020,Pages 228-237 - "IPMNs and MCNs are the only radiographically identifiable precursors of pancreatic cancer. Consequently, accurate assessment of the malignant potential of these cystic lesions may allow early detection of resectable PCLs prior to oncogenesis. The latest guidelines propose a practical approach for their management and surveillance, yet the clinical management of these mucinous cystic lesions remains challenging. The variable risk of malignant transformation combined with elevated risks associated with pancreatic surgery have led to conflicting recommendations for the management of mucinous cystic lesions.”
Radiomics in stratification of pancreatic cystic lesions: Machine learning in action
Vipin Dalala et al.
Cancer Letters,Volume 469,2020,Pages 228-237 - "Although only a few studies describing the use of radiomics in risk stratification of PCLs have been published, these studies have demonstrated that radiomics can be utilized to non-invasively discriminate between low-risk and high-risk PCLs before resection. This cost-effective approach would enable us to accurately recommend lifesaving surgery for individuals with malignant cysts and spare those with benign lesions the morbidity, mortality and high costs associated with pancreatic surgeries. Consequently, more studies are warranted to develop these imaging biomarkers which can be used to differentiate between benign and malignant PCLs.”
Radiomics in stratification of pancreatic cystic lesions: Machine learning in action
Vipin Dalala et al.
Cancer Letters,Volume 469,2020,Pages 228-237 
- “Pancreatic cysts are common and often pose a management dilemma, because some cysts are precancerous, whereas others have little risk of developing into invasive cancers. We used supervised machine learning techniques to develop a comprehensive test, CompCyst, to guide the management of patients with pancreatic cysts. The test is based on selected clinical features, imaging characteristics, and cyst fluid genetic and biochemical markers. Using data from 436 patients with pancreatic cysts, we trained CompCyst to classify patients as those who required surgery, those who should be routinely monitored, and those who did not require further surveillance. We then tested CompCyst in an independent cohort of 426 patients, with histopathology used as the gold standard. We found that clinical management informed by the CompCyst test was more accurate than the management dictated by conventional clinical and imaging criteria alone. Application of the CompCyst test would have spared surgery in more than half of the patients who underwent unnecessary resection of their cysts. CompCyst therefore has the potential to reduce the patient morbidity and economic costs associated with current standard-of-care pancreatic cyst management practices.”
A multimodality test to guide the management of patients with a pancreatic cyst.
Springer S, Masica DL, Dal Molin M, et al.
Sci Transl Med. 2019;11(501):eaav4772. doi:10.1126/scitranslmed.aav4772 - “We found that clinical management informed by the CompCyst test was more accurate than the management dictated by conventional clinical and imaging criteria alone. Application of the CompCyst test would have spared surgery in more than half of the patients who underwent unnecessary resection of their cysts. CompCyst therefore has the potential to reduce the patient morbidity and economic costs associated with current standard-of-care pancreatic cyst management practices.”
A multimodality test to guide the management of patients with a pancreatic cyst.
Springer S, Masica DL, Dal Molin M, et al.
Sci Transl Med. 2019;11(501):eaav4772. doi:10.1126/scitranslmed.aav4772 - “Two dilemmas make pancreatic cyst clinical management challenging. First, it is difficult to differentiate IPMNs and MCNs, collectively termed “mucin-producing cysts,” from cysts that have no malignant potential and do not require any follow-up. Second, it can be difficult to differentiate patients with mucin-producing cysts that harbor early invasive cancer or high-grade dysplasia from patients with less advanced mucin-producing cysts. Surgery is recommended for patients with advanced cysts, whereas intermittent surveillance with imaging, rather than surgery, is considered appropriate for patients with less advanced cysts. Currently available clinical tools, however, are imperfect at assigning the most appropriate management strategies for patients with cysts. This is highlighted by the fact that 25% of cyst patients who undergo surgical resection have a pancreatic cyst with no malignant potential, and up to 78% of mucin-producing cysts referred for surgical resection are ultimately found not to be advanced, that is, they do not harbor high-grade dysplasia or cancer.”
A multimodality test to guide the management of patients with a pancreatic cyst.
Springer S, Masica DL, Dal Molin M, et al.
Sci Transl Med. 2019;11(501):eaav4772. doi:10.1126/scitranslmed.aav4772 
A multimodality test to guide the management of patients with a pancreatic cyst.
Springer S, Masica DL, Dal Molin M, et al.
Sci Transl Med. 2019;11(501):eaav4772. doi:10.1126/scitranslmed.aav4772
A multimodality test to guide the management of patients with a pancreatic cyst.
Springer S, Masica DL, Dal Molin M, et al.
Sci Transl Med. 2019;11(501):eaav4772. doi:10.1126/scitranslmed.aav4772
A multimodality test to guide the management of patients with a pancreatic cyst.
Springer S, Masica DL, Dal Molin M, et al.
Sci Transl Med. 2019;11(501):eaav4772. doi:10.1126/scitranslmed.aav4772- “In conclusion, the use of a comprehensive test that evaluates clinical, imaging, and molecular features is imperfect but appears to offer substantial improvements over standard-of-care management of patients with pancreatic cysts. CompCyst does not replace conventional clinical tools. Instead, it contributes additional information, allowing clinicians to make more informed decisions. How and when tests like CompCyst can be implemented in routine clinical settings remains to be determined, but our results represent the next stage of research required for such implementation. An important next test of the markers presented here could be their validation in a follow-up, prospective study.”
A multimodality test to guide the management of patients with a pancreatic cyst.
Springer S, Masica DL, Dal Molin M, et al.
Sci Transl Med. 2019;11(501):eaav4772. doi:10.1126/scitranslmed.aav4772
- “IPMNs are cystic neoplasms with variable degree of malignant potential. They may evolve into dysplasia or invasive carcinoma and are associated with a higher risk for the development of PDAC in the gland separate from the IPMN sites. The rate of progression increases with time. Low-risk IPMNs have an approximately 8% chance of progression, whereas higher risk IPMNs have an approximately 25% chance of progression to PDAC in 10 years. Even presumed low- risk BD-IPMNs may demonstrate growth after 5 years.”
Incidental Pancreatic Cysts on Cross-Sectional Imaging
Shannon M. Navarro et al.
Radiol Clin N Am 59 (2021) 617–629
- OBJECTIVE. The purpose of this study is to retrospectively evaluate the differential CT features of isolated benign and malignant main pancreatic duct (MPD) dilatation and to investigate whether the diagnostic performance of radiologists can be improved with knowledge of these differential CT features.
CONCLUSION. Distal, long (≥ 6.1 mm), and abrupt transition, the absence of duct penetrating sign, and the presence of attenuation difference and PD or CBD enhancement were highly suggestive CT ndings for differentiation of malignant from benign MPD dilatation. The diagnostic performance of radiologists with regard to differentiation was signi cantly improved with knowledge of these highly suggestive CT criteria.
Isolated Main Pancreatic Duct Dilatation: CT Differentiation Between Benign and Malignant Causes Se Woo Kim et al AJR 2017; 209:1046–1055 - “In a 2013 study of the National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) registry, the estimated number of pancreatic cysts in the U.S. population between 40 and 84 years old was 3,428,874, with an overall cyst prevalence of 2.5%. Increased use of cross-sectional imaging has led to increased detection of such cysts in recent years; 2.2% of upper abdominal CT examinations and 19.6% of MRI examinations report a pancreatic cyst .”
Management of Incidental Pancreatic Cysts: A White Paper of the ACR Incidental Findings Committee. Megibow AJ et al. J Am Coll Radiol. 2017 Jul;14(7):911-923.
- PURPOSE: To compare diagnostic performance for prediction of malignant potential in IPMNs between EUS, contrast-enhanced CT and MRI.
CONCLUSION: Diagnostic performance of contrast-enhanced CT, MRI, and EUS for predicting malignant IPMNs was comparable with each modalities without significant difference.
Diagnostic performance and imaging features for predicting the malignant potential of intraductal papillary mucinous neoplasm of the pancreas: a comparison of EUS, contrast-enhanced CT and MRI. Choi SY et al. Abdom Radiol 2017 Jan 31. doi: 10.1007/s00261-017-1053-3. [Epub ahead of print] - RESULTS: Diagnostic performance of contrast-enhanced CT (AUC = 0.792 in R1, 0.830 in R2), MRI (AUC = 0.742 in R1, 0.776 in R2), and EUS (AUC = 0.733) for predicting malignant IPMNs were comparable without significant difference (p > 0.05). In multivariable analysis, enhancing solid component in contrast-enhanced CT and MRI and mural nodule in EUS (OR 1.8 in CT, 1.36 in MRI, 1.47 in EUS), MPD diameter ≥ 10 mm (OR 1.3 in CT, 1.4 in MRI, 1.66 in EUS), MPD diameter of 5-9 mm (OR 1.23 in CT, 1.31 in MRI), and thickened septa or wall (OR 1.3 in CT and MRI) were significant variables (p < 0.05). Interobserver agreement of thickened cyst septa or wall (k = 0.579-0.617) and abrupt caliber change of MPD (k = 0.689-0.788) was lower than other variables (k > 0.80).
Diagnostic performance and imaging features for predicting the malignant potential of intraductal papillary mucinous neoplasm of the pancreas: a comparison of EUS, contrast-enhanced CT and MRI. Choi SY et al. Abdom Radiol 2017 Jan 31. doi: 10.1007/s00261-017-1053-3. [Epub ahead of print]
- “The pancreas is an unusual site of secondary tumors. Melanoma, lung cancer and breast carcinoma are the most common origins of multiple pancreatic metastases, whereas renal cell carcinoma usually leads to a single pancreatic metastasis. The interval between the diagnosis of the primary tumor and the development of pancreatic metastases varies between 1 and 3years, except for renal cell carcinoma for which pancreatic metastases may appear after more than 20 years.”
Imaging features of rare pancreatic tumors M. Barrala, S.A. Faraound, E.K. Fishman, A. Dohan, C. Pozzesserea, M.-A. Berthelina,P. Bazeries, M. Barat, C. Hoeffel, P. Soyer Diagnostic and Interventional Imaging (2016) (in press)
- Management of Cystic Pancreatic Lesions
- Impact of MPCC
- Impact of MPCC
- “In conclusion, multidisciplinary input associated with a MPCC is helpful in the management of patients with pancreatic cysts and alters the management of up to 30 % of patients assessed.”
Role of a Multidisciplinary Clinic in the Management of Patients with Pancreatic Cysts: A Single-Center Cohort Study
Lennon AM, Manos LL, Hruban RH, Ali SY, Fishman EK et al.
Ann Surg Oncol DOI 10.1245/s10434-014-3739 - “The most common diagnosis was branch duct intraductal papillary mucinous neoplasm. MPCC review altered the risk category in 11 (8.0%) of 138 patients. The management category was altered in 68 (30.2%) of 225 patients. Management was increased in 52 patients, including 22 patients who were recommended surgical resection. Management was decreased in 16 patients, including 10 who had their recommendation changed from surgery to surveillance.”
Role of a Multidisciplinary Clinic in the Management of Patients with Pancreatic Cysts: A Single-Center Cohort Study
Lennon AM, Manos LL, Hruban RH, Ali SY, Fishman EK et al.
Ann Surg Oncol DOI 10.1245/s10434-014-3739 - “The MPCC altered the management of a third of patients assessed in the clinic. In the majority of cases, surveillance was recommended, with surgery recom- mended in just under 10 % of all patients, although no further follow-up was required in just under 2 % of patients who had benign disease. None of the patients in whom the recommendation was changed from surgery to surveillance developed evidence of malignancy during follow-up.”
Role of a Multidisciplinary Clinic in the Management of Patients with Pancreatic Cysts: A Single-Center Cohort Study
Lennon AM, Manos LL, Hruban RH, Ali SY, Fishman EK et al.
Ann Surg Oncol DOI 10.1245/s10434-014-3739 - “The Whipple procedure is associated with a set of common complications, including pancreatic fistula, postsurgical hemorrhage, postoperative pancreatitis, portomesenteric venous thrombosis, hepatic infarction, delayed gastric emptying, and anastomotic strictures.”
CT after pancreaticoduodenectomy: spectrum of normal findings and complications.
Raman SP, Horton KM, Cameron JL Fishman EK.
AJR Am J Roentgenol. 2013 Jul;201(1):2-13.
- “ CT might be useful for preoperatively evaluating the T category, lymph node metastasis, tumor size, and perineural invasion of IPMC. Main pancreatic duct dilatation and the presence of mural nodules are common findings of IPMC.”
Intraductal Papillary Mucinous Neoplasms With Associated Invasive Carcinoma of the Pancreas: Imaging Findings and Diagnostic Performance of MDCT for Prediction of Prognostic Factors
Kim JH et al.
AJR 2013; 201:565-572 - “ Tumor size is also reported to be a prognostic factor in IPMN. Some studies have suggested that tumor diameter of more than 3 cm is associated with an increased risk of malignancy. In our study, MDCT accurately measured the tumor size but was not statistically different from that of the surgical specimen.”
Intraductal Papillary Mucinous Neoplasms With Associated Invasive Carcinoma of the Pancreas: Imaging Findings and Diagnostic Performance of MDCT for Prediction of Prognostic Factors
Kim JH et al.
AJR 2013; 201:565-572
"Prediction of the pathologic subtypes of pancreatic IPMNs by CT is limited. Predominant main pancreatic duct involvement and a wide connection of a side branch lesion with the main pancreatic duct are the only CT findings that can be used to predict the pathologic subtype of pancreatic IPMN (carcinoma)."
Pancreatic Intraductal Papillary Neoplasms: Role of CT in Predicting Pathologic Subtypes
Gupta R et al.
AJR 2008; 191;1458-1464- IPMN: Histologic Characterization
- Adenoma
- Borderline malignancy
- Moderate dysplasia
- Carcinoma in situ
- Invasive carcinoma
- Progression may take 5 years or more "A diameter of the main pancreatic duct (MPD) of 6.0 mm or more, an abnormal attenuating area in the surrounding parenchyma,and a mural nodule in the MPD or in any associated cystic lesion of 3 mm or larger support the diagnosis of malignancy of the intraductal papillary neoplasm."
Intraductal Papillary Mucinous Neoplasm of the Pancreas: Assessment of the Likelihood of Invasiveness with Multisection CT
Ogawa H et al.
Radiology 2008; 248:876-886"Multiphase contrast enhanced CT with a multisection CT scanner is helpful for distinguishing among adenoma, noninvasive carcinoma, and invasive carcinoma in patients with IPMN and such a distinction provides valuable information to assist the clinician in guiding patient treatment."
Intraductal Papillary Mucinous Neoplasm of the Pancreas: Assessment of the Likelihood of Invasiveness with Multisection CT
Ogawa H et al.
Radiology 2008; 248:876-886"Multisection CT is useful for distinguishing among adenoma, noninvasive carcinoma and invasive carcinoma in patients with IPMN."
Intraductal Papillary Mucinous Neoplasm of the Pancreas: Assessment of the Likelihood of Invasiveness with Multisection CT
Ogawa H et al.
Radiology 2008; 248:876-886"Computed tomography findings suspicious for tumor recurrence include enlarging mass (either solid,cystic or both), progressive duct dilatation, or extrapancreatic disease."
Recurrence Patterns of Intraductal Papillary Mucinous Neoplasms of the Pancreas on Enhanced Computed Tomography
Landa J et al.
J Comput Assist Tomogr 2009;33: 838-843- IPMN: Patterns of Recurrence
- Enlarging mass at resection site
- New mass developing in remaining gland
- Progressive duct dilatation
- Extrapancreatic disease - "Allen and Brennan proposed that selected patients with mucinous cysts without a solid component and of less than 3-cm diameter can be safely followed because the risk of malignancy approximates the risk of mortality from surgical resection."
Prevalence of Unsuspected Pancreatic Cysts on MDCT
Laffan TA, Horton KM, Fishman EK, Hruban RH
AJR 2008;802-807
- "CT falls short of MRCP in detecting a ductal connection, estimating main duct involvement, and identification of small branch duct cysts. These factors influence diagnostic accuracy, cancer risk stratification and operative strategy."
CT vs MRCP:Optimal Classification of IPMN type and Extent
Waters JA et al.
J Gastrointest Surg (2008) 12:101-109
- "Of 214 patients treated with IPMN(1991-2006), 30 had preoperative CT and MRCP. Of these, 18 met imaging study criteria."
CT vs MRCP:Optimal Classification of IPMN type and Extent
Waters JA et al.
J Gastrointest Surg (2008) 12:101-109
comment: only axial CT used and to study duct CPR and 3D are ideal. Also study over many types of CT
- "CT is helpful in the differentiation of in situ and invasive IPMN. Classic vascular invasion criteria lead to the overestimation of surgical tumor unresectability in patients with malignant IPMN."
Malignant Intraductal Papillary Mucinous Neoplasm of the Pancreas: In Situ versus Invasive Carcinoma-Surgical Resectability
Vullierme MP et al.
Radiology 2007;245:483-490
- "Radiographic features that correlated with malignancy were presence of a solid component, main pancreatic duct dilatation, common bile duct diltation, and lymphadenopathy. Twenty seven of 31 (87%) patients with malignant lesions had at least one radiographic feature concerning for malignancy."
Risk of Malignancy in Resected Cystic Tumors of the Pancreas =3cm in Size:Is it Safe to Observe Asymptomatic Patients? A Multi-Institutional Report
Lee CJ et al.
J Gastrointest Surg (2008) 12:234-242
- "Based on retrospective analysis, this multi-institutional review of resection data of small cystic lesions from high volume centers suggests that a group of patients with a low risk of malignancy can be identified and be safely followed in accordance with the current consensus guidelines."
Risk of Malignancy in Resected Cystic Tumors of the Pancreas =3cm in Size:Is it Safe to Observe Asymptomatic Patients? A Multi-Institutional Report
Lee CJ et al.
J Gastrointest Surg (2008) 12:234-242
- "Pancreas protocol CT imaging appears to be a better predictor of resectability compared with EUS. EUS accuracy is affected by the presence of biliary stents."
Endoscopic Ultrasound and Computed Tomography Predictors of Pancreatic Cancer Resectability
Bao PQ et al
J Gastrointest Surg (2008) 12:10-16
- Cystic Pancreatic Tumors: Features For Low Risk of Malignancy
- Asymptomatic patient
- Size under 3 cm
- Main pancreatic duct under 6 mm
- No solid component (mural nodule) within or associated with the cystic lesion
- No evidence of adenopathy
- No common bile duct dilatation
- "Radiographic features that correlated with malignancy were presence of a solid component, main pancreatic duct dilatation, common bile duct diltation, and lymphadenopathy. Twenty seven of 31 (87%) patients with malignant lesions had at least one radiographic feature concerning for malignancy."
Risk of Malignancy in Resected Cystic Tumors of the Pancreas =3cm in Size:Is it Safe to Observe Asymptomatic Patients? A Multi-Institutional Report
Lee CJ et al.
J Gastrointest Surg (2008) 12:234-242
- "Based on retrospective analysis, this multi-institutional review of resection data of small cystic lesions from high volume centers suggests that a group of patients with a low risk of malignancy can be identified and be safely followed in accordance with the current consensus guidelines."
Risk of Malignancy in Resected Cystic Tumors of the Pancreas =3cm in Size:Is it Safe to Observe Asymptomatic Patients? A Multi-Institutional Report
Lee CJ et al.
J Gastrointest Surg (2008) 12:234-242
- "Our results suggest that by combining data from both CT and EUS, a clinically relevant scoring system can be utilized to help select appropriate interventions and therapy for patients with pancreatic cancer."
Predicting Unresectability in Pancreatic Cancer Patients: The Additive Effects of CT and Endoscopic Ultrasound
Yovino S et al.
J Gastrointest Surg (2007) 11:36-42
- "Arterial dominant phase CT is useful for detecting invasive carcinoma derived from IPMNs and is an effective followup method."
Invasive Carcinomas Derived From Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Long term Follow-up Assessment with CT Imaging
Yamada Y et al.
J Comput Assist Tomogr 2006;30:885-890
- IPMN
- 1. IPMN Adenoma
- 2. IPMN Borderline
- 3. IPMN Carcinoma in situ
- 4. IPMN Invasive carcinoma
- A. Colloid Carcinoma-Muc 2
- B. Ductal Carcinoma- Muc 1
- Intraductal Papillary Mucinous Neoplasm
- 1.Proliferation of mucinous epithelial cells lining pancreatic ducts- arranged in papillary patterns.
- 2. Intraluminal accumulation of mucin and cystic dilatation of ducts.
- 3. Spectrum of architectural atypia from benign to malignant.
- IPMN
- 4. 1/3 of cases associated with invasive carcinoma.
- 5. Communicate with pancreatic duct, ( unlike MCN ).
- 6. No ovarian stroma.
- 7. Mucin may be seen pouring into duodenum from patulous orifice of pancreatic duct.
- - 1.Proliferation of mucinous epithelial cells lining pancreatic ducts- arranged in papillary patterns.
- 2. Intraluminal accumulation of mucin and cystic dilatation of ducts.
- 3. Spectrum of architectural atypia from benign to malignant.
- Guidelines
- 1. Asymptomatic cystic lesions without main duct dilatation [> 6 mm], those without mural nodules, and those < 30 mm in size have a low risk of progressing to invasive cancer in near-term [ 12 –to 36 month] followup.
- 2. Yearly followup if lesion is <10 mm in size. 6-12 month follow-up for lesions 10-20 mm. 3-6 month followup for lesions >20 mm.
- 3. Interval can be lengthened after 2 yrs of no change
- 4. Appearance of sx attributable to the cyst [eg pancreatitis], presence of intramural nodules, cyst size > 30 mm, or dilatation of pancreatic duct >6mm are indications for resection.
- Question #3 - Are there any endorsed criteria for conservative follow-up of a cystic pancreatic lesion?
- Tanaka M et al. International Consensus Guidelines for Management of Intraductal Papillary Mucinous Neoplasms and Mucinous Cystic Neoplasms of the Pancreas. Pancreatology 2006; 6:17-32.
- Consensus of the Working Group of the International Association of Pancreatology.
- Conclusions from recent studies
- Commonest small cysts are MCN, IPMN, and serous.
- Very few pseudocysts in absense of pancreatitis.
- Fewer than 5% of incidentally detected pancreatic cysts <2cm are malignant.
- Patient’s choice: Follow, Bx under US, surgery.
- General consensus:
- 1. Under 2 cm observe.
- 2. >2cm Young and middle-aged resect.
- 3. >2cm older and less fit. Endoscopic US with fine needle aspiration, [ 40-50% sensitivity, 99+% specificity ]. Resect if mucin, high CEA, mucinous epithelium, malignant cells, or neuroendocrine cells.
- The natural history of the incidentally discovered small simple pancreatic cyst; long term follow-up and clinical implications
- Handrich SJ et al. AJR 2005; 184: 20-23. Mayo Clinic.
- <2.0 cm cysts dx by sonography or CT 1985-1996.
- 79 pts. 49 adequate follow-up.
- 13 [ 59% ] no change or smaller. Mean size 8 mm, mean follow-up 9 years.
- 9 [ 415 ] enlarged. Mean 14 mm to 26 mm. Mean follow-up 8 years. One pt operated on- pseudocyst.
- 27 clinical follow-up or response to questionaire. Mean follow-up 10 years. None developed pancreatic disease.
- 18 patients died. No suggestion of pancreatic disease.
- 12 patients lost to follow-up.
- Pancreatic cysts 3 cm or smaller: How aggressive should treatment be?
- Sahani DV et al Radiology 2006; 238: 912-919. Mass General
- 510 pts with cysts 1998-2004. 122 pancreatitis excld. 313/388 {80.6%} <3cm.
- 86 patients in study with adequate data. Aged 24-89 years.
- 48 surgery vs 38 non surgical.
- 75 benign, 8 borderline malignant, 3 ca in situ.
- Results of surgery: 37 benign MCN 13, IPMN side branch 14, serous 3, pseudocyst, cystic neuroendocrine 2, lymphoepithelial cyst 1, unclass 2 11 malignant
- 8 borderline : 6 side-branch, 2 MCN. 3 ca in situ: 2 side-branch, 1 MCN.
- 38 pts followed, all had US bx -1 later developed side-branch IMN with ca in situ.
- Cystic pancreatic neoplasms- Observe or operate?
- Spinnelli KS et al. Annals of Surgery 2004; 239: 651-659. U.Wisconsin. 1995-2002.
- 290 cysts 1.2%. 132 hx pancreatitis thus, 168, 0.7% incidence of presumed neoplastic cysts.
- 79 patients followed -16 months mean.
- 15 increased in size [ 19% ]
- 47 no change in size [ 59% ]
- 17 decrease in size [ 22% ]
- 49 had surgery
- 14 benign 10 serous, 2 SPEN, 1 lymphoep, 1 simple cyst
- 25 premalignant 16 MCN, 5 IPMn, 4 cystic neuroendocrine
- 10 malignant 7 IPMN with Ca, 3 MCN
- Recommend surgery if symptomatic, increasing, or fit older pts, since 60% of cysts in pts over 60 were malignant.
- "Pathologic analysis revealed carcinoma in situ in seven patients (19%) and invasive carcinoma in 15 patients (42%) arising from the IPMN. With invasive carcinoma, the size of the tumor in branch duct type and combined type, and the caliber of the main pancreatic duct were significantly larger compared with the lesions without invasive carcinoma (4.7 +/- 1.7 cm vs 2.6 +/- 1.4 cm [p = 0.0007] and 9.3 +/- 5.5 mm vs 4.6 +/- 4.1 mm [p = 0.006], respectively)."
MDCT of intraductal papillary mucinous neoplasm of the pancreas: evaluation of features predictive of invasive carcinoma
Kawamoto S et al.
AJR 2006 March;186(3):687-695.
- "The use of high resolution axial, multiplanar reformatted, and three dimensional reformatted images as demonstrated by Kawamoto et al using 16 slice MDCT improves diagnostic performance and enables depiction of the connection between the cystic lesions of IPMN and the pancreatic duct."
Stoupis C (commentary)
RadioGraphics 2005; 25:1468-1470
- Intraductal Papillary Mucinous Neoplasms of the Pancreas
- Dilated main pancreatic duct
- Diffuse or multifocal involvement
- Presence of a large mural nodule or a solid mass
- Large size of the mass
- Obstruction of the common bile duct
- Intraductal Papillary Mucinous Tumor (IPMN): Facts
- Equal frequency men and woman
- Usually detected in 6th and 7th decade
- Commonly associated with dilated pancreatic duct
- Lesions may be multiple and variable in size
- Intraductal Papillary Mucinous Tumor (IPMN): Facts
- Initially referred to as mucin producing pancreatic neoplasms
- May be incidental finding or patients present with pancreatitis like symptoms
- Up to 60% occur in the head/uncinate process
- Cystic Endocrine Tumors
- Insulinomas
- Gastrinomas
- Glucagonomas
- Non-functioning tumors
- IPMN: facts
- Main or side branch duct dilatation common
- Most common in uncinate
- Can be multiple throughout the pancreatic gland
- "The use of high resolution axial, multiplanar reformatted, and three dimensional reformatted images as demonstrated by Kawamoto et al using 16 slice MDCT improves diagnostic performance and enables depiction of the connection between the cystic lesions of IPMN and the pancreatic duct."
Stoupis C (commentary)
RadioGraphics 2005; 25:1468-1470
- Intraductal Papillary Mucinous Neoplasms of the Pancreas
- Dilated main pancreatic duct
- Diffuse or multifocal involvement
- Presence of a large mural nodule or a solid mass
- Large size of the mass
- Obstruction of the common bile duct
- "Preoperative multidetector CT can help predict the presence of invasive carcinoma associated with IPMN."
Intraductal Papillary Mucinous Neoplasm of the Pancreas: Can Benign Lesions Be Differentiated from Malignant Lesions with MDCT?
Kawamoto S, Horton KM, Lawler LP, Hruban RH, Fishman EK
RadioGraphics 2005; 25:1451-1470