Pancreatic cystic lesions in diabetes mellitus patients.

INTRODUCTION: According to the literature exocrine pancreatic insufficiency is relatively common among patients with diabetes mellitus (DM). Pseudocysts are the most common cystic lesions and may be formed in the setting of acute or chronic pancreatitis. However, whether DM is involved or not in pancreatic cyst formation is still not well established. AIM: To investigate the frequency and risk factors of cystic lesions in diabetic patients. MATERIAL AND METHODS: One hundred and sixty-one patients with DM, with no previous history of pancreatic diseases, were prospectively included in the study. Endosonography followed by fine needle aspiration biopsy was then performed. RESULTS: Finally, 33 of 161 patients (20.5%) were recognized with cystic lesions of the pancreas. Among them 5 patients were classified as cystic neoplasms, and 28 as pseudocysts. In the group of patients with pseudocysts, cystic lesions were significantly more prevalent in individuals with DM lasting less than 3 years. Prevalence of cystic lesions was significantly higher in metformin users in comparison to other diabetic patients (p < 0.05). Cystic lesions were more frequent in patients above 50 years of age (p < 0.05). CONCLUSIONS: The prevalence of cystic lesions in the diabetic population is higher than in the general population. DM seems to play a major role in the process of cyst development, especially in patients without previous history of pancreatitis. Higher prevalence of cystic lesions in early diabetes seems to be the first stage of pancreatic injury. The exact role of diabetes duration and type of treatment should be established.

Diagnostic and therapeutic recommendations in pancreatic ductal adenocarcinoma. Recommendations of the Working Group of the Polish Pancreatic Club.

These recommendations refer to the current management in pancreatic ductal adenocarcinoma (PDAC), a neoplasia characterised by an aggressive course and extremely poor prognosis. The recommendations regard diagnosis, surgical, adjuvant and palliative treatment, with consideration given to endoscopic and surgical methods. A vast majority of the statements are based on data obtained in clinical studies and experts' recommendations on PDAC management, including the following guidelines: International Association of Pancreatology/European Pancreatic Club (IAP/EPC), American Society of Clinical Oncology (ASCO), European Society for Medical Oncology (ESMO), National Comprehensive Cancer Network (NCCN) and Polish Society of Gastroenterology (PSG) and The National Institute for Health and Care Excellence (NICE). All recommendations were voted on by members of the Working Group of the Polish Pancreatic Club. Results of the voting and brief comments are provided with each recommendation.

Cystic fluid neutrophil gelatinase-associated lipocalin (NGAL) concentration in differential diagnosis of pancreatic cystic lesions: a new factor enters the scene?

INTRODUCTION: Neutrophil gelatinase-associated lipocalin - 25 kDa peptide - is at present one of the most fascinating and unrecognised proteins implicated in the process of tumour development. Precise assessment of pancreatic cystic lesions is crucial for selecting available treatment options, such as conservative therapy or surgical resection. AIM: To determine the utility of NGAL concentration in cyst fluid obtained by endoscopic ultrasound (EUS) with EUS-guided fine-needle aspiration (EUS-FNA) to distinguish neoplastic pancreatic cysts from pseudocysts. MATERIAL AND METHODS: Twenty-two patients underwent EUS and FNA of a pancreatic cystic lesion; 9 of these patients underwent surgical resection, providing a histologic diagnosis of the cystic lesion. Furthermore, the final diagnosis was based on cyst fluid cytology, cyst fluid tumour markers (CEA, CA 72-4, CA 19-9), and medical history. Patients were divided in two groups: cystic neoplasms and inflammatory cysts (pseudocysts). RESULTS: The final diagnosis was pseudocyst in 7 patients, serous cystadenoma in 4, mucinous cystadenoma in 3, intraductal papillary mucinous neoplasms in 6 patients, and cystic form of pancreatic adenocarcinoma in 2. Cyst fluid analysis of these patients showed that median cyst fluid NGAL for the cystic neoplasm group (211 ng/ml; n = 15) was significantly lower (p = 0.02) than the inflammatory cystic group (4689 ng/ml; n = 7). Correlation analysis showed that only fluid CA 72-4 was positively related to NGAL (r = 0.8, p < 0.01). CONCLUSIONS: In this single-centre study, pancreatic cyst fluid NGAL concentration appeared to be useful in distinguishing neoplastic pancreatic cysts from pseudocysts. Larger studies are recommended to evaluate this role further.

Pancreatic cyst fluid analysis for differential diagnosis between benign and malignant lesions.

The majority of pancreatic cysts are detected incidentally when abdominal imaging is performed during unrelated procedures. The aim of the present study was to assess the diagnostic utility and clinical value of carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9) and amylase analysis in pancreatic cyst fluid. The study included 52 patients with pancreatic cystic lesions, who underwent fine-needle aspiration biopsy to collect cystic fluid for cytological and biochemical analysis. Cysts were classified as benign (simple cysts, pseudocysts and serous cystadenomas) in 36 patients or premalignant/malignant (mucinous cyst-adenomas, intraductal papillary mucinous neoplasm and cystadenocarcinomas) in 16 patients. CEA and CA 19-9 were elevated in patients with malignant cysts (238±12.5 ng/ml and 222±31.5 U/ml, respectively) compared with benign lesions (34.5±3.7 ng/ml and 18.5±1.9 U/ml, respectively; P<0.001). Based on these results, the sensitivity and specificity of CEA were 91.8 and 63.9% and of CA 19-9 were 81.3 and 69.4%, respectively. Mean amylase levels in benign lesions (27825.7±91.9 U/l) were higher compared with malignant pancreatic cysts (8359.2±32.7 U/l; P<0.05). Cyst fluid analysis may prove a safe and useful adjunct for the differential diagnosis of pancreatic cystic lesions. In the present study, promising results for CEA and CA 19-9 have been demonstrated, however, the clinical value of these molecules must be confirmed.

A comparative analysis of K-ras mutation and carcinoembryonic antigen in pancreatic cyst fluid.

BACKGROUND/AIMS: Analysis of cystic fluid may be useful in distinguishing between benign and malignant cysts which has significant impact on their management. The aim of our study was to assess the diagnostic utility of carcinoembryonic antigen (CEA) and K-ras gene mutation in pancreatic cysts fluid. METHODS: The study included 56 patients with pancreatic cystic fluid collected for analysis. The cysts were classified as benign (simple cysts, pseudocysts, serous cystadenoma) - 39 patients or premalignant/malignant (mucinous cystadenoma, IPMN, cystadenocarcinoma) - 17 patients. The patients history, CEA fluid concentrations and presence of K-ras mutation were analyzed. RESULTS: CEA were higher in patients with malignant cysts (mean levels 238 ± 12.5 ng/ml; range 32.8-4985 ng/ml) compared to benign lesions (mean levels 34.5 ± 3.7 ng/ml; range 3.9-693 ng/ml; p < 0.001). K-ras mutation correctly classified 11 of 17 patients with premalignant/malignant lesions. It was also detected in 1 patient with final diagnosis of benign cyst (the sensitivity 64.7% and the specificity 97.4%; p < 0.01). If CEA and molecular analysis were combined in that cysts with either CEA level>45 ng/ml or presence of K-ras mutation, than 16 of 17 premalignant/malignant cysts were correctly identified (94.1%). CONCLUSION: Molecular analysis of pancreatic cyst fluid adds diagnostic value to the preoperative diagnosis and should be considered when cyst cytologic examination is negative for malignancy.

[Antibiotic prophylaxis in acute pancreatitis]. / Antybiotykoterapia w ostrym zapaleniu trzustki.

In most patients, acute pancreatitis (AP) is a mild self-limiting disease, however for about 20% patients with clinically severe acute pancreatitis it is a live treating disease with 30% mortality. Mortality increases in patient with sterile necrosis and especially when infection has occurred. Prevention and optimal treatment of infection in AP have become a principal therapeutic target for improving the outcome of this disease. Several controlled clinical trials, often controversial, demonstrated a significant reduction of hospital mortality. In this article, we review the current opinion of the antibiotics treatment in AP.

N-acetylcysteine does not prevent post-endoscopic retrograde cholangiopancreatography hyperamylasemia and acute pancreatitis.

AIM: Acute pancreatitis (AP) is the most common and often severe complication of endoscopic retrograde cholangiopancreatography (ERCP). The early step in the pathogenesis of acute pancreatitis is probably the capillary endothelial injury mediated by oxygen-derived free radicals. N-acetylcysteine - a free radical scavenger may be potentially effective in preventing post-ERCP acute pancreatitis and it is also known that N-acetylcysteine (ACC) can reduce the severity of disease in experimental model of AP. METHODS: One hundred and six patients were randomly allocated to two groups. Fifty-five patients were given N-acetylcysteine (two 600 mg doses orally 24 and 12 h before ERCP and 600 mg was given iv, twice a day for two days after the ERCP). The control group consisted of 51 patients who were given iv. isotonic saline twice a day for two days after the ERCP. Serum and urine amylase activities were measured before ERCP and 8 and 24 h after the procedure. The primary outcome parameter was post-ERCP acute pancreatitis and the secondary outcome parameters were differences between groups in serum and urine amylase activity. RESULTS: There were no significant differences in the rate of post-ERCP pancreatitis between two groups (10 patients overall, 4 in the ACC group and 6 in the control group). There were also no significant differences in baseline and post-ERCP serum and urine amylase activity between ACC group and control group. CONCLUSION: N-acetylcysteine fails to demonstrate any significant preventive effect on post-ERCP pancreatitis, as well as on serum and urine amylase activity.