Classification of pancreatic cystic neoplasms using radiomic feature analysis is equivalent to an experienced academic radiologist: a step toward computer-augmented diagnostics for radiologists.

PURPOSE: A wide array of benign and malignant lesions of the pancreas can be cystic and these cystic lesions can have overlapping imaging appearances. The purpose of this study is to compare the diagnostic accuracy of a radiomics-based pancreatic cyst classifier to an experienced academic radiologist. METHODS: In this IRB-approved retrospective single-institution study, patients with surgically resected pancreatic cysts who underwent preoperative abdominal CT from 2003 to 2016 were identified. Pancreatic cyst(s) and background pancreas were manually segmented, and 488 radiomics features were extracted. Random forest classification based on radiomics features, age, and gender was evaluated with fourfold cross-validation. An academic radiologist blinded to the final pathologic diagnosis reviewed each case and provided the most likely diagnosis. RESULTS: 214 patients were included (64 intraductal papillary mucinous neoplasms, 33 mucinous cystic neoplasms, 60 serous cystadenomas, 24 solid pseudopapillary neoplasms, and 33 cystic neuroendocrine tumors). The radiomics-based machine learning approach showed AUC of 0.940 in pancreatic cyst classification, compared with AUC of 0.895 for the radiologist. CONCLUSION: Radiomics-based machine learning achieved equivalent performance as an experienced academic radiologist in the classification of pancreatic cysts. The high diagnostic accuracy can potentially maximize the efficiency of healthcare utilization by maximizing detection of high-risk lesions.

Endoscopic Ultrasound-Guided Ablation of Focal Pancreatic Lesions: The GRUPUGE Perspective.

Focal pancreatic lesions include a heterogeneous group of solid and cystic lesions, with different natures and variable clinical, imagiological, and pathological characteristics. Several endoscopic ultrasound (EUS)-guided ablative techniques have been tested during the last decade for the treatment of these pancreatic lesions, mostly consisting of the injection of ablative agents and, more recently, radiofrequency ablation. The most encouraging EUS-guided ablation outcomes are being reached in the treatment of some pancreatic cystic neoplasms and small (≤2 cm) pancreatic neuroendocrine tumours (pNETs). Data supporting a potential role of ablative therapies in the treatment of pancreatic ductal adenocarcinoma is still lacking. In this article, GRUPUGE presents an updated perspective of the potential role of EUS-guided ablation for the treatment of pancreatic cystic neoplasms and pNETs, addressing the selection criteria and technical issues of different techniques and analysing recent data on their safety and efficacy.

As lesões focais do pâncreas integram grupos heterogéneos de lesões sólidas e quísticas, de diferentes naturezas e com características clínicas, imagiológicas e patológicas variáveis. Na última década foram avaliadas diversas técnicas ablativas guiadas por ecoendoscopia para o tratamento destas lesões pancreáticas focais, consistindo maioritariamente na injeção de agentes ablativos e, mais recentemente, na ablação por radiofrequência. Os resultados mais promissores das técnicas ablativas guiadas por ecoendoscopia têm surgido no tratamento de algumas lesões quísticas do pâncreas e pequenos tumores neuro-endócrinos pancreáticos (≤2 cm). Ainda existem poucos dados a suportar um potencial papel das terapêuticas ablativas no tratamento do adenocarcinoma ductal do pancreas. No presente artigo o GRUPUGE apresentada uma perspectiva atual do potencial papel da ablação guiada por ecoendoscopia no tratamento de neoplasias quísticas do pâncreas e de tumores neuro-endócrinos pancreáticos, focando aspectos relativos à seleção dos doentes, questões técnicas dos vários procedimentos disponíveis e analisando dados recentes relativos à sua segurança e eficácia.

Pancreatic Cystic Lesions: Pathogenesis and Malignant Potential.

Pancreatic cancer remains one of the most lethal cancers despite extensive research. Further understanding of precursor lesions may enhance the ability to treat and prevent pancreatic cancer. Pancreatic cystic lesions (PCLs) with malignant potential include: mucinous PCLs (intraductal papillary mucinous neoplasms and mucinous cystic neoplasm), solid pseudopapillary tumors and cystic neuroendocrine tumors. This review summarizes the latest literature describing what is known about the pathogenesis and malignant potential of these PCLs, including unique epidemiological, radiological, histological, genetic and molecular characteristics.

Insights into the Pathogenesis of Pancreatic Cystic Neoplasms.

With the current epidemic of diagnosed pancreatic cystic neoplasms on the rise, a substantial amount of work has been done to unravel their biology, thus leading to implications on clinical decision making. Recent genetic profiling of resected human specimens has identified alterations in signaling pathways involving KRAS and GNAS signaling as early events in the pathogenesis of intraductal pancreatic mucinous neoplasms. Progressively, mutations in genes such as TP53, SMAD4, RNF43, and others are thought to characterize invasive and advanced lesions. The role of inflammation in fueling the growth and transformation of these cysts has also begun to be studied with greater interest. A number of promising clinical studies have attempted to integrate these genetic insights into classifying these cysts and treating patients. We have reviewed existing literature on similar lines besides commenting on some useful animal models that recapitulate molecular and phenotypic progression of these cysts.

Pancreas divisum: A risk factor for pancreaticobiliary tumors - an analysis of 1628 MR cholangiography examinations.

PURPOSE: This retrospective study was conducted to evaluate the relationships between pancreas divisum, biliary duct anatomical variations and pancreaticobiliary tumors using magnetic resonance cholangiopancreatography (MRCP). MATERIALS AND METHOD: The MRCP examinations of 1628 patients were retrospectively reviewed for the presence of pancreas divisum, biliary duct anatomical variations and pancreaticobiliary tumors. Of these, 90 patients (31 men, 59 women) with a mean age of 62.6 years±15.8 (SD) (range: 22-101 years) had pancreas divisum. MRCP images were analyzed by two independent readers with discordances resolved by consensus opinion. RESULTS: A total of 1538/1628 patients (94.5%) had a dominant duct of Wirsung; of them 54/1538 patients (3.5%) had pancreaticobiliary tumors. A total of 90/1628 patients had pancreas divisum; of them, 7/90 patients (7.8%) had pancreaticobiliary tumors, including intrapancreatic mucinous neoplasm (n=3), ampullary carcinoma (n=2), pancreas carcinoma and gallbladder carcinoma (n=1 each). Pancreaticobiliary tumors were more frequent in patients with pancreas divisum than in those with a dominant duct of Wirsung (P=0.0383). CONCLUSIONS: The results of our study suggest that patients with pancreas divisum and biliary anatomical variations are more likely to develop pancreaticobiliary tumors and should be followed up closely using MRCP. However, our results should be confirmed by further prospective studies.

Imaging of the Pancreas.

The evaluation of pancreatic lesions, from solid pancreatic masses to pancreatic cysts, remains a clinical challenge. Although cross-sectional imaging remains the cornerstone of the initial evaluation of an indeterminate pancreatic lesion, advances in imaging with the advent of endoscopic ultrasound scan, elastography, contrast-enhanced endoscopic ultrasound scan, and probe-based confocal laser endomicroscopy have allowed us to visualize the pancreas in even higher resolution and diagnose premalignant and malignant lesions of the pancreas with improved accuracy. This report reviews the range of imaging tools currently available to evaluate pancreatic lesions, from solid tumors to pancreatic cysts.

Full laparoscopic total pancreatectomy with and without spleen and pylorus preservation: a feasibility report.

BACKGROUND/PURPOSE: Laparoscopic pancreatic surgery is gaining acceptance and clear advantages have been demonstrated in distal resection. Total pancreaticoduodenectomy (TPD) combines the operative steps of distal pancreatectomy and pancreaticoduodenectomy, but facilitates reconstruction and lowers the risk of common complications by avoiding the need for a pancreatic anastomosis. The aim of this report is to analyse the feasibility of laparoscopic total pancreaticoduodenectomy, with and without spleen and pylorus preservation. METHODS: Two patients underwent laparoscopic TPD for pancreatic intraductal mucinous neoplasm and endocrine tumors. Total splenopancreaticoduodenectomy (TSP) and pylorus- and spleen-preserving total pancreaticoduodenectomy (PSPTP) were performed. RESULTS: The two procedures were successfully completed laparoscopically. PSPTP was more time-consuming (420 vs. 360 min) and had an increased risk of hemorrhage (600 vs. 200 ml) compared with TSP. After both procedures, the postoperative outcome was uneventful and the postoperative length of hospital stay was 8 days. CONCLUSIONS: This report confirms the feasibility of full laparoscopic TPD, and presents the first full laparoscopic pylorus- and spleen-preservation technique with conservation of the splenic vessels, without robotic assistance. No conclusions can be drawn from this report, but it shows that the laparoscopic approach provides visual magnification, improved exposure, and delicate manipulation of tissues, which may reproduce the clear advantages of laparoscopic distal pancreatectomy.

Ethanol Lavage Therapy to Prevent Recurrent Pancreatitis in a Patient with Pancreatic Mucinous Neoplasm / 대한내과학회지

An 88-year-old woman diagnosed with recurrent pancreatitis and pancreatic cyst at a local clinic was admitted for upper abdominal pain. The pain was aggravated after a meal, and the patient had lost 3 kg over the past 6 months. MRCP examination revealed a 68 mm-sized septated pancreatic cyst compressing the main pancreatic duct. EUS-FNA to differentiate the cystic component retrieved a high viscosity fluid. A diagnosis of mucin-producing pancreatic cystic neoplasm was made. The patient refused surgical treatment, and alternative treatments, including methods to decompress the pancreatic cyst, were performed. The patient was treated with aspiration of cystic fluid, observation with diet control, and 99% ethanol lavage to ablate the pancreatic cyst. The treatment of 99% ethanol lavage provided the longest symptom-free period, ranging from 7 to 18 months without complications. The authors report that repeated ethanol lavage of a pancreatic cyst causing recurrent pancreatitis can be an effective treatment option for patients who are poor surgical candidates.

Ethanol Lavage Therapy to Prevent Recurrent Pancreatitis in a Patient with Pancreatic Mucinous Neoplasm / 대한내과학회지

An 88-year-old woman diagnosed with recurrent pancreatitis and pancreatic cyst at a local clinic was admitted for upper abdominal pain. The pain was aggravated after a meal, and the patient had lost 3 kg over the past 6 months. MRCP examination revealed a 68 mm-sized septated pancreatic cyst compressing the main pancreatic duct. EUS-FNA to differentiate the cystic component retrieved a high viscosity fluid. A diagnosis of mucin-producing pancreatic cystic neoplasm was made. The patient refused surgical treatment, and alternative treatments, including methods to decompress the pancreatic cyst, were performed. The patient was treated with aspiration of cystic fluid, observation with diet control, and 99% ethanol lavage to ablate the pancreatic cyst. The treatment of 99% ethanol lavage provided the longest symptom-free period, ranging from 7 to 18 months without complications. The authors report that repeated ethanol lavage of a pancreatic cyst causing recurrent pancreatitis can be an effective treatment option for patients who are poor surgical candidates.