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Invasive carcinoma (colloid carcinoma) arising from IPMN. Photomicrograph (original magnification , 100; hematoxylin-eosin stain) of a surgical specimen shows well-defined pools of mucin embedded in the stroma of the gland, with malignant epithelial cells floating within the mucin in clusters.
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Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a distinct clinicopathologic entity that is being recognized with increasing frequency. In 25%-44% of IPMNs treated with surgical resection, associated invasive carcinoma has been reported. Surgical resection is the treatment of choice for most IPMNs. Preoperative determination of th...
Context in source publication
Context 1
... invasive, an IPMN may be called papillary mucinous carcinoma since it is no longer only intraductal. Approximately half of the invasive carcinomas associated with IPMNs are colloid (mucinous noncystic) carcinomas (Fig 3), and most of the remainder are conventional tubular adenocarci- nomas (23,26,27). IPMNs with an associated colloid type invasive carcinoma have a better prognosis than do IPMNs with an associated tubular type invasive carcinoma (2,26). ...
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Endoscopic ultrasound (EUS), with or without fine needle aspiration (FNA), has become an essential tool in the evaluation of pancreatobiliary diseases. Although conventional EUS is superior to multidetector computed tomography in tumor detection and staging, there are situations when characterization of various pancreatobiliary lesions remains diff...
Citations
... The clinical, pathological, and radiological characteristics of IPMN have been investigated extensively during the past years. With recent improvements in imaging techniques, pancreatic intraductal lesions, especially IPMN, are being detected with increasing frequency [6][7][8][9][10] . By contrast, there is limited knowledge on ITPN as precancerous lesions and on the invasive carcinoma arising from ITPN. ...
Intraductal tubulopapillary neoplasms (ITPN) are rare pancreatic tumors (< 1% of exocrine neoplasms) and are considered to have better prognosis than classical pancreatic ductal adenocarcinoma (PDAC). The present study aimed to evaluate imaging features of ITPN in computed tomography (CT) and magnetic resonance (MR) imaging. We performed monocentric retrospective analysis of 14 patients with histopathologically verified ITPN, operated in 2003–2018. Images were available for 12 patients and were analysed independently by two radiologists, blinded to reports. Imaging features were compared to a matched control group consisting of 43 patients with PDAC, matched for sex and age. Histopathologic analysis showed invasive carcinoma component in all ITPN patients. CT-attenuation values of ITPN were higher in arterial and venous phases (62.3 ± 14.6 HU and 68 ± 15.6 HU) than in unenhanced phase (39.2 ± 7.9 HU), compatible with solid lesion enhancement. Compared to PDAC, ITPN lesions had significantly higher HU-values in both arterial and venous phases (arterial and venous phases, p < 0.001). ITPN were significantly larger than PDAC (4.1 ± 2.0 cm versus 2.6 ± 0.84 cm, p = 0.021). ITPN lesions were more often well-circumscribed (p < 0.002). Employing a multiple logistic regression analysis with forward stepwise method, higher HU density in the arterial phase (p = 0.012) and well-circumscribed lesion margins (p = 0.047) were found to be significant predictors of ITPN versus PDAC. Our study identified key imaging features for differentiation of ITPN and PDAC. Isodensity or moderate hypodensity and well-circumscribed margins favor the diagnosis of ITPN over PDAC. Being familiar with CT-features of these rare pancreatic tumors is essential for radiologists to accelerate the diagnosis and narrow the differentials.
... When MPD diameter is larger than 5 mm, either diffusely or segmentally, without an obstructing stone, mass, acute or chronic pancreatitis, or prior trauma, a diagnosis of main duct IPMN should be considered [5,27]. Diffuse dilatation of the MPD to the level of the major papilla and protrusion of the major papilla into the duodenum are virtually diagnostic of main duct IPMN, corresponding to the mucin-extruding "fish mouth" papilla seen on endoscopy [31,32]. Main duct wall thickening, enhancement, and internal enhancing solid components should be described if seen on imaging because they are signs of more aggressive biology such as high-grade dysplasia or invasive carcinoma [33] (Fig. 1). ...
Radiomics is the process of extraction of high-throughput quantitative imaging features from medical images. These features represent non-invasive quantitative biomarkers that go beyond the traditional imaging features visible to the human eye. This article first reviews the steps of the radiomics pipeline, including image acquisition, ROI selection and image segmentation, image preprocessing, feature extraction, feature selection, and model development and application. Current evidence for the application of radiomics in abdominopelvic solid-organ cancers is then reviewed. Applications including diagnosis, subtype determination, treatment response assessment, and outcome prediction are explored within the context of hepatocellular and pancreatic cancer, renal cell carcinoma, prostate cancer, gynecologic cancer, and adrenal masses. This literature summary focuses on the strongest available evidence, including systematic reviews, meta-analyses, and large multicenter studies. Limitations of the available literature are highlighted, including marked heterogeneity in radiomics methodology, frequent use of small sample sizes with high risk of overfitting, as well as lack of prospective design, external validation, and standardized radiomics workflow. Thus, while studies have laid a foundation that supports continued investigation into radiomic models, stronger evidence is needed before clinical adoption.
... Up to 40% of surgically resected IPMNs with invasive carcinoma will recur within 12 months, and the reported associated 5-year survival rate is 36%. The most common sites for recurrence are other sites in the pancreas and distant metastases (including the liver and lymph nodes) (49,50). ...
The widespread use of high-spatial-resolution cross-sectional imaging has led to an increase in detection of incidental pancreatic cystic lesions. These lesions are a diverse group, ranging from indolent and premalignant lesions to invasive cancers. The diagnosis of several of these lesions can be suggested on the basis of their imaging appearance, while many other lesions require follow-up imaging and/or aspiration. The smaller cystic lesions, often branch-duct intraductal papillary mucinous neoplasms, have overlapping imaging characteristics that make diagnostic assessment of the natural history and malignancy risk confusing. Expert panels have developed societal guidelines, based on a consensus, for surveillance of these lesions. However, these guidelines are often inconsistent and are constantly evolving as additional scientific data are accumulated. Identification of features associated with increased risk of malignancy is important for proper management. The concept of field defect, whereby pancreatic adenocarcinoma develops at a site different from the site of the pancreatic cyst, adds to the complexity of screening guidelines. As a result of the differences in guidelines, key stakeholders (eg, radiologists, gastroenterologists, and surgeons) must review and come to a consensus regarding which guideline, or combination of guidelines, to follow at their individual institutions. Standardized reporting and macros are helpful for ensuring the uniformity of interpretations. Radiologists play a critical role in the detection and characterization of pancreatic cystic lesions, in the follow-up recommendations for these lesions, and in the detection of associated cancer. An invited commentary by Zaheer is available online. Online supplemental material is available for this article. ©RSNA, 2021.
... IPMC indicates progression from its precursor IPMN to invasive adenocarcinoma, which is similar to the usually seen PDAC not arising in association with an IPMN. Imaging features favoring IPMC include complicated tubular cystic mass with predominantly intraductal enhancing mural nodules, dilation of the upstream and downstream pancreatic duct, and communication between cystic mass and the main pancreatic duct [20,21]. ...
Pancreatic ductal adenocarcinomas (PDACs) occasionally have atypical and uncommon imaging presentations that can present a diagnostic dilemma and result in false interpretation. This article aimed to illustrate these CT and MR imaging findings, including isoattenuating PDAC, coexisting acute pancreatitis, PDAC with a cystic feature, groove PDAC, diffuse PDAC, hypointensity on diffusion-weighted imaging (DWI), multifocal PDAC, intratumoral calcification, and extrapancreatic invasion with a barely discernable mass. A subset of PDACs with atypical features are occasionally encountered during routine clinical practice. Knowledge of and attention to these atypical and uncommon variable imaging features may allow radiologists to avoid misinterpretation and a delayed diagnosis.
... MCNs, IPMN and SCNs are said to display differences when examined by imaging modalities. However, the performance characteristics of high-resolution computed tomography (CT) scanning in making these distinctions are suboptimal, and its main role is, therefore, to determine the extent of any malignant spread [5,6]. ...
Background: The diagnosis and management of cystic lesions of the pancreas is an increasingly recognized problem in clinical practice and many of the cystic pancreatic lesions are neoplastic and asymptomatic. Despite the significant advances occurred over the last decades, it remains difficulty to accurately distinguish between benign (serous cystic lesions) and malignant or potentially malignant (mucinous cystic lesions) pancreatic cysts before resecting them. Mucinous cystic neoplasms (MCNs), intrapapillary mucinous neoplasms (IPMN) and serous cystic neoplasms (SCNs) can display differences when examined by imaging modalities, endoscopic ultrasonography (EUS) and cytological and biochemical analyses of cyst fluid. The performance characteristics of high-resolution computed tomography (CT) scanning and magnetic resonance imaging (MRI) in making these distinctions are, however, disappointing. The aim of this study is to evaluate the role of endoscopic ultrasound guided fine needle aspiration (FNA) in diagnosis of cystic pancreatic lesions and its accuracy in discrimination between benign, malignant and potentially malignant cysts. Methods: The study was organized as a prospective study and conducted over 51 patients with identified cystic pancreatic lesions from prior radiological imaging (CT or MRI). Results: EUS guided FNA has shown superior sensitivity, specificity, positive predictive value and negative predictive value in comparison to EUS alone in discriminating mucinous from non-mucinous cysts. This difference was remarkable specially for malignant cysts (mucinous cystadenocarcinoma, adenocarcinoma) and cystic lymphangioma. EUS-FNA associated with chemical and physical analysis of cyst fluid was 100% sensitive and specific. Cyst fluid CEA revealed significant importance in differentiating mucinous from non mucinous cysts. Cyst fluid amylase was significantly high in pseudocysts while mucin stain was important to discriminate mucinous from non-mucinous cystic lesions. Conclusion: EUS-FNA has proven greater sensitivity and specificity, positive predictive, negative predictive value in differentiating mucinous and non-mucinous pancreatic cystic lesions as well as pathological categorization into subtypes.
... The American Gastroenterological Association and the International Association of Pancreatology have described the high-risk radiological futures of IPMN [72,83], and the resection of branch-duct IPMN is performed based on these guidelines [72,73,82]. Mural nodules may be the most predictive finding of high-grade IPMN and IPMC [83][84][85] and can be detected by existing radiological imaging modalities, such as enhanced computed tomography (CT), magnetic resonance imaging (MRI), and endoscopic ultrasound (EUS) [73,[86][87][88]. The diagnostic sensitivity and specificity of mural nodules 5-10 mm in diameter in the context of IPMC and high-grade IPMN are 73-100% and 73-85%, respectively [89][90][91][92][93][94][95]. ...
Simple Summary
Pancreatic ductal adenocarcinoma (PDAC) is typically associated with an extremely poor prognosis; however, small PDAC tumors show good prognosis. High-grade pancreatic intra-epithelial neoplasia (PanIN), which precedes invasive PDAC, is a primary target for improving the prognosis of PDAC. However, detection of high-grade PanIN without invasive carcinoma by existing imaging modalities is difficult because the lesions are only microscopically detectable. Recent studies have reported the characteristics of imaging findings associated with localized high-grade PanIN and the usefulness of serial pancreatic-juice aspiration cytologic examination as a method to confirm the pre-operative histopathology. In this review, we aimed to clarify recent clinical findings regarding detection of localized high-grade PanIN, which may contribute to improvement of the prognosis of patients with PDAC.
Abstract
Pancreatic ductal adenocarcinoma (PDAC) arises from precursor lesions, such as pancreatic intra-epithelial neoplasia (PanIN) and intraductal papillary mucinous neoplasm (IPMN). The prognosis of high-grade precancerous lesions, including high-grade PanIN and high-grade IPMN, without invasive carcinoma is good, despite the overall poor prognosis of PDAC. High-grade PanIN, as a lesion preceding invasive PDAC, is therefore a primary target for intervention. However, detection of localized high-grade PanIN is difficult when using standard radiological approaches. Therefore, most studies of high-grade PanIN have been conducted using specimens that harbor invasive PDAC. Recently, imaging characteristics of high-grade PanIN have been revealed. Obstruction of the pancreatic duct due to high-grade PanIN may induce a loss of acinar cells replaced by fibrosis and lobular parenchymal atrophy. These changes and additional inflammation around the branch pancreatic ducts (BPDs) result in main pancreatic duct (MPD) stenosis, dilation, retention cysts (BPD dilation), focal pancreatic parenchymal atrophy, and/or hypoechoic changes around the MPD. These indirect imaging findings have become important clues for localized, high-grade PanIN detection. To obtain pre-operative histopathological confirmation of suspected cases, serial pancreatic-juice aspiration cytologic examination is effective. In this review, we outline current knowledge on imaging characteristics of high-grade PanIN.
... Congenital cysts, SCA, the macrocytic variant MCN, IPMN of the branch duct type, and tumors with cystic change-including solid pseudopapillary and neuroendocrine tumors-and PDAC may have macrocytic morphologic features that overlap on imaging despite having different malignant potential [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17]. Benign cysts, including congenital cysts and macrocytic SCA, can be clinically managed unless the lesions are symptomatic. ...
... Benign cysts, including congenital cysts and macrocytic SCA, can be clinically managed unless the lesions are symptomatic. Conversely, MCN and IPMN of the branch duct type and tumors with cystic change are premalignant or malignant and typically require surgical resection [3][4][5][6][7][8][9][10][11][12][13]. ...
... Additionally, size, shape, calcification, and dilation of the pancreatic duct help differentiate benign from malignant cystic neoplasms [5,11,12,16,29,30]. Lesion, location, age, and sex may also be helpful distinguishing features [9,7,69]. ...
Purpose
It is important to identify features on computed tomography (CT) that can distinguish between benign and premalignant or malignant pancreatic cysts to avoid unnecessary surgeries. This study investigated the preoperative diagnostic evaluation of cystic pancreatic lesions to determine how advanced imaging and clinical factors should guide management.
Methods
In total, 53 patients with 27 benign and 26 premalignant or malignant cysts were enrolled. CT features of the cysts were compared using univariate and multivariate analyses.
Results
On univariate analysis, a solid component (p < 0.01), septation (p < 0.01), location (p < 0.01), border (p < 0.01), wall enhancement (p = 0.01), lesion margins (p < 0.01), pancreatic atrophy (p = 0.04), and a cystic wall (p < 0.01) were all significantly different between benign and premalignant or malignant cysts. On multivariate analysis, only a solid component (p < 0.01) and septation (p < 0.01) were significant.
Conclusion
A thin cystic wall, uniform homogeneity, a clear border, the presence of septation, pancreatic atrophy, and the absence of both wall enhancements and solid components were more frequently seen in benign cysts. A thick wall, lack of homogeneity, the presence of wall enhancements and solid components, absence of septation, only a small degree of pancreatic atrophy, and unclear borders were more frequent among premalignant or malignant cysts. The only CT features to differentiate benign from premalignant or malignant cysts were a solid component and septation.
... Furthermore, some studies have reported that a marked dilatation of the MPD could be a major risk factor for malignancy. [25][26][27][28][29] In our series, we also observed that a MPD dilation ≥10 mm was a significant predictor for invasive carcinoma both in the univariable and multivariable analysis. ...
Background and objective:
The management of branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) is determined by a number of guidelines. The current weight of risk factors by EUS predicting invasive cancer is unknown. The aim of this study is to develop a risk score for early prediction of invasive cancer according to morphological characterization by EUS in a surgical cohort.
Materials and methods:
This is an observational, multicenter retrospective study. All consecutive patients with a histologically proven BD-IPMN who underwent previous EUS between 2005 and 2017 were included. Morphological features by EUS were evaluated. A score using a logistic regression model was performed to assess the risk of invasive cancer.
Results:
Of 335 patients who underwent pancreatic surgery, 131 (median age: 66 years, 50.4% - male) were included. By multivariable analysis, lymph nodes (odds ratio [OR]: 17.7 [confidence interval (CI) 95%: 2.8-112.6], P = 0.002, 4 points), main pancreatic duct ≥10 mm (OR: 8.6 [CI 95%: 1.9-39.5], P = 0.006, 2 points), abrupt change of pancreatic duct (OR: 5.5 [CI 95%: 1.4-22.2], P = 0.016, 1.5 points), and solid component (OR: 4.2 [CI 95%: 1.3-13.6], P = 0.017, 1 point) were independent factors associated with invasive cancer and included in the model. The following categories of the score (0-8.5 points) - A (0-1), B (1.5-3), C (3.5-5), and D (5.5-8.5 points) - presented a positive predictive value of 8.5%, 38.9%, 62.5%, and 100%, respectively. The area under the curve was 0.857 (P < 0.001), with an overall sensitivity and specificity of 84% and 70% in the internal validation of the score.
Conclusion:
This EUS predictive score for invasive cancer in BD-IPMN has a high accuracy and could be an additional tool to consider in patient management.
... Asymptomatic branch-duct IPMNs without high-risk features are usually followed using serial exams [114]. Although MDCT and MRI are traditionally used for these serial assessments, the solid components of IPMNs and superimposed PDACs can be difficult to detect on non-contrast MRI and MDCT [110,117]. At our institution, MRCP is routinely performed with IV contrast to facilitate detection of a solid component or synchronous PDAC. ...
Multidetector computed tomography (MDCT) is a widely used cross-sectional imaging modality for initial evaluation of patients with suspected pancreatic ductal adenocarcinoma (PDAC). However, diagnosis of PDAC can be challenging due to numerous pitfalls associated with image acquisition and interpretation, including technical factors, imaging features, and cognitive errors. Accurate diagnosis requires familiarity with these pitfalls, as these can be minimized using systematic strategies. Suboptimal acquisition protocols and other technical errors such as motion artifacts and incomplete anatomical coverage increase the risk of misdiagnosis. Interpretation of images can be challenging due to intrinsic tumor features (including small and isoenhancing masses, exophytic masses, subtle pancreatic duct irregularities, and diffuse tumor infiltration), presence of coexisting pathology (including chronic pancreatitis and intraductal papillary mucinous neoplasm), mimickers of PDAC (including focal fatty infiltration and focal pancreatitis), distracting findings, and satisfaction of search. Awareness of pitfalls associated with the diagnosis of PDAC along with the strategies to avoid them will help radiologists to minimize technical and interpretation errors. Cognizance and mitigation of these errors can lead to earlier PDAC diagnosis and ultimately improve patient prognosis.
... IPMN, similar to adenoma-to-cancer progression with colorectal cancer, is thought to be a precursor lesion that can progress through a spectrum of dysplastic changes from low-to high-grade dysplasia to pancreatic ductal adenocarcinoma (PDAC) [45]. IPMNs are divided into three subtypes according to the pattern of ductal involvement: main-duct IPMN (MD-IPMN), branchduct IPMN (BD-IPMN), and mixed type IPMN, in which neoplasia occupies both the main and branch ducts [44,46]. BD-IPMNs usually appear unilocular, multicystic, or tubular in morphology [14] (Fig. 7). ...
... The likelihood of malignancy also increases with increased ductal dilatation, particularly when greater than 10 mm [34]. Other imaging features which can be assessed by CT or MRI include the presence of enhancing mural nodularity or septations [38,46]. Mural nodules measuring 5 mm or greater have been associated with higher likelihood of high-grade dysplasia or invasive cancer [49]. ...
Cystic neoplasms in the pancreas are encountered frequently on imaging, often detected incidentally during evaluation for other conditions. They can have a variety of clinical and imaging presentations, and similarly, wide-ranging prognostic and treatment implications. In the majority, imaging helps in diagnosis of pancreatic cystic neoplasms (PCNs) and guides management decisions. But, a significant minority of the PCNs remain indeterminate. There have been multiple recent advances in biomarkers and molecular genetics which will likely prove helpful in risk stratification of PCNs. Several prominent national and international societies, as well as consensus groups have put forth recommendations to help guide management of PCNs. The purpose of this article is to discuss the role of imaging in evaluation of PCNs, review the recent advances in molecular genetics and pancreatic cyst fluid analysis, and analyze the pros and cons of major evidence-based and consensus guidelines for management of PCNs.
