Minimal main pancreatic duct dilatation in small branch duct intraductal papillary mucinous neoplasms associated with high-grade dysplasia or invasive carcinoma

182 Background: Intraductal papillary-mucinous neoplasms (IPMNs) of the pancreas are characterized by intraductal papillary epithelial growth, mucin hypersecretion, and cystic dilation of main or branch pancreatic ducts. However, it is still difficult to differentiate between benign and malignant, when it only involves the branch duct. The purpose of this study was to evaluate the role of endoscopic ultrasound (EUS) scoring in predicting malignancy in branch-duct type IPMNs, thus providing a convenient guideline to a clinician before considering surgical resection. Methods: We retrospectively reviewed all patients between Dec 1997 and April 2010 who underwent diagnostic and/or preoperative EUS for IPMNs. Borderline malignancy and invasive carcinoma were defined as a malignancy. Results: Of the 32 patients (mean age, 62 years), 13 male and 19 female were identified. Twelve people underwent operation, and there were 23 benign cases, and 9 malignant cases (borderline, n=6; invasive carcinoma, n=3). Among the six parameters (age, cyst size, mural nodule, associated main pancreatic duct dilation, patulous opening, thick septum) that have been known as important parameters for predicting malignancy in main duct type IPMNs, four were significant by Fisher's exact tests—namely, cyst size (p=.002), mural nodule (p =.003), associated main pancreatic duct dilation (p =.001), patulous opening (p =.05). In sizing the cysts, we scored 0 (cyst size ≤10 mm), 1 (11-20 mm), 2 (21-30 mm), 3 (>30 mm). In sizing the mural nodules, we scored 0 (no mural nodule), 1 (<5 mm), 2 (5-<10 mm), 3 (≥10 mm). For main pancreatic duct dilation, we scored 2, if there presented any associated main pancreatic duct dilation, and 0 if not. For the patulous opening, we scored 1 for present, 0 for not. Patients were dispersed from the highest score nine, to the lowest score zero. Mean score for benign cases was 2.47 (±1.59 SD), and 6.33 (±1.87 SD) for malignant cases (p =.001). Conclusions: We strongly recommend a radical surgery for patients scoring above 7(score 7, 8, 9), and a consideration of operation for scoring between 4 and 6, and careful follow up for scoring below 3. No significant financial relationships to disclose.

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Long-Term Follow-Up of Low-Risk Branch Duct IPMNs of the Pancreas: Watch for Main Pancreatic Duct Dilatation, and for How Long?

Clinical and Translational Gastroenterology ◽

10.1038/s41424-018-0065-9 ◽

2018 ◽

Vol 9 (10) ◽

pp. e198

Author(s):

Thiruvengadam Muniraj ◽

Harry R. Aslanian

Keyword(s):

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Low Risk ◽

Branch Duct ◽

Duct Dilatation ◽

Long Term Follow Up ◽

Main Pancreatic Duct Dilatation ◽

Pancreatic Duct Dilatation

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The CT fish mouth ampulla sign: a highly specific finding in main duct and mixed intraductal papillary mucinous neoplasms

British Journal of Radiology ◽

10.1259/bjr.20190461 ◽

2019 ◽

Vol 92 (1103) ◽

pp. 20190461

Author(s):

Ting Ting Zhang ◽

Timothy J Sadler ◽

Siobhan Whitley ◽

Rebecca Brais ◽

Edmund Godfrey

Keyword(s):

Pancreatic Duct ◽

Predictive Value ◽

High Grade Dysplasia ◽

High Grade ◽

Main Duct ◽

Intraductal Papillary Mucinous Neoplasms ◽

Control Series ◽

Duct Dilatation ◽

Mucinous Neoplasms ◽

Pancreatic Duct Dilatation

Objective: Main duct and mixed intraductal papillary mucinous neoplasms (IPMN) are pre-malignant cystic pancreatic neoplasms associated with pancreatic duct dilatation. Distinguishing these from benign causes of pancreatic duct dilatation is important in order to allow appropriate surveillance or surgery. A patulous duodenal papilla with extrusion of mucus at endoscopic evaluation, the endoscopic fish mouth ampulla (E-FMA) sign, is reported in main duct and mixed IPMN. We aimed to establish whether a CT correlate (CT-FMA) of this sign exists and whether this was associated with the presence of invasion or high-grade dysplasia. We defined the CT-FMA sign as an uninterrupted column of water attenuation material running from the pancreatic duct to the duodenal lumen. Methods: A retrospective, blinded review of 44 patients with histologically confirmed IPMN and 87 age-matched controls with pancreatic duct dilatation on CT was undertaken. A case–control series matched for the degree of pancreatic duct dilatation was used to compare the rates of invasion or high-grade dysplasia between main duct and mixed IPMN patients, with and without a CT-FMA sign. Results: The CT-FMA sign could be identified in 18.5% patients with main duct/mixed IPMN with specificity 100%, positive predictive value 100% and negative predictive value 79.8%. A significant association was found between CT-FMA in main duct/mixed IPMN compared to controls, but not with the presence of high-grade dysplasia or invasion. Conclusions: The CT-FMA sign is a newly reported, highly specific sign of MD and mixed IPMN. Advances in knowledge: If a fish mouth ampulla is identified at CT, a diagnosis of main duct or mixed IPMN is highly likely.

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Cytological analysis of small branch-duct intraductal papillary mucinous neoplasms provides a more accurate risk assessment of malignancy than symptoms

CytoJournal ◽

10.4103/1742-6413.90084 ◽

2011 ◽

Vol 8 ◽

pp. 21 ◽

Cited By ~ 25

Author(s):

Jill Ono ◽

Kurt A. Yaeger ◽

Muriel Genevay ◽

Mari Mino-Kenudson ◽

William R. Brugge ◽

...

Keyword(s):

Predictive Value ◽

High Threshold ◽

Imaging Features ◽

High Grade ◽

Positive Cytology ◽

Intraductal Papillary Mucinous Neoplasms ◽

Branch Duct ◽

Small Branch ◽

Mucinous Neoplasms ◽

Sensitivity Specificity

Objectives: The Sendai guidelines for management of patients with clinically suspected intraductal papillary mucinous neoplasms (IPMN) recommend resection of cysts > 30 mm, a dilated main pancreatic duct (MPD) > 6 mm, a mural nodule (MN), symptoms or positive cytology. Although sensitive, asymptomatic cysts, nonspecific symptoms, and a high threshold for positive cytology limit the specificity of the guidelines. We have assessed the value of cytology relative to symptom for predicting malignancy in IPMNs without high-risk imaging features. Materials and Methods: We retrospectively reviewed the clinical, radiological, and cytological data of 31 small branch-duct IPMNs without a MN. The cytological presence of high-grade atypical epithelial cells (HGA) was considered true positive, with a corresponding histology of high-grade dysplasia or invasive carcinoma. The performance of cytology versus symptoms was evaluated by calculating the sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy. Results: The sensitivity (0.80), specificity (0.85), and accuracy (0.84) of HGA were higher than the corresponding performance characteristics of symptoms (0.60, 0.45, and 0.48, respectively). The NPV of no HGA on cytology was > 95%. Conclusions: Cytology is a better predictor of malignancy than symptoms, for the conservative management of small branch-duct IPMNs. Cytology contributes to a highly accurate triple negative test for malignancy in small IPMN: No dilated MPD, MN or HGA.

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LATERAL SPREAD ALONG THE MAIN PANCREATIC DUCT IN BRANCH-DUCT INTRADUCTAL PAPILLARY-MUCINOUS NEOPLASMS OF THE PANCREAS: USEFULNESS OF INTRADUCTAL ULTRASONOGRAPHY FOR ITS EVALUATION

Digestive Endoscopy ◽

10.1111/j.1443-1661.2010.01063.x ◽

2010 ◽

Vol 23 (1) ◽

pp. 62-68 ◽

Cited By ~ 14

Author(s):

Go Kobayashi ◽

Naotaka Fujita ◽

Yutaka Noda ◽

Kei Ito ◽

Jun Horaguchi ◽

...

Keyword(s):

Pancreatic Duct ◽

Main Pancreatic Duct ◽

Lateral Spread ◽

Intraductal Papillary Mucinous Neoplasms ◽

Branch Duct ◽

Intraductal Ultrasonography ◽

Mucinous Neoplasms

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Endoscopic ultrasonography-guided pancreaticoduodenostomy with a lumen-apposing metal stent to treat main pancreatic duct dilatation

Endoscopy ◽

10.1055/a-1408-0148 ◽

2021 ◽

Author(s):

Masaki Kuwatani ◽

Kosuke Nagai ◽

Yunosuke Takishin ◽

Ryutaro Furukawa ◽

Hajime Hirata ◽

...

Keyword(s):

Pancreatic Duct ◽

Endoscopic Ultrasonography ◽

Main Pancreatic Duct ◽

Metal Stent ◽

Duct Dilatation ◽

Main Pancreatic Duct Dilatation ◽

Pancreatic Duct Dilatation

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Radiomic nomogram based on MRI to predict grade of branching type intraductal papillary mucinous neoplasms of the pancreas: a multicenter study

Cancer Imaging ◽

10.1186/s40644-021-00395-6 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Sijia Cui ◽

Tianyu Tang ◽

Qiuming Su ◽

Yajie Wang ◽

Zhenyu Shu ◽

...

Keyword(s):

Calibration Curve ◽

Main Pancreatic Duct ◽

Validation Cohort ◽

External Validation ◽

High Grade ◽

Intraductal Papillary Mucinous Neoplasms ◽

Training Cohort ◽

Independent Validation ◽

Medical Centers ◽

Mucinous Neoplasms

Abstract Background Accurate diagnosis of high-grade branching type intraductal papillary mucinous neoplasms (BD-IPMNs) is challenging in clinical setting. We aimed to construct and validate a nomogram combining clinical characteristics and radiomic features for the preoperative prediction of low and high-grade in BD-IPMNs. Methods Two hundred and two patients from three medical centers were enrolled. The high-grade BD-IPMN group comprised patients with high-grade dysplasia and invasive carcinoma in BD-IPMN (n = 50). The training cohort comprised patients from the first medical center (n = 103), and the external independent validation cohorts comprised patients from the second and third medical centers (n = 48 and 51). Within 3 months prior to surgery, all patients were subjected to magnetic resonance examination. The volume of interest was delineated on T1-weighted (T1-w) imaging, T2-weighted (T2-w) imaging, and contrast-enhanced T1-weighted (CET1-w) imaging, respectively, on each tumor slice. Quantitative image features were extracted using MITK software (G.E.). The Mann-Whitney U test or independent-sample t-test, and LASSO regression, were applied for data dimension reduction, after which a radiomic signature was constructed for grade assessment. Based on the training cohort, we developed a combined nomogram model incorporating clinical variables and the radiomic signature. Decision curve analysis (DCA), a receiver operating characteristic curve (ROC), a calibration curve, and the area under the ROC curve (AUC) were used to evaluate the utility of the constructed model based on the external independent validation cohorts. Results To predict tumor grade, we developed a nine-feature-combined radiomic signature. For the radiomic signature, the AUC values of high-grade disease were 0.836 in the training cohort, 0.811 in external validation cohort 1, and 0.822 in external validation cohort 2. The CA19–9 level and main pancreatic duct size were identified as independent parameters of high-grade of BD-IPMNs using multivariate logistic regression analysis. The CA19–9 level and main pancreatic duct size were then used to construct the radiomic nomogram. Using the radiomic nomogram, the high-grade disease-associated AUC values were 0.903 (training cohort), 0.884 (external validation cohort 1), and 0.876 (external validation cohort 2). The clinical utility of the developed nomogram was verified using the calibration curve and DCA. Conclusions The developed radiomic nomogram model could effectively distinguish high-grade patients with BD-IPMNs preoperatively. This preoperative identification might improve treatment methods and promote personalized therapy in patients with BD-IPMNs.

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