Role of Pancreatic Juice Cytology in the Preoperative Management of Intraductal Papillary Mucinous Neoplasm of the Pancreas in the Era of International Consensus Guidelines 2012

Ohtsuka, Takao; Matsunaga, Taketo; Kimura, Hideyo; Watanabe, Yusuke; Tamura, Koji; Ideno, Noboru; Aso, Teijiro; Miyasaka, Yoshihiro; Ueda, Junji; Takahata, Shunichi; Osoegawa, Takashi; Igarashi, Hisato; Ito, Tetsuhide; Ushijima, Yasuhiro; Ookubo, Fumihiko; Oda, Yoshinao; Mizumoto, Kazuhiro; Tanaka, Masao

doi:10.1007/s00268-014-2684-y

Cited by 32 publications

(22 citation statements)

References 40 publications

(60 reference statements)

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“…At present, only invasive carcinoma derived from IPMN is considered malignant, and high-grade dysplasia is not considered malignant [4,6]. However, this has recently been questioned, as there have been some reported cases of high-grade dysplasia recurring as a distant metastasis after resection [8,9]. High-grade dysplasia is regarded as an indication for surgical resection as stated in the Fukuoka guidelines [4], although it is not clearly defined as malignant [6].…”

Section: Definitions and Classificationmentioning

confidence: 99%

Thirty Years of Experience with Intraductal Papillary Mucinous Neoplasm of the Pancreas: From Discovery to International Consensus

Tanaka¹

2014

Digestion

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Background: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is characterized by intraductal papillary proliferation of mucin-producing epithelial cells that exhibit various degrees of dysplasia. IPMN is classified as the main duct type (MD-IPMN) and the branch duct type (BD-IPMN) according to the location of involvement, and into four histological subtypes (gastric, intestinal, pancreatobiliary, and oncocytic) according to the histomorphological and immunohistochemical characteristics. Mucin core protein expression correlates with the biological behavior and prognosis of the tumor. DNA analysis has shown that IPMN is associated with a number of gene mutations, but the roles of many of these mutations require further investigation. Most patients with MD-IPMN undergo tumor resection. Patients with BD-IPMN who do not undergo resection may develop malignant change, and concomitant separate pancreatic cancer occurs in 2-10% of patients with IPMN. Patients with a strong family history may develop multiple BD-IPMNs as well as concomitant pancreatic cancer. Malignant changes are relatively easy to detect, especially by endoscopic ultrasonography (EUS), but the optimal surveillance protocol is currently unclear. Key Messages: The 2012 guidelines for the management ofIPMN recommend that patients with ‘high-risk stigmata' (obstructive jaundice, enhanced solid component, and main pancreatic duct size ≥10 mm) should undergo resection. Patients with ‘worrisome features' (cyst size ≥3 cm, thickened enhanced cyst walls, non-enhanced mural nodules, main pancreatic duct size 5-9 mm, abrupt change in main pancreatic duct caliber with distal pancreatic atrophy, lymphadenopathy, and clinical acute pancreatitis) should be evaluated by EUS. EUS is a more sensitive test than computed tomography or magnetic resonance imaging for the early detection of malignancy. Conclusions: Most patients with MD-IPMN should undergo tumor resection. Patients with BD-IPMN who do not undergo resection should undergo careful surveillance including EUS for the early detection of malignant change and separate pancreatic cancer.

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Section: Definitions and Classificationmentioning

confidence: 99%

Thirty Years of Experience with Intraductal Papillary Mucinous Neoplasm of the Pancreas: From Discovery to International Consensus

Tanaka¹

2014

Digestion

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“…In addition to a mural nodule and dilated MPD, several studies have found that cytology and/or tumor markers, including carcinoembryonic antigen (CEA) in the cystic fluid obtained by EUS-guided fine needle aspiration (EUS-FNA), or in the pancreatic juice obtained from MPD by endoscopic retrograde pancreatography (ERP), were useful to establish surgical indication for IPMN [36][37][38][39][40][41]. The diagnostic accuracy of cystic fluid or pancreatic juice cytology for HGD/invasive IPMC is poor because the sensitivity rate is low [36][37][38]. However, the positive predictive value (PPV) of cytology for HGD/invasive IPMC is excellent and might be a useful method to determine surgical indication [36,37].…”

Section: Predictive Factors Associated With Hgd/invasive Ipmcmentioning

confidence: 99%

Surgical strategy for intraductal papillary mucinous neoplasms of the pancreas

Hirono

Yamaue

2019

Surg Today

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The current treatment strategy for intraductal papillary mucinous neoplasms (IPMNs), based on the international consensus guideline, has been accepted widely. However, reported outcomes after surgical resection for IPMN show that once the tumor progresses to invasive intraductal papillary mucinous carcinoma (IPMC), recurrence is not uncommon. The surgical treatment for IPMN is invasive and sometimes followed by complications. Therefore, the best timing for resection might be at the point when high-grade dysplasia (HGD) is evident. According to previous reports, main duct type IPMN has a high malignant potential and its surgical resection is universally accepted, whereas, the incidence of HGD/invasive IPMC in branch duct and mixed type IPMNs is thought to be lower. In addition to mural nodules and a dilated main pancreatic duct, cytology and measurement of the carcinoembryonic antigen level in the pancreatic juice might be useful to differentiate HGD/ invasive IPMC from low-grade dysplasia. The nomogram proposed recently to predict the risk of HGD/invasive IPMC in IPMN patients might help surgeons decide on the best treatment strategy, depending on the patient's age and general condition. Second resection for high-risk lesions in the remnant pancreas might improve the survival of IPMN patients.

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“…73 In contrast, an evaluation of pancreatic juice cytology obtained by routine preoperative ERCP in 70 patients with IPMN found that the addition of pancreatic juice cytology altered treatment in two patients with branch-duct (BD)-IPMN from observation to surgical resection. 74 Moreover, three IPMNconcomitant pancreatic ductal adenocarcinomas (PDAC) were diagnosed only by ERCP that included pancreatic juice cytology. One potential drawback of ERCP assessment of pancreatic juice cytology, however, is post-ERCP pancreatitis (PEP).…”

Section: Assessment Of Pancreatic Juice By a Transpapillary Approachmentioning

confidence: 99%

Endoscopic diagnosis of cystic lesions of the pancreas

Kamata

Kitano

2018

Digestive Endoscopy

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Endoscopic methods are increasingly used in the diagnosis of cystic lesions of the pancreas. The two major endoscopic approaches are endoscopic ultrasonography (EUS) and transpapillary diagnosis. EUS-guided fine-needle aspiration cytology and EUS-guided fine needle-based confocal laser endomicroscopy have been used in the differential diagnosis of mucinous and non-mucinous pancreatic cysts. EUS is the most sensitive modality for detecting mural nodules (MN) in intraductal papillary mucinous neoplasms (IPMN). Contrast-enhanced harmonic EUS (CH-EUS), as an add-on to EUS, is useful for identifying and characterizing MN. Recent studies show that CH-EUS has a sensitivity of 60-100% and a specificity of 75-92.9% for diagnosing malignant cysts. Intraductal ultrasonography and peroral pancreatoscopy are especially useful for detecting MN and IPMN. A recent meta-analysis showed that cytological assessment of pancreatic juice using a transpapillary approach had a pooled sensitivity, specificity, and accuracy of 35.1%, 97.2%, and 92.9%, respectively, for diagnosing malignant IPMN. Further studies are warranted to determine the indications for each of these novel techniques in assessing cystic lesions of the pancreas.

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Role of Pancreatic Juice Cytology in the Preoperative Management of Intraductal Papillary Mucinous Neoplasm of the Pancreas in the Era of International Consensus Guidelines 2012

Abstract: Pancreatic juice cytology potentially has important roles to determine the adequate treatment choice in patients with IPMNs with "worrisome features," and to detect significant lesions that could not be detected by other imaging modalities.

Cited by 32 publications

References 40 publications

Thirty Years of Experience with Intraductal Papillary Mucinous Neoplasm of the Pancreas: From Discovery to International Consensus

Thirty Years of Experience with Intraductal Papillary Mucinous Neoplasm of the Pancreas: From Discovery to International Consensus

Surgical strategy for intraductal papillary mucinous neoplasms of the pancreas

Endoscopic diagnosis of cystic lesions of the pancreas

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