Risk Analysis Of Pancreatic Cystic Neoplasms Based On Cross-section Imaging Techniques And Endoscopic Ultrasonography

Pancreatic cystic lesions(PCLS)mainly include pseudocysts,true cysts,and pancreatic cystic neoplasms(PCNs).The management of PCNs is a key and difficult point in clinical practice.However,there remains a difficulty to differential PCNsfrom other PCL subtypes.In general,PCNs can be classified into four primary types:serous cystic neoplasms(SCNs),mucinous cystic neoplasms(MCNs),intraductal papillary mucinous neoplasms(IPMNs),and solid pseudopapillary neoplasms(SPNs).Nearly 90% of all PCNs consist of these 4 pathological types.IPMNs and MCNs are mucinous neoplasms,which represent the tumors that have the potential for malignant transformation.PCNs are being detected more frequently due to advances in radiological technologies.The prevalence of PCNs varies in different races.However,the prevalence of PCNs in Chinese population is still unknown.The rate of high risk PCNs which means medical intervention is needed in common population is unknown,either.Meanwhile,how to select high risk PCN patients to undergo high resolution imaging examinations is need to be explored,too.The risk of PCNs mainly depends on imaging evaluation at present.If a high-risk factor is identified by imaging modality,the PCN patient will be recommended to undergo further medical intervention to assist evaluating the possibility of malignant PCNs(direct surgical resection or cyst fluid analysis obtained by endoscopic ultrasound guided fine needle aspiration).However,the high-risk factors recommend by current guidelines are not consistent,and the recommendations for PCNs patients with high-risk factors are not consistent,either.More importantly,some guidelines are designed for specific subtype of PCNs(IPMN and MCN).However,the classification of subtype PCNs for imaging modalities are not accurate.As a result,the application of these guidelines may cause bias in the management of PCNs,leading to missed diagnosis of malignant PCNs and over treatment of benign PCNs.There is no conclusion about which guideline is the most accurate for PCN management.Based on the background above,we designed this study to explore the prevalence,screening modalities and high-risk factors for PCNs,a nomogram was established to facility early diagnosis of advanced PC.1.Prevalence of pancreatic cystic lesions detected by magnetic resonance imaging in the Chinese populationBackground and Aim: Incidental pancreatic cystic lesions(PCLs)are being diagnosed more frequently.However,little is known about the prevalence of PCLs in the Chinese population.The aim of the study was to assess the crude prevalence of PCLs in individuals who underwent magnetic resonance imaging(MRI).Methods: Data from consecutive patients who underwent MRI without pancreatic indications were included.MRI images were reviewed for the presence of pancreatic cysts.The prevalence of PCLs and high-risk PCLs in different gender and age groups was calculated.To assess the crude prevalence,the prevalence and demographic data were standardized on the basis of Chinese national population data in 2017.Results: A total of 10 987 individuals were included(7344 men).Incidental PCLs were identified in 212 individuals(128 men).The prevalence of PCLs was 1.93%,and PCLs were more often discovered in women(1.74% vs 2.31%,P = 0.043).Prevalence increased with age(r = 0.804,P < 0.001).The prevalence of high-risk PCLs was 0.12%(n = 13).Gender predominance and age distribution showed no difference between highrisk PCLs and low risk PCLs(P = 0.234 and P = 0.855),but cysts located in the pancreatic head were more likely to develop into high-risk PCLs(P = 0.001).After data standardization,the crude prevalence of PCLs was 1.31%,and PCLs were more often discovered in women(1.11% vs 1.5%,P < 0.001).The crude prevalence of high-risk PCLs was 0.07%.Conclusion: Pancreatic cystic lesions in the Chinese population are not rare.The prevalence of PCLs increased with age and is higher in the female population.The prevalence of high-risk PCLs should not be ignored.2.Validation of Serum Tumor Biomarkers in Predicting Advanced Cystic Mucinous Neoplasm of the PancreasBackground: Early detection of advanced cystic mucinous neoplasms(A-c MNs,defined as high-grade dysplasia or malignancy)of the pancreas is of great significance.As a simple and feasible detection method,serum tumor markers(STMs)may be used to predict advanced intraductal papillary mucinous neoplasms(IPMNs)and mucinous cystic neoplasms(MCNs).However,there are few studies on the usefulness of STMs other than carbohydrate antigen(CA)19-9 for early detection of malignancies.Aim: To study the ability of five STMs—CA19-9,CEA,CA125,CA724 and CA242— to predict A-c MNs and distinguish IPMNs and MCNs.Methods: We mainly measured the levels of each STM in patients pathologically diagnosed with c MNs.The mean levels of STMs and the number of A-c MN subjects with a higher STM level than the cutoff were compared respectively to identify the ability of STMs to predict A-c MNs and distinguish MCNs from IPMNs.A receiver operating characteristic curve with the area under curve(AUC)was also created to identify the performance of the 5 STMs.Results: A total of 187 patients with c MNs were identified and 72 of them showed A-c MNs.We found that CA19-9 exhibited the highest sensitivity(54.2%)and accuracy(76.5%)and a moderate ability(AUC=0.766)to predict A-c MNs.In predicting highgrade dysplasia IPMNs,the sensitivity of CA19-9 decreased to 38.5%.The ability of CEA,CA125,and CA724 to predict A-c MNs was low(AUC=0.651,0.583 and 0.618,respectively).The predictive ability of CA242 was not identified.The combination of STMs improved the sensitivity to 62.5%.CA125 may be specific to the diagnosis of advanced MCNs.Conclusion: CA19-9 had a moderate ability,and CEA,CA125,and CA724 had a low ability to predict A-c MNs.The combination of STM testing could improve sensitivity in predicting A-c MNs.3.Validation of European evidence-based guidelines and American College of Gastroenterology guidelines as predictors of advanced neoplasia in patients with suspected mucinous pancreatic cystic neoplasmsBackground and Aim: The European evidence-based guidelines(EEG)and American College of Gastroenterology Guidelines(ACGG)have been published to guide the management of pancreatic cystic lesions.We aim to evaluate the value of both guidelines in predicting advanced pancreatic cystic lesions(A-PCLs)with preoperatively imaging suspected cystic mucinous pancreatic neoplasms(c MNs).Methods: One hundred ninety-eight patients who underwent resections from 2013 to 2019 for suspected c MNs were retrospectively reviewed.Receiver operating characteristic curves were calculated and compared with measure diagnostic value.Results: Sixty-two patients were diagnosed with A-PCLs pathologically.Crossimaging modalities had comparable diagnostic accuracy to endoscopic ultrasound in type classification and A-PCLs prediction.Receiver operating characteristic curve comparison analyses showed that EEG absolute + MCN(EEG AM)and EEG relative +MCN(EEG RM)having at least one indications criteria were comparable to the ACGG(P = 0.21 and P = 0.45).For the criteria having at least two indications,ACGG was superior to EEG AM(P= 0.001)but comparable to EEG RM(P = 0.12).EEG AM ? 1 indication criteria was superior to ? 2 indications criteria(P = 0.02).EEG RM ? 1 indication criteria had comparable diagnostic performance with ? 2 indications criteria(P = 0.86).ACGG ? 2indications criteria was superior to ? 1 indication criteria(P = 0.02).Conclusion: On the basis of cross-imaging evaluations,both sets of guidelines were found to be helpful in identifying A-PCLs in suspected c MNs with comparable performance.EEG AM ? 1 indication criteria was superior to ? 2 indications criteria.ACGG ? 2 indications criteria was superior to ? 1 indication criteria.4.High?Risk Characteristics Associated with Advanced Pancreatic Cystic Lesions and Development of a Preoperative Nomogram for Predicting the rick of Pancreatic Cystic LesionsBackground and Aim: The management of pancreatic cystic lesions(PCLs)remains controversial.We performed a retrospective study to determine characteristics associated with advanced PCLs(A-PCLs)and whether these characteristics vary in different pathological types of PCLs.The additional diagnostic value of endoscopic ultrasound(EUS)was also evaluated.Methods: Patients who underwent surgical resection for an identified PCLs by imaging modalities were included.A logistic regression model was developed to identify significant characteristics for A-PCLs.A nomogram was established to predict malignancy possibility based on the results of logistic regression model.EUS data was assessed separately.Results: Three hundred and fifty-three patients were included,and 125 patients(35.4%)were A-PCLs.The presence of main pancreatic duct(MPD)diameter ? 10 mm(odds ratio [OR],11.7;95% confidence interval [CI],1.53–89.2;P = 0.018),mural nodules ? 5 mm(OR,11.67;95% CI,2.3–59.05;P = 0.003),solid components within cysts(OR,30.87;95% CI,7.23–131.7;P < 0.0001)and high serum CA19-9 levels(OR,1.006;95% CI,1.001–1.011;P = 0.02)were independently associated with the presence of A-PCLs.The presence of septa was independently associated with the presence of non-A-PCLs(OR,0.147;95% CI,0.04–0.6;P = 0.008).Males who had a history of tobacco abuse(P < 0.0001)and had a greatly dilated MPD(P < 0.0001)were more common in advanced intraductal papillary mucinous neoplasms(IPMC)patients.Solid pseudopapillary neoplasm(SPT)often occurred in young women(P < 0.0001),mostly asymptomatically(P < 0.0001)and with lower serum CA19-9 levels(P < 0.0001).The nomogram constructed with these risk factors achieved good concordance indexes with AUC= 0.843(95% CI: 0.7995-0.888).In the 124 patients who underwent EUS-guided fine-needle aspiration(EUS-FNA),five additional characteristics(4 mural nodules and 1 MPD involvement)were identified by EUS imaging and 17 patients were identified with abnormal cytological results(13atypical cells and 4 suspicious for malignancy cells)by EUS-FNA.Conclusion: On the basis of a retrospective study with large sample size,the presence of MPD ? 10 mm,mural nodules,solid components,and high serum CA19-9levels were independently associated with the presence of A-PCLs.The high-risk characteristics may vary across different types of A-PCLs.EUS and EUS-FNA could provide additional diagnostic information for PCLs.