Korean Journal of Radiology

The Korean Society of Radiology (대한영상의학회)
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Incidental, Small (< 3 cm), Unilocular, Pancreatic Cysts: Factors That Predict Lesion Progression during Imaging Surveillance

  • Kim, Go Eun (Department of Radiology, Chonnam National University Hospital) ;
  • Shin, Sang Soo (Department of Radiology, Chonnam National University Medical School) ;
  • Kim, Jin Woong (Department of Radiology, Chonnam National University Medical School) ;
  • Heo, Suk Hee (Department of Radiology, Chonnam National University Medical School) ;
  • Lim, Hyo Soon (Department of Radiology, Chonnam National University Medical School) ;
  • Jun, Chung Hwan (Department of Gastroenterology, Chonnam National University Medical School) ;
  • Jeong, Yong Yeon (Department of Radiology, Chonnam National University Medical School)
  • Received : 2017.01.02
  • Accepted : 2017.05.30
  • Published : 2017.12.01
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Abstract

Objective: To explore the features that predict size increase and development of potential malignant features in incidentally detected, unilocular cystic pancreatic lesions (CPLs) less than 3 cm in diameter, during subsequent follow-up. Materials and Methods: We retrieved data of patients diagnosed with unilocular CPLs less than 3 cm in diameter during the period from November 2003 through December 2014, using a computerized search. All serial CT and MR images were analyzed to identify the number, size, and location of CPLs; dilatation of the main pancreatic duct; and occurrence of worrisome features and high-risk stigmata of malignancy in the lesion. The characteristics of CPLs were compared between the increase (i.e., size increase during subsequent follow-up) and no-increase groups. For CPLs in the increase group, subgroup analysis was performed according to the lesion size at the last follow-up (< 3 cm vs. ${\geq}3cm$). Results: Among 553 eligible patients, 132 (23.9%) had CPLs that increased in size, and 421 (76.1%) had CPLs that did not, during follow-up. Of the 132, 12 (9.1%) CPLs increased to diameters ${\geq}3cm$ at the final follow-up. Among the various factors, follow-up duration was a significant independent factor for an interval size increase of CPLs (p < 0.001). In the increase group, initial cyst size was a significant independent factor to predict later size increase to or beyond 3 cm in diameter (p < 0.001), and the initial cyst diameter ${\geq}1.5cm$ predicted such a growth with a sensitivity and specificity of 83% and 72%, respectively. No significant factors to predict the development of potential malignant features were identified. Conclusion: Follow-up duration was associated with an interval size increase of CPLs. Among the growing CPLs, initial cyst size was associated with future lesion growth to and beyond 3 cm.

Keywords

References

  1. Zhang XM, Mitchell DG, Dohke M, Holland GA, Parker L. Pancreatic cysts: depiction on single-shot fast spin-echo MR images. Radiology 2002;223:547-553 https://doi.org/10.1148/radiol.2232010815
  2. Laffan TA, Horton KM, Klein AP, Berlanstein B, Siegelman SS, Kawamoto S, et al. Prevalence of unsuspected pancreatic cysts on MDCT. AJR Am J Roentgenol 2008;191:802-807 https://doi.org/10.2214/AJR.07.3340
  3. de Jong K, Nio CY, Hermans JJ, Dijkgraaf MG, Gouma DJ, van Eijck CH, et al. High prevalence of pancreatic cysts detected by screening magnetic resonance imaging examinations. Clin Gastroenterol Hepatol 2010;8:806-811 https://doi.org/10.1016/j.cgh.2010.05.017
  4. Lee KS, Sekhar A, Rofsky NM, Pedrosa I. Prevalence of incidental pancreatic cysts in the adult population on MR imaging. Am J Gastroenterol 2010;105:2079-2084 https://doi.org/10.1038/ajg.2010.122
  5. Scheiman JM, Hwang JH, Moayyedi P. American gastroenterological association technical review on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015;148:824-848.e22 https://doi.org/10.1053/j.gastro.2015.01.014
  6. Handrich SJ, Hough DM, Fletcher JG, Sarr MG. The natural history of the incidentally discovered small simple pancreatic cyst: long-term follow-up and clinical implications. AJR Am J Roentgenol 2005;184:20-23 https://doi.org/10.2214/ajr.184.1.01840020
  7. Kim YH, Saini S, Sahani D, Hahn PF, Mueller PR, Auh YH. Imaging diagnosis of cystic pancreatic lesions: pseudocyst versus nonpseudocyst. Radiographics 2005;25:671-685 https://doi.org/10.1148/rg.253045104
  8. Sahani DV, Kadavigere R, Saokar A, Fernandez-del Castillo C, Brugge WR, Hahn PF. Cystic pancreatic lesions: a simple imaging-based classification system for guiding management. Radiographics 2005;25:1471-1484 https://doi.org/10.1148/rg.256045161
  9. Sahani DV, Saokar A, Hahn PF, Brugge WR, Fernandez-Del Castillo C. Pancreatic cysts 3 cm or smaller: how aggressive should treatment be? Radiology 2006;238:912-919 https://doi.org/10.1148/radiol.2382041806
  10. Nougaret S, Reinhold C, Chong J, Escal L, Mercier G, Fabre JM, et al. Incidental pancreatic cysts: natural history and diagnostic accuracy of a limited serial pancreatic cyst MRI protocol. Eur Radiol 2014;24:1020-1029 https://doi.org/10.1007/s00330-014-3112-2
  11. Sahani DV, Kambadakone A, Macari M, Takahashi N, Chari S, Fernandez-del Castillo C. Diagnosis and management of cystic pancreatic lesions. AJR Am J Roentgenol 2013;200:343-354 https://doi.org/10.2214/AJR.12.8862
  12. Fernandez-del Castillo C, Targarona J, Thayer SP, Rattner DW, Brugge WR, Warshaw AL. Incidental pancreatic cysts: clinicopathologic characteristics and comparison with symptomatic patients. Arch Surg 2003;138:427-434 https://doi.org/10.1001/archsurg.138.4.427
  13. Gore RM, Wenzke DR, Thakrar KH, Newmark GM, Mehta UK, Berlin JW. The incidental cystic pancreas mass: a practical approach. Cancer Imaging 2012;12:414-421 https://doi.org/10.1102/1470-7330.2012.9054
  14. Adsay NV. Cystic neoplasia of the pancreas: pathology and biology. J Gastrointest Surg 2008;12:401-404 https://doi.org/10.1007/s11605-007-0348-z
  15. Parra-Herran CE, Garcia MT, Herrera L, Bejarano PA. Cystic lesions of the pancreas: clinical and pathologic review of cases in a five year period. JOP 2010;11:358-364
  16. de Jong K, van Hooft JE, Nio CY, Gouma DJ, Dijkgraaf MG, Bruno MJ, et al. Accuracy of preoperative workup in a prospective series of surgically resected cystic pancreatic lesions. Scand J Gastroenterol 2012;47:1056-1063 https://doi.org/10.3109/00365521.2012.674970
  17. Fernandez-Del Castillo C, Tanaka M. Management of pancreatic cysts: the evidence is not here yet. Gastroenterology 2015;148:685-687 https://doi.org/10.1053/j.gastro.2015.02.034
  18. Hol L, Bruno MJ, Cahen DL. Follow-up of asymptomatic pancreatic cysts in clinical practice: a vignette questionnaire. Pancreatology 2016;16:416-422 https://doi.org/10.1016/j.pan.2016.02.007
  19. Walsh RM, Vogt DP, Henderson JM, Zuccaro G, Vargo J, Dumot J, et al. Natural history of indeterminate pancreatic cysts. Surgery 2005;138:665-670; discussion 670-671 https://doi.org/10.1016/j.surg.2005.07.019
  20. Hoffman RL, Gates JL, Kochman ML, Ginsberg GG, Ahmad NA, Chandrasekhara V, et al. Analysis of cyst size and tumor markers in the management of pancreatic cysts: support for the original Sendai criteria. J Am Coll Surg 2015;220:1087-1095 https://doi.org/10.1016/j.jamcollsurg.2015.02.013
  21. Ip IK, Mortele KJ, Prevedello LM, Khorasani R. Focal cystic pancreatic lesions: assessing variation in radiologists' management recommendations. Radiology 2011;259:136-141 https://doi.org/10.1148/radiol.10100970
  22. Tanaka M, Fernandez-del Castillo C, Adsay V, Chari S, Falconi M, Jang JY, et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 2012;12:183-197 https://doi.org/10.1016/j.pan.2012.04.004
  23. Edge MD, Hoteit M, Patel AP, Wang X, Baumgarten DA, Cai Q. Clinical significance of main pancreatic duct dilation on computed tomography: single and double duct dilation. World J Gastroenterol 2007;13:1701-1705 https://doi.org/10.3748/wjg.v13.i11.1701
  24. Lennon AM, Manos LL, Hruban RH, Ali SZ, Fishman EK, Kamel IR, et al. Role of a multidisciplinary clinic in the management of patients with pancreatic cysts: a single-center cohort study. Ann Surg Oncol 2014;21:3668-3674 https://doi.org/10.1245/s10434-014-3739-x
  25. Macari M, Megibow AJ. Focal cystic pancreatic lesions: variability in radiologists' recommendations for follow-up imaging. Radiology 2011;259:20-23 https://doi.org/10.1148/radiol.11102437
  26. Curry CA, Eng J, Horton KM, Urban B, Siegelman S, Kuszyk BS, et al. CT of primary cystic pancreatic neoplasms: can CT be used for patient triage and treatment? AJR Am J Roentgenol 2000;175:99-103 https://doi.org/10.2214/ajr.175.1.1750099
  27. Visser BC, Yeh BM, Qayyum A, Way LW, McCulloch CE, Coakley FV. Characterization of cystic pancreatic masses: relative accuracy of CT and MRI. AJR Am J Roentgenol 2007;189:648-656 https://doi.org/10.2214/AJR.07.2365
  28. Chiang AL, Lee LS. Clinical approach to incidental pancreatic cysts. World J Gastroenterol 2016;22:1236-1245 https://doi.org/10.3748/wjg.v22.i3.1236
  29. Yamada Y, Mori H, Matsumoto S, Kamei N, Hongo N. Invasive carcinomas derived from intraductal papillary mucinous neoplasms of the pancreas: a long-term follow-up assessment with CT imaging. J Comput Assist Tomogr 2006;30:885-890 https://doi.org/10.1097/01.rct.0000220801.76276.0f
  30. Tanno S, Nakano Y, Nishikawa T, Nakamura K, Sasajima J, Minoguchi M, et al. Natural history of branch duct intraductal papillary-mucinous neoplasms of the pancreas without mural nodules: long-term follow-up results. Gut 2008;57:339-343 https://doi.org/10.1136/gut.2007.129684
  31. Fritz S, Klauss M, Bergmann F, Hackert T, Hartwig W, Strobel O, et al. Small (Sendai negative) branch-duct IPMNs: not harmless. Ann Surg 2012;256:313-320 https://doi.org/10.1097/SLA.0b013e31825d355f
  32. Wong J, Weber J, Centeno BA, Vignesh S, Harris CL, Klapman JB, et al. High-grade dysplasia and adenocarcinoma are frequent in side-branch intraductal papillary mucinous neoplasm measuring less than 3 cm on endoscopic ultrasound. J Gastrointest Surg 2013;17:78-84; discussion 84-85
  33. Campbell NM, Katz SS, Escalon JG, Do RK. Imaging patterns of intraductal papillary mucinous neoplasms of the pancreas: an illustrated discussion of the International Consensus Guidelines for the Management of IPMN. Abdom Imaging 2015;40:663-677 https://doi.org/10.1007/s00261-014-0236-4
  34. Tanaka S, Nakao M, Ioka T, Takakura R, Takano Y, Tsukuma H, et al. Slight dilatation of the main pancreatic duct and presence of pancreatic cysts as predictive signs of pancreatic cancer: a prospective study. Radiology 2010;254:965-972 https://doi.org/10.1148/radiol.09090992
  35. Matsubara S, Tada M, Akahane M, Yagioka H, Kogure H, Sasaki T, et al. Incidental pancreatic cysts found by magnetic resonance imaging and their relationship with pancreatic cancer. Pancreas 2012;41:1241-1246 https://doi.org/10.1097/MPA.0b013e31824f5970
  36. Chernyak V, Flusberg M, Haramati LB, Rozenblit AM, Bellin E. Incidental pancreatic cystic lesions: is there a relationship with the development of pancreatic adenocarcinoma and allcause mortality? Radiology 2015;274:161-169 https://doi.org/10.1148/radiol.14140796
  37. Brook OR, Beddy P, Pahade J, Couto C, Brennan I, Patel P, et al. Delayed growth in incidental pancreatic cysts: are the current American College of Radiology recommendations for follow-up appropriate? Radiology 2016;278:752-761 https://doi.org/10.1148/radiol.2015140972
  38. Uehara H, Nakaizumi A, Ishikawa O, Iishi H, Tatsumi K, Takakura R, et al. Development of ductal carcinoma of the pancreas during follow-up of branch duct intraductal papillary mucinous neoplasm of the pancreas. Gut 2008;57:1561-1565 https://doi.org/10.1136/gut.2007.145631
  39. Vege SS, Ziring B, Jain R, Moayyedi P; Clinical Guidelines Committee; American Gastroenterology Association. American gastroenterological association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015;148:819-822 https://doi.org/10.1053/j.gastro.2015.01.015
  40. Das A, Wells CD, Nguyen CC. Incidental cystic neoplasms of pancreas: what is the optimal interval of imaging surveillance? Am J Gastroenterol 2008;103:1657-1662 https://doi.org/10.1111/j.1572-0241.2008.01893.x
  41. Wu BU, Sampath K, Berberian CE, Kwok KK, Lim BS, Kao KT, et al. Prediction of malignancy in cystic neoplasms of the pancreas: a population-based cohort study. Am J Gastroenterol 2014;109:121-129 https://doi.org/10.1038/ajg.2013.334
  42. Spinelli KS, Fromwiller TE, Daniel RA, Kiely JM, Nakeeb A, Komorowski RA, et al. Cystic pancreatic neoplasms: observe or operate. Ann Surg 2004;239:651-657; discussion 657-659 https://doi.org/10.1097/01.sla.0000124299.57430.ce
  43. Tsai HM, Chuang CH, Shan YS, Liu YS, Chen CY. Features associated with progression of small pancreatic cystic lesions: a retrospective study. World J Gastroenterol 2015;21:13309-13315 https://doi.org/10.3748/wjg.v21.i47.13309
  44. Yoen H, Kim JH, Lee DH, Ahn SJ, Yoon JH, Han JK. Fate of small pancreatic cysts (< 3 cm) after long-term follow-up: analysis of significant radiologic characteristics and proposal of follow-up strategies. Eur Radiol 2017;27:2591-2599 https://doi.org/10.1007/s00330-016-4589-7
  45. Berland LL, Silverman SG, Gore RM, Mayo-Smith WW, Megibow AJ, Yee J, et al. Managing incidental findings on abdominal CT: white paper of the ACR incidental findings committee. J Am Coll Radiol 2010;7:754-773 https://doi.org/10.1016/j.jacr.2010.06.013
  46. Singhi AD, Zeh HJ, Brand RE, Nikiforova MN, Chennat JS, Fasanella KE, et al. American Gastroenterological Association guidelines are inaccurate in detecting pancreatic cysts with advanced neoplasia: a clinicopathologic study of 225 patients with supporting molecular data. Gastrointest Endosc 2016;83:1107-1117.e2 https://doi.org/10.1016/j.gie.2015.12.009
  47. Del Chiaro M, Verbeke C, Salvia R, Kloppel G, Werner J, McKay C, et al. European experts consensus statement on cystic tumours of the pancreas. Dig Liver Dis 2013;45:703-711 https://doi.org/10.1016/j.dld.2013.01.010
  48. Kang MJ, Jang JY, Kim SJ, Lee KB, Ryu JK, Kim YT, et al. Cyst growth rate predicts malignancy in patients with branch duct intraductal papillary mucinous neoplasms. Clin Gastroenterol Hepatol 2011;9:87-93 https://doi.org/10.1016/j.cgh.2010.09.008
  49. Italian Association of Hospital Gastroenterologists and Endoscopists; Italian Association for the Study of the Pancreas, Buscarini E, Pezzilli R, Cannizzaro R, De Angelis C, et al. Italian consensus guidelines for the diagnostic workup and follow-up of cystic pancreatic neoplasms. Dig Liver Dis 2014;46:479-493 https://doi.org/10.1016/j.dld.2013.12.019

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