Rapid advances in radiologic technology and increased cross-sectional imaging have led to a sharp rise in incidental discoveries of pancreatic cystic lesions. These cystic lesions include non-neoplastic cysts with no ...Rapid advances in radiologic technology and increased cross-sectional imaging have led to a sharp rise in incidental discoveries of pancreatic cystic lesions. These cystic lesions include non-neoplastic cysts with no risk of malignancy, neoplastic non-mucinous serous cystadenomas with little or no risk of malignancy, as well as neoplastic mucinous cysts and solid pseudopapillary neoplasms both with varying riskof malignancy. Accurate diagnosis is imperative as management is guided by symptoms and risk of malignancy. Endoscopic ultrasound(EUS) allows high resolution evaluation of cyst morphology and precise guidance for fine needle aspiration(FNA) of cyst fluid for cytological, chemical and molecular analysis. Initially, clinical evaluation and radiologic imaging, preferably with magnetic resonance imaging of the pancreas and magnetic resonance cholangiopancreatography, are performed. In asymptomatic patients where diagnosis is unclear and malignant risk is indeterminate, EUSFNA should be used to confirm the presence or absence of high-risk features, differentiate mucinous from non-mucinous lesions, and diagnose malignancy. After analyzing the cyst fluid for viscosity, cyst fluid carcinoembryonic antigen, amylase, and cyst wall cytology should be obtained. DNA analysis may add useful information in diagnosing mucinous cysts when the previous studies are indeterminate. New molecular biomarkers are being investigated to improve diagnostic capabilities and management decisions in these challenging cystic lesions. Current guidelines recommend surgical pancreatic resection as the standard of care for symptomatic cysts and those with high-risk features associated with malignancy. EUSguided cyst ablation is a promising minimally invasive, relatively low-risk alternative to both surgery and surveillance.展开更多
Background:Endoscopic ultrasound-guided ethanol ablation(EUS-EA)for pancreatic cystic lesions(PCLs)has been used in recent years as a feasible treatment modality for low malignant probability PCLs or patients consider...Background:Endoscopic ultrasound-guided ethanol ablation(EUS-EA)for pancreatic cystic lesions(PCLs)has been used in recent years as a feasible treatment modality for low malignant probability PCLs or patients considered high-risk for surgery.The present study aimed to confirm the safety of EUS-EA and to find predictive factors for adverse event(AE).Methods:A retrospective review was performed from the prospectively maintained database of patients who underwent EUS-EA for PCLs from June 2006 to April 2018 at Seoul National University Hospital.The primary outcomes of the study were the rates of AEs and severe AEs by EUS-EA.The secondary outcome was the predictive factors of AEs including acute pancreatitis and abdominal pain.Results:A total of 214 patients were evaluated and the diagnoses of PCLs according to cystic fluid analysis and clinical features were as follows:serous cystic neoplasm(32.2%),mucinous cystic neoplasm(26.6%),branch duct type intraductal papillary mucinous neoplasm(BD-IPMN)(29.4%),and pseudocyst(11.7%).Three patients(1.4%)experienced severe AEs.Overall,AEs occurred in 71(33.2%)patients.BD-IPMN(OR:2.87;95%CI:1.05–7.84;P=0.040),multilocular cysts(OR:3.59;95%CI:1.09–11.85;P=0.036),suspected ethanol leakage during procedure(OR:10.68;95%CI:1.98–57.53;P=0.006),and sticky cystic fluid(OR:3.83;95%CI:1.20–12.24;P=0.024)were predictive factors for post-procedural acute pancreatitis.PCLs of uncinate process(OR:2.99;95%CI:1.22–7.35;P=0.017)and PCLs with exophytic portion(OR:3.70;95%CI:1.96–7.01;P<0.001)were predictive factors for post-procedural abdominal pain.Conclusions:EUS-EA is a safe procedure with a very low rate of severe AEs.It seems possible to predict the AEs according to the features of the procedure and PCLs.展开更多
Pancreatic cystic lesions are increasingly identified on routine imaging.One specific lesion,known as intraductal papillary mucinous neoplasm(IPMN),is a mucinous,pancreatic lesion characterized by papillary cells proj...Pancreatic cystic lesions are increasingly identified on routine imaging.One specific lesion,known as intraductal papillary mucinous neoplasm(IPMN),is a mucinous,pancreatic lesion characterized by papillary cells projecting from the pancreatic ductal epithelium.The finding of mucin extruding from the ampulla is essentially pathognomonic for diagnosing these lesions.IPMNs are of particular interest due to their malignant potential.Lesions range from benign,adenomatous growths to highgrade dysplasia and invasive cancer.These mucinous lesions therefore require immediate attention to determine the probability of malignancy and whether observation or resection is the best management choice.Unresected lesions need long-term surveillance monitoring for malignant transformation.The accurate diagnosis of these lesions is particularly challenging due to the substantial similarities in morphology of pancreatic cystic lesions and limitations in current imaging technologies.Endoscopic evaluation of these lesions provides additional imaging,molecular,and histologic data to aid in the identification of IPMN and to determine treatment course.The aim of this article is to focus on the diagnostic and therapeutic endoscopic approaches to IPMN.展开更多
Nearly 2.5% of cross-sectional imaging studies will report a finding of a cystic pancreatic lesion. Eventhough most of these are incidental findings, it remains very concerning for both patients and treating clinician...Nearly 2.5% of cross-sectional imaging studies will report a finding of a cystic pancreatic lesion. Eventhough most of these are incidental findings, it remains very concerning for both patients and treating clinicians. Differentiating and predicting malignant transformation in pancreatic cystic lesions is clinically challenging. Current evaluation of suspicious cystic lesions includes a combination of radiologic imaging, endoscopic ultrasound(EUS) and cyst fluid analyses. Despite these attempts, precise diagnostic stratification among nonmucinous, mucinous, and malignant cystic lesions is often not possible until surgical resection. EUS-guided needle based confocal laser endomicroscopy(n CLE) for evaluation of pancreatic cysts is emerging as a powerful technique with remarkable potential. Though limited imaging data from 3 large clinical trials(INSPECT, DETECT and CONTACT) are currently the reference standard for n CLE imaging, nonetheless these have not been validated in large studies. The aim of this review article is to review the evolving role of EUS-guided n CLE in management of pancreatic cystic lesions in terms of its significance, adverse events, limitations, and implications.展开更多
文摘Rapid advances in radiologic technology and increased cross-sectional imaging have led to a sharp rise in incidental discoveries of pancreatic cystic lesions. These cystic lesions include non-neoplastic cysts with no risk of malignancy, neoplastic non-mucinous serous cystadenomas with little or no risk of malignancy, as well as neoplastic mucinous cysts and solid pseudopapillary neoplasms both with varying riskof malignancy. Accurate diagnosis is imperative as management is guided by symptoms and risk of malignancy. Endoscopic ultrasound(EUS) allows high resolution evaluation of cyst morphology and precise guidance for fine needle aspiration(FNA) of cyst fluid for cytological, chemical and molecular analysis. Initially, clinical evaluation and radiologic imaging, preferably with magnetic resonance imaging of the pancreas and magnetic resonance cholangiopancreatography, are performed. In asymptomatic patients where diagnosis is unclear and malignant risk is indeterminate, EUSFNA should be used to confirm the presence or absence of high-risk features, differentiate mucinous from non-mucinous lesions, and diagnose malignancy. After analyzing the cyst fluid for viscosity, cyst fluid carcinoembryonic antigen, amylase, and cyst wall cytology should be obtained. DNA analysis may add useful information in diagnosing mucinous cysts when the previous studies are indeterminate. New molecular biomarkers are being investigated to improve diagnostic capabilities and management decisions in these challenging cystic lesions. Current guidelines recommend surgical pancreatic resection as the standard of care for symptomatic cysts and those with high-risk features associated with malignancy. EUSguided cyst ablation is a promising minimally invasive, relatively low-risk alternative to both surgery and surveillance.
文摘Background:Endoscopic ultrasound-guided ethanol ablation(EUS-EA)for pancreatic cystic lesions(PCLs)has been used in recent years as a feasible treatment modality for low malignant probability PCLs or patients considered high-risk for surgery.The present study aimed to confirm the safety of EUS-EA and to find predictive factors for adverse event(AE).Methods:A retrospective review was performed from the prospectively maintained database of patients who underwent EUS-EA for PCLs from June 2006 to April 2018 at Seoul National University Hospital.The primary outcomes of the study were the rates of AEs and severe AEs by EUS-EA.The secondary outcome was the predictive factors of AEs including acute pancreatitis and abdominal pain.Results:A total of 214 patients were evaluated and the diagnoses of PCLs according to cystic fluid analysis and clinical features were as follows:serous cystic neoplasm(32.2%),mucinous cystic neoplasm(26.6%),branch duct type intraductal papillary mucinous neoplasm(BD-IPMN)(29.4%),and pseudocyst(11.7%).Three patients(1.4%)experienced severe AEs.Overall,AEs occurred in 71(33.2%)patients.BD-IPMN(OR:2.87;95%CI:1.05–7.84;P=0.040),multilocular cysts(OR:3.59;95%CI:1.09–11.85;P=0.036),suspected ethanol leakage during procedure(OR:10.68;95%CI:1.98–57.53;P=0.006),and sticky cystic fluid(OR:3.83;95%CI:1.20–12.24;P=0.024)were predictive factors for post-procedural acute pancreatitis.PCLs of uncinate process(OR:2.99;95%CI:1.22–7.35;P=0.017)and PCLs with exophytic portion(OR:3.70;95%CI:1.96–7.01;P<0.001)were predictive factors for post-procedural abdominal pain.Conclusions:EUS-EA is a safe procedure with a very low rate of severe AEs.It seems possible to predict the AEs according to the features of the procedure and PCLs.
文摘Pancreatic cystic lesions are increasingly identified on routine imaging.One specific lesion,known as intraductal papillary mucinous neoplasm(IPMN),is a mucinous,pancreatic lesion characterized by papillary cells projecting from the pancreatic ductal epithelium.The finding of mucin extruding from the ampulla is essentially pathognomonic for diagnosing these lesions.IPMNs are of particular interest due to their malignant potential.Lesions range from benign,adenomatous growths to highgrade dysplasia and invasive cancer.These mucinous lesions therefore require immediate attention to determine the probability of malignancy and whether observation or resection is the best management choice.Unresected lesions need long-term surveillance monitoring for malignant transformation.The accurate diagnosis of these lesions is particularly challenging due to the substantial similarities in morphology of pancreatic cystic lesions and limitations in current imaging technologies.Endoscopic evaluation of these lesions provides additional imaging,molecular,and histologic data to aid in the identification of IPMN and to determine treatment course.The aim of this article is to focus on the diagnostic and therapeutic endoscopic approaches to IPMN.
文摘Nearly 2.5% of cross-sectional imaging studies will report a finding of a cystic pancreatic lesion. Eventhough most of these are incidental findings, it remains very concerning for both patients and treating clinicians. Differentiating and predicting malignant transformation in pancreatic cystic lesions is clinically challenging. Current evaluation of suspicious cystic lesions includes a combination of radiologic imaging, endoscopic ultrasound(EUS) and cyst fluid analyses. Despite these attempts, precise diagnostic stratification among nonmucinous, mucinous, and malignant cystic lesions is often not possible until surgical resection. EUS-guided needle based confocal laser endomicroscopy(n CLE) for evaluation of pancreatic cysts is emerging as a powerful technique with remarkable potential. Though limited imaging data from 3 large clinical trials(INSPECT, DETECT and CONTACT) are currently the reference standard for n CLE imaging, nonetheless these have not been validated in large studies. The aim of this review article is to review the evolving role of EUS-guided n CLE in management of pancreatic cystic lesions in terms of its significance, adverse events, limitations, and implications.
