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Tu1227 Long-Term Follow up of Branch Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Single Center Experience
ductal carcinoma of the pancreas, and 3 patients died of other benign diseases. Thus, no patients died of IPMN itself during the follow-up period. CONCLUSION; Of 116 BD-IPMNs, morphological change was observed in 18.1% during the mean follow-up period of 90 months and no patients died of IPMN itself. This suggests that observation may be a reasonable approach to BD-IPMNs until morphological changes. Tu1228 High Prevalence of Cystic Pancreatic Lesions in Patients With Advanced Liver Disease Seth N. Sclair, Emmanuel Coronel, Simon Abramson, David Jativa, Victor J. Casillas, Paul Martin, Beatrice L. Madrazo Background: Routine abdominal imaging frequently uncovers unsuspected masses. Recent studies report a prevalence of incidentally detected pancreatic cystic lesions (PCL) in the general population of 2.4% to 2.6% (De Jong 2010, Laffan 2008). We have observed increasing numbers of PCL in cirrhotic patients receiving routine abdominal imaging for hepatocellular carcinoma surveillance. The aim of this study is to establish PCL prevalence in patients with advanced liver disease. Methods: This was a cross-sectional study comparing three groups of cirrhotic patients: 1) "Clinic" (hepatology clinic patients, 2010-11), 2) "MRI" (consecutive patients with cirrhosis and abdominal MRI, 2009-11), and 3) "Transplant" (liver transplant recipients, 2010-11). Patients with cirrhosis and CT and MR imaging studies were included. For liver-transplanted patients, only pre-transplant images were considered. Key exclusions were age ,18y, history of pancreatitis, and polycystic liver and/or kidney disease. One imaging study per eligible patient was blindly reviewed by a team of radiologists. We calculated PCL prevalence in each group and also correlated PCL prevalence with Model of End Stage Liver Disease (MELD) score and etiology of liver disease. Statistical analysis was performed using 3x2 Chi-square, Fisher exact, and Mann Whitney tests. Results: Sevenhundred and twenty-three patients were screened and 585 were eligible (cirrhosis with CT or MR scans). From these 585 patients, 65 were excluded due to age, pancreatitis, and polycystic liver and/or kidney disease. Two-hundred and twenty-eight patients were in the Clinic group, 150 in the MRI group, and 142 in the Transplant group. Mean age was 59, 57, and 56 in the 3 groups, respectively. Male patients comprised 69%, 55%, and 75% of the 3 groups, respectively. Key results are listed in tables 1 and 2. Additionally, median MELD score and interquartile range in patients with cysts (n=43) was 15 (10-18) and without cysts (n=457) was 11 (9-15), p=.03. PCL prevalence in patients with non-alcoholic steatohepatitis (NASH) related cirrhosis was 1/64 (1.6%) compared to PCL prevalence of 42/456 (9.2%) in all other liver disease (p ,.05). Discussion: Overall, there is a marked increase in PCL prevalence in our cirrhosis cohorts compared to the non-cirrhotic population. The prevalence of PCL is highest in adult cirrhotic patients who underwent liver transplantation. Further, there is a statistically significant association with increasing MELD score and PCL prevalence. The prevalence of PCL in patients with NASH-cirrhosis is similar to the prevalence in the non-cirrhotic population, while PCL prevalence is higher in patients with cirrhosis from viral hepatitis, alcoholic, and other liver disease. Prospective studies are needed to define pathogenesis and management of these incidental lesions in cirrhotic patients. Table 1 - Prevalence of PCL by Cirrhosis Cohort
Tu1226 In Vivo Characterization of Pancreatic Serous Cystadenomas by Needle-Based Confocal Laser Endomicroscopy (nCLE). Intra and Inter Observer Agreement Contact Study Bertrand Napoleon, Bertrand Pujol, Anne-Isabelle Lemaistre, Fabrice Caillol, Damien Lucidarme, Bernard Filoche, Blandine Mialhe-Morellon, Fabien Fumex, Vincent Lepilliez, Marc Giovannini Introduction: nCLE enables microscopic observation of solid organs, in vivo and in realtime, during an EUSFNA procedure. A prospective multicentric french study (CONTACT) aims at assessing the diagnostic performance of nCLE for the diagnosis of pancreatic cysts. The chosen interpretation criteria have been defined during a previous study (INSPECT), but the definition of complementary criteria was considered after the inclusion of the first 10 patients. 2 investigators and 2 pathologists reviewed the 10 recordings and identified a new aspect: the superficial vascular networking (SVN). It matches the serous cystadenoma (SCA) histology. The aim of this preliminary study is to validate this criteria by assessing its diagnostic performance for the diagnosis of SCA, as well as the inter (IOA) and intra observer agreements. Materials and methods:Over 6 months, 18 patients without chronic pancreatitis and with a lonely pancreatic cyst . 2cm large were enrolled. Following EUS examination, the nCLE miniprobe was introduced in a 19G needle and real-time video sequences of the cyst wall were recorded.Fluid obtained by FNA was analyzed. Final diagnosis of SCA (n=8) was based on the following characteristics: -transsonor fluid, absence of nodule, parietal vegetations or solid tumor on EUS, -absence of cytologic criteria suggesting a mucinous lesion +/- SCA cells, -intracystic tumoral marker CEA , 5.The other lesions were considered as mucinous cystadenoma (n=5,proven by surgery),IPMN (n=3),pseudocysts (n= 2). IOA was evaluated by 6 investigators (4 experts,2 beginners) who reviewed a set of 18 video sequences (8 SCA and 10 non SCA) in a randomized order after a basic training on image interpretation (2 cases, one with SVN). The intraobserver agreement was evaluated, in parallel, by 1 beginner and 1 expert who reviewed twice the same set in a different order. Following this evaluation, a joint review was done for cases for which a discrepancy of interpretation was observed. A final consensus for the diagnosis was proposed if possible. Results:The intraobserver agreement was excellent and identical for the beginner and the expert (κ 0.87).The IOA was good to excellent ( κ 0.69). In 72% of cases the agreement between the 6 observers was complete.A final consensus was obtained in the 28% remaining cases.Compared to the final diagnosis, the accurracy, sensitivity, specificity, PPV and NPV for the diagnosis of SCA by nCLE were respectively 83%, 62.5%, 100%, 100% and 77%. Conclusion: The presence of SVN is a histological particularity of SCA, which can be highlighted by nCLE. The specificity and PPV of the sign is 100% in this preliminary series. Its presence could avoid unnecessary surgery for SCA. The second phase of the study should enable to validate prospectively this sign and confirm the interest of nCLE for the diagnosis of pancreatic cystic tumors.
Table 2 - Prevalence of PCL by MELD Score
Twenty patients had missing labs and therefore were excluded from the MELD sub-analysis.
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Tu1229
Long-Term Follow up of Branch Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Single Center Experience Manabu Osanai, Hiroyuki Maguchi, Kei Yane, Toshifumi Kin, Ryo Takaki, Kazuyuki Matsumoto, Tomoaki Matsumori, Katsushige Gon, Akio Katanuma, Kuniyuki Takahashi
Pancreatic Cyst Prevalence and the Risk of Mucin-Producing Adenocarcinoma in United States Adults Timothy B. Gardner, Lisa M. Glass, Stuart R. Gordon BACKGROUND & AIMS: The presence of a pancreatic cyst often prompts concern, although the rate of malignant transformation to mucin-producing adenocarcinoma is not known. We aimed to determine the prevalence rate of mucin-producing adenocarcinoma in United States adults with pancreatic cysts. METHODS: This retrospective, population-based crosssectional study calculated the annual number of mucin-producing adenocarcinomas using the SEER 18 database and the 2010 United States census. The overall prevalence rate of cysts in the population was found using data from large cross-sectional imaging studies of incidental cyst prevalence. Prevalence rates were then calculated by dividing the annual number of mucin-producing adenocarcinomas by the cyst prevalence rate. RESULTS: Between 2005 and 2009, 1,336 mucin-producing adenocarcinomas were estimated to be found annually in a United States adult population of 137,154,960. The total number of pancreas cysts, given a cyst prevalence rate of 2.5%, was 4,110,737. Therefore, the prevalence of mucin-producing adenocarcinoma arising in patients with pancreatic cysts was 32.5 per 100,000 (95% C.I. 21.8, 43.2). The prevalence rate was 31.2 per 100,000 (20.3, 42.1) in females and 34.0 per 100,000 (22.6, 45.4) in males. As expected, the rate of malignant transformation increased linearly with advancing age (highest 45.1 per 100,000 in 80-84 year old males). CONCLUSION: Malignant transformation of pancreatic cysts into mucinproducing adenocarcinoma in United States adults is a very rare event. Current clinical
BACKGROUND & AIMS; In the IPMN/MCN international consensus guidelines, branch duct IPMN (BD-IPMN) have changed from rather early resection to more deliberate observation. However, long term follow-up result of BD-IPMN has been limited, the aim of this study was to clarify the natural history of BD-IPMN. METHODS; 582 patients with BD-IPMNs were treated in our institute from 1997 to 2012. 116 patients with BD-IPMNs with more than 5 years imaging follow-up were identified and their cases reviewed. Evaluation points were 1) initial clinical data, 2) progression rate, 3) incidence of ordinary pancreatic cancer, and 4) outcomes. RESULTS; 1)Mean observation period was 90 months (61 to 185 months) (M:F=41:75; median age, 66y). The initial mean size of the cystic lesion is 19.9mm (10~45), diameter of the main pancreatic duct (MPD) is 3.0mm (2~10). 97 patients (86%) had no mural nodules, while 19 patients initially had mural nodules (1~9mm, mean 3.5mm). 2) Twenty-one patients (18.1%) exhibited progression with an increasing cyst size, MPD diameter, or appearance and/or enlargement of mural nodules. Surgical resection was performed in 7 (33.3%) of 21 patients with progression and 5 (5.3%) of 95 patients without changes. Pathological diagnosis; with progression group was 5 adenoma, 1 carcinoma in situ, and 1 invasive IPMC, without progression group was 4 adenoma and 1 minimally invasive IPMC. 3) Two patients died of extrapancreatic malignancies, 2 patients died of newly developed
S-797
AGA Abstracts
AGA Abstracts
included studies that compare the diagnostic accuracy of cystic fluid CEA with the histological diagnosis. We requested further information from the authors if any clarification was needed. Pooled estimates of sensitivity, specificity, likelihood ratio (LR) and diagnostic odds ratio (DOR) were calculated using random-effects models. Summary receiver-operating characteristic (sROC) curves were used to analyze the diagnostic accuracy of cystic fluid CEA in distinguishing benign and malignant pancreatic cysts. Results: Of 842 articles, 8 studies (n= 504) met the inclusion criteria. The cut-off for determining malignant cyst ranged from 109.9 - 6,000 ng/ml among various studies. The pooled estimates of intracystic CEA level in prediction of malignant pancreatic cysts were poor, with a pooled sensitivity of 63% (95% CI, 55-69), pooled specificity of 63% (95% CI, 57-68). The positive LR was 1.89 (95% CI, 1.13-3.16) and the negative LR was 0.62 (95% CI, 0.40-0.97). The DOR was 3.84 (95% CI, 1.37-10.74). Heterogeneity was observed (I2 = 76%, p , 0.0001). The area under the sROC curve was 0.70 with an SE of 0.09. The maximum joint sensitivity and specificity (Q* value) was 0.66 with an SE of 0.07. In subgroup analysis of patients with mucinous cysts (mucinous cystic neoplasm and IPMN) (5 studies, 227 patients), the pooled sensitivity of intracystic CEA level in prediction of malignant pancreatic cysts was 65% (95% CI, 5773), with the pooled specificity of 66% (95% CI, 59-72) and DOR of 4.74 (95% CI, 1.4615.37). Conclusion: This meta-analysis suggested that the accuracy of intracystic CEA level in differentiating benign and malignant pancreatic cysts was poor. The decision to perform surgical resection for pancreatic cystic lesions including IPMN should not be based solely on a very high intracystic CEA level.
Tu1226 In Vivo Characterization of Pancreatic Serous Cystadenomas by Needle-Based Confocal Laser Endomicroscopy (nCLE). Intra and Inter Observer Agreement Contact Study Bertrand Napoleon, Bertrand Pujol, Anne-Isabelle Lemaistre, Fabrice Caillol, Damien Lucidarme, Bernard Filoche, Blandine Mialhe-Morellon, Fabien Fumex, Vincent Lepilliez, Marc Giovannini Introduction: nCLE enables microscopic observation of solid organs, in vivo and in realtime, during an EUSFNA procedure. A prospective multicentric french study (CONTACT) aims at assessing the diagnostic performance of nCLE for the diagnosis of pancreatic cysts. The chosen interpretation criteria have been defined during a previous study (INSPECT), but the definition of complementary criteria was considered after the inclusion of the first 10 patients. 2 investigators and 2 pathologists reviewed the 10 recordings and identified a new aspect: the superficial vascular networking (SVN). It matches the serous cystadenoma (SCA) histology. The aim of this preliminary study is to validate this criteria by assessing its diagnostic performance for the diagnosis of SCA, as well as the inter (IOA) and intra observer agreements. Materials and methods:Over 6 months, 18 patients without chronic pancreatitis and with a lonely pancreatic cyst . 2cm large were enrolled. Following EUS examination, the nCLE miniprobe was introduced in a 19G needle and real-time video sequences of the cyst wall were recorded.Fluid obtained by FNA was analyzed. Final diagnosis of SCA (n=8) was based on the following characteristics: -transsonor fluid, absence of nodule, parietal vegetations or solid tumor on EUS, -absence of cytologic criteria suggesting a mucinous lesion +/- SCA cells, -intracystic tumoral marker CEA , 5.The other lesions were considered as mucinous cystadenoma (n=5,proven by surgery),IPMN (n=3),pseudocysts (n= 2). IOA was evaluated by 6 investigators (4 experts,2 beginners) who reviewed a set of 18 video sequences (8 SCA and 10 non SCA) in a randomized order after a basic training on image interpretation (2 cases, one with SVN). The intraobserver agreement was evaluated, in parallel, by 1 beginner and 1 expert who reviewed twice the same set in a different order. Following this evaluation, a joint review was done for cases for which a discrepancy of interpretation was observed. A final consensus for the diagnosis was proposed if possible. Results:The intraobserver agreement was excellent and identical for the beginner and the expert (κ 0.87).The IOA was good to excellent ( κ 0.69). In 72% of cases the agreement between the 6 observers was complete.A final consensus was obtained in the 28% remaining cases.Compared to the final diagnosis, the accurracy, sensitivity, specificity, PPV and NPV for the diagnosis of SCA by nCLE were respectively 83%, 62.5%, 100%, 100% and 77%. Conclusion: The presence of SVN is a histological particularity of SCA, which can be highlighted by nCLE. The specificity and PPV of the sign is 100% in this preliminary series. Its presence could avoid unnecessary surgery for SCA. The second phase of the study should enable to validate prospectively this sign and confirm the interest of nCLE for the diagnosis of pancreatic cystic tumors.
Table 2 - Prevalence of PCL by MELD Score
Twenty patients had missing labs and therefore were excluded from the MELD sub-analysis.
Tu1227
Tu1229
Long-Term Follow up of Branch Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Single Center Experience Manabu Osanai, Hiroyuki Maguchi, Kei Yane, Toshifumi Kin, Ryo Takaki, Kazuyuki Matsumoto, Tomoaki Matsumori, Katsushige Gon, Akio Katanuma, Kuniyuki Takahashi
Pancreatic Cyst Prevalence and the Risk of Mucin-Producing Adenocarcinoma in United States Adults Timothy B. Gardner, Lisa M. Glass, Stuart R. Gordon BACKGROUND & AIMS: The presence of a pancreatic cyst often prompts concern, although the rate of malignant transformation to mucin-producing adenocarcinoma is not known. We aimed to determine the prevalence rate of mucin-producing adenocarcinoma in United States adults with pancreatic cysts. METHODS: This retrospective, population-based crosssectional study calculated the annual number of mucin-producing adenocarcinomas using the SEER 18 database and the 2010 United States census. The overall prevalence rate of cysts in the population was found using data from large cross-sectional imaging studies of incidental cyst prevalence. Prevalence rates were then calculated by dividing the annual number of mucin-producing adenocarcinomas by the cyst prevalence rate. RESULTS: Between 2005 and 2009, 1,336 mucin-producing adenocarcinomas were estimated to be found annually in a United States adult population of 137,154,960. The total number of pancreas cysts, given a cyst prevalence rate of 2.5%, was 4,110,737. Therefore, the prevalence of mucin-producing adenocarcinoma arising in patients with pancreatic cysts was 32.5 per 100,000 (95% C.I. 21.8, 43.2). The prevalence rate was 31.2 per 100,000 (20.3, 42.1) in females and 34.0 per 100,000 (22.6, 45.4) in males. As expected, the rate of malignant transformation increased linearly with advancing age (highest 45.1 per 100,000 in 80-84 year old males). CONCLUSION: Malignant transformation of pancreatic cysts into mucinproducing adenocarcinoma in United States adults is a very rare event. Current clinical
BACKGROUND & AIMS; In the IPMN/MCN international consensus guidelines, branch duct IPMN (BD-IPMN) have changed from rather early resection to more deliberate observation. However, long term follow-up result of BD-IPMN has been limited, the aim of this study was to clarify the natural history of BD-IPMN. METHODS; 582 patients with BD-IPMNs were treated in our institute from 1997 to 2012. 116 patients with BD-IPMNs with more than 5 years imaging follow-up were identified and their cases reviewed. Evaluation points were 1) initial clinical data, 2) progression rate, 3) incidence of ordinary pancreatic cancer, and 4) outcomes. RESULTS; 1)Mean observation period was 90 months (61 to 185 months) (M:F=41:75; median age, 66y). The initial mean size of the cystic lesion is 19.9mm (10~45), diameter of the main pancreatic duct (MPD) is 3.0mm (2~10). 97 patients (86%) had no mural nodules, while 19 patients initially had mural nodules (1~9mm, mean 3.5mm). 2) Twenty-one patients (18.1%) exhibited progression with an increasing cyst size, MPD diameter, or appearance and/or enlargement of mural nodules. Surgical resection was performed in 7 (33.3%) of 21 patients with progression and 5 (5.3%) of 95 patients without changes. Pathological diagnosis; with progression group was 5 adenoma, 1 carcinoma in situ, and 1 invasive IPMC, without progression group was 4 adenoma and 1 minimally invasive IPMC. 3) Two patients died of extrapancreatic malignancies, 2 patients died of newly developed
S-797
AGA Abstracts
AGA Abstracts
included studies that compare the diagnostic accuracy of cystic fluid CEA with the histological diagnosis. We requested further information from the authors if any clarification was needed. Pooled estimates of sensitivity, specificity, likelihood ratio (LR) and diagnostic odds ratio (DOR) were calculated using random-effects models. Summary receiver-operating characteristic (sROC) curves were used to analyze the diagnostic accuracy of cystic fluid CEA in distinguishing benign and malignant pancreatic cysts. Results: Of 842 articles, 8 studies (n= 504) met the inclusion criteria. The cut-off for determining malignant cyst ranged from 109.9 - 6,000 ng/ml among various studies. The pooled estimates of intracystic CEA level in prediction of malignant pancreatic cysts were poor, with a pooled sensitivity of 63% (95% CI, 55-69), pooled specificity of 63% (95% CI, 57-68). The positive LR was 1.89 (95% CI, 1.13-3.16) and the negative LR was 0.62 (95% CI, 0.40-0.97). The DOR was 3.84 (95% CI, 1.37-10.74). Heterogeneity was observed (I2 = 76%, p , 0.0001). The area under the sROC curve was 0.70 with an SE of 0.09. The maximum joint sensitivity and specificity (Q* value) was 0.66 with an SE of 0.07. In subgroup analysis of patients with mucinous cysts (mucinous cystic neoplasm and IPMN) (5 studies, 227 patients), the pooled sensitivity of intracystic CEA level in prediction of malignant pancreatic cysts was 65% (95% CI, 5773), with the pooled specificity of 66% (95% CI, 59-72) and DOR of 4.74 (95% CI, 1.4615.37). Conclusion: This meta-analysis suggested that the accuracy of intracystic CEA level in differentiating benign and malignant pancreatic cysts was poor. The decision to perform surgical resection for pancreatic cystic lesions including IPMN should not be based solely on a very high intracystic CEA level.