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Su1464 Features Associated With Interval Progression of Small Pancreatic Cystic Lesions - A Retrospective Study
Su1464
of symptom, diabetes, and level of CA19-9 were not significant different between two groups. Mortality was also not different between non-surgery and surgery patients during median follow-up period of 36.1 months since the diagnosis of high risk IPMN (1 vs. 2, P=0.570). In the non-surgery group, 25 (65%) patients showed progression, three of whom underwent invasive transformation radiologically. Median time to progression was 43 months. Size ≥ 2 cm (P=0.011) and presence of symptom (P=0.018) were proved to be risk factors of progression in the univariate analysis. Conclusion: This study suggests that watchful waiting could be possible in some IPMN patients with high-risk stigmata, particularly in asymptomatic cysts smaller than 2 cm.
AGA Abstracts
Features Associated With Interval Progression of Small Pancreatic Cystic Lesions - A Retrospective Study Chiung-Yu Chen, Chiao-Hsiung Chuang, Hong-Ming Tsai Background Small pancreatic cystic lesions without concerning findings such as mural nodule are advised to undergo surveillance. However, they can trigger significant anxiety for patients and their physicians. We aimed to investigate the progression of pancreatic cystic lesion and find if any clinical and imaging features that might be associated with the progression. Patients and Methods Patients with pancreatic cystic lesions other than pseudocyst detected incidentally by sonography, computed tomography, or magnetic resonance imaging with at least one year follow-up were retrospectively enrolled. Cystic lesions larger than 3 cm in size or had solid component or accompanied with dilated pancreatic duct more than 5mm were excluded. The interval progression of cystic lesions was checked and the rate of change was determined. The clinical features of patients and imaging characteristics were compared between the patients with and without progression of pancreatic cystic lesion. Results In total, 166 patients were enrolled. The mean follow-up period was 4.3 ± 2.3 years (range 1.0 to 10.1 years) and the mean progression was 0.8 ± 1.3 mm/ year (range 0 to 6.1 mm). One hundred and seven patients had interval progression of pancreatic cystic lesion. These patients were further divided into two nearly equal groups, the minimal change group (n = 53) and the progression group (n = 54), by using a progression rate less or more than 1 mm/year. Regarding to the imaging features, tubular component, septation, or dilated pancreatic duct were more frequently associated with progressive pancreatic cystic lesions than minimal changed or unchanged lesions (p < 0.05). Compared to the unchanged lesions, the pancreatic cystic lesions were likely to be progressive if they had septation (OR 4.534, 95% CI: 1.384 - 14.852, p = 0.013) or tubular components (OR 4.247, 95% CI: 1.312 - 13.748, p = 0.016). Besides, patients with progressive cystic lesion were older than the other patients (p < 0.05). Conclusions Small pancreatic cystic lesion progressed slowly. However, lesions with tubular component, septation or pancreatic duct dilation may be related to mucinous neoplasm and therefore, were more apt to be progressive. Presence of these imaging features and together with an older age of patients may require a shorter surveillance interval. Clinical and Imaging Characteristic of Patients
Su1466 The Value of KRAS Mutation Testing With CEA for the Diagnosis of Pancreatic Mucinous Cysts Abdurrahman Kadayifci, Mohammad A. Al-Haddad, Mustafa Atar, John M. DeWitt, David G. Forcione, Stuart Sherman, Brenna Casey, Carlos Fernandez-del Castillo, C. Max Schmidt, Martha B. Pitman, William R. Brugge Background and aim: The presence of a KRAS mutation in pancreatic cyst fluid (PCF) has been suggested as a highly specific test for the diagnosis of a mucinous cyst. Traditionally, PCF CEA has been used as the most accurate test for a mucinous cyst. This study aimed to assess the value of PCF KRAS mutational analysis added to CEA for the diagnosis of mucinous cysts. Methods: The study was a retrospective analysis of prospectively collected endoscopic ultrasonography fine needle aspiration data at two academic centers. In the past 8 years, KRAS mutational analysis was added to PCF testing (fluid volume >0.5ml). KRAS mutation was determined by RedPath Integrated Pathology laboratory (Pittsburgh, PA) or by SNaPshot (Life technologies) genotyping. PCF CEA level was measured by radioimmunoassay (Abbott diagnostics). CEA value >192 ng/ml was considered diagnostic of a mucinous cyst. Cytology was considered diagnostic of a mucinous cyst with the identification of mucinous epithelium with cytoplasmic mucin, high-grade dysplasia or adenocarcinoma. Cysts were classified by histology (surgical cohort) or findings of institutional cytology and EUS (thickened wall, mural nodules, septation, adjacent mass, or ductal communication) (clinical cohort). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy and area under curve (AUC) of KRAS, CEA and their combination were calculated for the diagnosis of a mucinous cyst. Results: A total of 932 patients underwent investigation; 136 in surgical cohort (100 mucinous, 36 non-mucinous), 796 in clinical cohort (539 mucinous, 257 non-mucinous). The diagnostic characteristics of KRAS, CEA and KRAS-CEA combination for mucinous and non-mucinous differentiation are summarized in the Table 1. KRAS and CEA each have high specificity, but low sensitivity for the diagnosis of a mucinous cyst in both surgical and clinical cohorts. The combination of KRAS and CEA increased the sensitivity. Accordingly, the diagnostic accuracy and AUC of the combined tests was significantly higher than KRAS or CEA alone in the clinical cohort. KRAS mutation was significantly more frequent in malignant mucinous cysts compared to histologically confirmed non-malignant mucinous cysts (78% vs. 41%, p=0.001). The NPV of KRAS mutation was 87.5% in differentiating non-malignant from malignant cysts. Conclusion: The detection of a KRAS mutation in PCF is a highly specific test for mucinous cysts. The addition of KRAS testing to CEA improves the accuracy of the diagnosis of pancreatic mucinous cysts in a clinical cohort. The absence of a KRAS mutation may also have a role in risk stratification of mucinous cysts in predicting a non-malignant mucinous cyst. Table 1. The diagnostic value of CEA, KRAS and their combination to differentiate mucinous vs. non-mucinous cysts.
^p<0.01 vs KRAS+ , >0.05 vs CEA↑ alone, *p<0.0001 vs. KRAS+ and CEA↑ alone, ~p>0.05 vs. KRAS+ and CEA↑ alone
†By ANOVA and Chi square test; a significant difference when compared with unchanged group, b significant difference when compared with minimal change group c significant difference when compared with progression group
Su1467 Su1465 Success of Endoscopic Ultrasound-Guided Ethanol Ablation of Pancreatic Cysts: A Meta-Analysis and Systematic Review Manasa Kandula, Harsha Moole, Michael D. Cashman, Fritz-Henry Volmar, Matthew L. Bechtold, Srinivas R. Puli
Prognosis of Non-Surgery Patients With High-Risk Intraductal Papillary Mucinous Neoplasm Dong Kee Jang, Kwang Hyun Chung, Ban Seok Lee, Joo Kyung Park, Sang Hyub Lee, Ji Kon Ryu, Yong-Tae Kim
Background: Pancreatic cystic lesions represent a wide spectrum of histopathology that includes pseudocysts, non-neoplastic pancreatic cysts and pancreatic cystic neoplasms. Surgical resection is the recommended standard of care for symptomatic and pre-malignant lesions. However, surgery is associated with a peri-operative morbidity of 20 to 36% and a mortality of 2%. Previous studies have shown that endoscopic ultrasound (EUS)-guided ethanol ablation may be a feasible alternative for the management of pancreatic cysts. This is a meta-analysis and systematic review to assess the overall safety and efficacy of EUS guided ethanol ablation of pancreatic cysts. Aim: To evaluate the efficacy and safety of EUSguided ethanol injection for the ablation of pancreatic cysts. Method: Study Selection Criteria: EUS-guided ethanol ablation of pancreatic cysts Data collection & extraction: Articles were searched in Medline, Pubmed, Ovid journals, CINAH, International pharmaceutical abstracts,old Medline, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews. Two reviewers independently searched and extracted data. Any differences were resolved by mutual agreement. Statistical Method:
Background/aim: According to the 2012 international guidelines, surgery should be considered in all main-duct (MD)/mixed type and branch-duct (BD) type intraductal papillary mucinous neoplasm (IPMN) with high-risk stigmata. The aim of this study was to evaluate the prognosis of non-surgery patients with high-risk IPMN. Methods: One hundred fifty patients with highrisk IPMN diagnosed at Seoul National University Hospital between 2004 and 2014 were retrospectively enrolled. High-risk features included all MD/mixed type and BD type IPMNs with mural nodules, main pancreatic duct dilation of ≥10 mm, or obstructive jaundice. Patients with invasive or unresectable IPMN were excluded. In the non-surgery patients, "progression" was defined as either growth at least 20% or invasive transformation radiologically. Results: A total of 136 subjects composed of 41 non-surgery and 95 surgery patients were included in the analysis. The surgery group had larger mean cyst size (3.54 vs. 2.66 cm, P=0.046) and less proportion of subjects with multifocal cysts (22.1 vs. 51.2%, P= 0.001). Other characteristics including age, type of IPMN, kinds of risk factors, sites, presence
AGA Abstracts
S-520
of symptom, diabetes, and level of CA19-9 were not significant different between two groups. Mortality was also not different between non-surgery and surgery patients during median follow-up period of 36.1 months since the diagnosis of high risk IPMN (1 vs. 2, P=0.570). In the non-surgery group, 25 (65%) patients showed progression, three of whom underwent invasive transformation radiologically. Median time to progression was 43 months. Size ≥ 2 cm (P=0.011) and presence of symptom (P=0.018) were proved to be risk factors of progression in the univariate analysis. Conclusion: This study suggests that watchful waiting could be possible in some IPMN patients with high-risk stigmata, particularly in asymptomatic cysts smaller than 2 cm.
AGA Abstracts
Features Associated With Interval Progression of Small Pancreatic Cystic Lesions - A Retrospective Study Chiung-Yu Chen, Chiao-Hsiung Chuang, Hong-Ming Tsai Background Small pancreatic cystic lesions without concerning findings such as mural nodule are advised to undergo surveillance. However, they can trigger significant anxiety for patients and their physicians. We aimed to investigate the progression of pancreatic cystic lesion and find if any clinical and imaging features that might be associated with the progression. Patients and Methods Patients with pancreatic cystic lesions other than pseudocyst detected incidentally by sonography, computed tomography, or magnetic resonance imaging with at least one year follow-up were retrospectively enrolled. Cystic lesions larger than 3 cm in size or had solid component or accompanied with dilated pancreatic duct more than 5mm were excluded. The interval progression of cystic lesions was checked and the rate of change was determined. The clinical features of patients and imaging characteristics were compared between the patients with and without progression of pancreatic cystic lesion. Results In total, 166 patients were enrolled. The mean follow-up period was 4.3 ± 2.3 years (range 1.0 to 10.1 years) and the mean progression was 0.8 ± 1.3 mm/ year (range 0 to 6.1 mm). One hundred and seven patients had interval progression of pancreatic cystic lesion. These patients were further divided into two nearly equal groups, the minimal change group (n = 53) and the progression group (n = 54), by using a progression rate less or more than 1 mm/year. Regarding to the imaging features, tubular component, septation, or dilated pancreatic duct were more frequently associated with progressive pancreatic cystic lesions than minimal changed or unchanged lesions (p < 0.05). Compared to the unchanged lesions, the pancreatic cystic lesions were likely to be progressive if they had septation (OR 4.534, 95% CI: 1.384 - 14.852, p = 0.013) or tubular components (OR 4.247, 95% CI: 1.312 - 13.748, p = 0.016). Besides, patients with progressive cystic lesion were older than the other patients (p < 0.05). Conclusions Small pancreatic cystic lesion progressed slowly. However, lesions with tubular component, septation or pancreatic duct dilation may be related to mucinous neoplasm and therefore, were more apt to be progressive. Presence of these imaging features and together with an older age of patients may require a shorter surveillance interval. Clinical and Imaging Characteristic of Patients
Su1466 The Value of KRAS Mutation Testing With CEA for the Diagnosis of Pancreatic Mucinous Cysts Abdurrahman Kadayifci, Mohammad A. Al-Haddad, Mustafa Atar, John M. DeWitt, David G. Forcione, Stuart Sherman, Brenna Casey, Carlos Fernandez-del Castillo, C. Max Schmidt, Martha B. Pitman, William R. Brugge Background and aim: The presence of a KRAS mutation in pancreatic cyst fluid (PCF) has been suggested as a highly specific test for the diagnosis of a mucinous cyst. Traditionally, PCF CEA has been used as the most accurate test for a mucinous cyst. This study aimed to assess the value of PCF KRAS mutational analysis added to CEA for the diagnosis of mucinous cysts. Methods: The study was a retrospective analysis of prospectively collected endoscopic ultrasonography fine needle aspiration data at two academic centers. In the past 8 years, KRAS mutational analysis was added to PCF testing (fluid volume >0.5ml). KRAS mutation was determined by RedPath Integrated Pathology laboratory (Pittsburgh, PA) or by SNaPshot (Life technologies) genotyping. PCF CEA level was measured by radioimmunoassay (Abbott diagnostics). CEA value >192 ng/ml was considered diagnostic of a mucinous cyst. Cytology was considered diagnostic of a mucinous cyst with the identification of mucinous epithelium with cytoplasmic mucin, high-grade dysplasia or adenocarcinoma. Cysts were classified by histology (surgical cohort) or findings of institutional cytology and EUS (thickened wall, mural nodules, septation, adjacent mass, or ductal communication) (clinical cohort). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy and area under curve (AUC) of KRAS, CEA and their combination were calculated for the diagnosis of a mucinous cyst. Results: A total of 932 patients underwent investigation; 136 in surgical cohort (100 mucinous, 36 non-mucinous), 796 in clinical cohort (539 mucinous, 257 non-mucinous). The diagnostic characteristics of KRAS, CEA and KRAS-CEA combination for mucinous and non-mucinous differentiation are summarized in the Table 1. KRAS and CEA each have high specificity, but low sensitivity for the diagnosis of a mucinous cyst in both surgical and clinical cohorts. The combination of KRAS and CEA increased the sensitivity. Accordingly, the diagnostic accuracy and AUC of the combined tests was significantly higher than KRAS or CEA alone in the clinical cohort. KRAS mutation was significantly more frequent in malignant mucinous cysts compared to histologically confirmed non-malignant mucinous cysts (78% vs. 41%, p=0.001). The NPV of KRAS mutation was 87.5% in differentiating non-malignant from malignant cysts. Conclusion: The detection of a KRAS mutation in PCF is a highly specific test for mucinous cysts. The addition of KRAS testing to CEA improves the accuracy of the diagnosis of pancreatic mucinous cysts in a clinical cohort. The absence of a KRAS mutation may also have a role in risk stratification of mucinous cysts in predicting a non-malignant mucinous cyst. Table 1. The diagnostic value of CEA, KRAS and their combination to differentiate mucinous vs. non-mucinous cysts.
^p<0.01 vs KRAS+ , >0.05 vs CEA↑ alone, *p<0.0001 vs. KRAS+ and CEA↑ alone, ~p>0.05 vs. KRAS+ and CEA↑ alone
†By ANOVA and Chi square test; a significant difference when compared with unchanged group, b significant difference when compared with minimal change group c significant difference when compared with progression group
Su1467 Su1465 Success of Endoscopic Ultrasound-Guided Ethanol Ablation of Pancreatic Cysts: A Meta-Analysis and Systematic Review Manasa Kandula, Harsha Moole, Michael D. Cashman, Fritz-Henry Volmar, Matthew L. Bechtold, Srinivas R. Puli
Prognosis of Non-Surgery Patients With High-Risk Intraductal Papillary Mucinous Neoplasm Dong Kee Jang, Kwang Hyun Chung, Ban Seok Lee, Joo Kyung Park, Sang Hyub Lee, Ji Kon Ryu, Yong-Tae Kim
Background: Pancreatic cystic lesions represent a wide spectrum of histopathology that includes pseudocysts, non-neoplastic pancreatic cysts and pancreatic cystic neoplasms. Surgical resection is the recommended standard of care for symptomatic and pre-malignant lesions. However, surgery is associated with a peri-operative morbidity of 20 to 36% and a mortality of 2%. Previous studies have shown that endoscopic ultrasound (EUS)-guided ethanol ablation may be a feasible alternative for the management of pancreatic cysts. This is a meta-analysis and systematic review to assess the overall safety and efficacy of EUS guided ethanol ablation of pancreatic cysts. Aim: To evaluate the efficacy and safety of EUSguided ethanol injection for the ablation of pancreatic cysts. Method: Study Selection Criteria: EUS-guided ethanol ablation of pancreatic cysts Data collection & extraction: Articles were searched in Medline, Pubmed, Ovid journals, CINAH, International pharmaceutical abstracts,old Medline, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews. Two reviewers independently searched and extracted data. Any differences were resolved by mutual agreement. Statistical Method:
Background/aim: According to the 2012 international guidelines, surgery should be considered in all main-duct (MD)/mixed type and branch-duct (BD) type intraductal papillary mucinous neoplasm (IPMN) with high-risk stigmata. The aim of this study was to evaluate the prognosis of non-surgery patients with high-risk IPMN. Methods: One hundred fifty patients with highrisk IPMN diagnosed at Seoul National University Hospital between 2004 and 2014 were retrospectively enrolled. High-risk features included all MD/mixed type and BD type IPMNs with mural nodules, main pancreatic duct dilation of ≥10 mm, or obstructive jaundice. Patients with invasive or unresectable IPMN were excluded. In the non-surgery patients, "progression" was defined as either growth at least 20% or invasive transformation radiologically. Results: A total of 136 subjects composed of 41 non-surgery and 95 surgery patients were included in the analysis. The surgery group had larger mean cyst size (3.54 vs. 2.66 cm, P=0.046) and less proportion of subjects with multifocal cysts (22.1 vs. 51.2%, P= 0.001). Other characteristics including age, type of IPMN, kinds of risk factors, sites, presence
AGA Abstracts
S-520