A new combined criterion to better predict malignant lesions in patients with pancreatic cystic neoplasms

Abstract

Objective:Cystic lesions of the pancreas have been increasingly recognized. Some lesions exhibit benign behavior, while others have unequivocal malignant potential. Thus, accurate identification of malignancy in patients diagnosed with pancreatic cystic neoplasms (PCNs) remains a major challenge. The aim of this study was to define a combined criterion to better predict malignant lesions in patients with PCNs.Methods:We retrospectively analyzed 165 patients who underwent resection of PCNs from October 2011 to May 2017. The relationship among malignancy and serum carbohydrate antigen 19-9 (CA19-9), preoperative neutrophil-to-lymphocyte ratio (NLR), and the presence of enhanced solid component on imaging was analyzed.Results:NLR before surgery in patients with malignant PCNs (2.81±2.14) was significantly higher than that in patients diagnosed with pancreatic neuroendocrine tumor (1.90±0.69, P=0.013) or healthy volunteers (1.40±0.48; P<0.001). Serum CA19-9 ≥39 U/mL, NLR >1.976 and presence of enhanced solid component were independent predictors of PCN malignancy. A combined criterion meeting any two or more of the three elements including CA19-9 ≥39 U/mL, NLR >1.976, and presence of enhanced solid component on computed tomography imaging is an indicator with a high positive predictive value of 80.5% and a high negative predictive value of 87.9%, and thus, represents a highly accurate test (86.1%). Conclusions:The new combined criterion is an effective predictor of tumor malignancy in patients with PCNs.

Diagnostic approaches for pancreatic cystic lesions

“…4 There was a significant association between the preoperative levels of tumour marker levels and PCN malignancy (CA 19-9 P < 0.001, CA 242 P < 0.001, CEA P = 0.010). 4 Furthermore a CA 19-9 level of ≥39 U/mL was shown to have a 68.4% sensitivity and 88.2% specificity for predicting PCN malignancy. Despite the low sensitivity of CA 19-9 as an independent marker, when combined with the presence of enhanced solid components on CT imaging the sensitivity and specificity rises to 83.3% and 85.1%, respectively.…”

“…Despite the low sensitivity of CA 19-9 as an independent marker, when combined with the presence of enhanced solid components on CT imaging the sensitivity and specificity rises to 83.3% and 85.1%, respectively. 4…”

“…4,6 Accurate and timely diagnoses enables appropriate management protocols to be instigated, potentially prevents the development of malignant lesions which are unlikely to be cured while avoiding unnecessary surgical procedures and the associated morbidity. 4,5 The currently available guidelines recommend a multidisciplinary approach to the investigation and diagnosis of PCLs. This approach combines clinical and radiological findings, assisted by endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA), EUS-FNA cytology, cyst fluid analysis and tumour markers.…”

“…The pre‐operative diagnosis of cystic lesions of the pancreas, which can be inflammatory or proliferative, continue to present clinicians with an increasingly common diagnostic challenge due to the heterogeneity of the pathological processes involved 1,3 . From benign epithelial cysts to aggressive and invasive mucinous cystadenocarcinomas, cystic lesions of the pancreas constitute an entity of diverse histology 4,5 . Although rare, the known potential for malignant transformation of a number of these benign lesions and the opportunity for curative surgery if performed at an appropriate stage, makes it essential that our diagnostic approach is accurate, reproducible and timely and applicable to all the lesions that are encompassed within the range of PCLs 4,6 .…”

“…From benign epithelial cysts to aggressive and invasive mucinous cystadenocarcinomas, cystic lesions of the pancreas constitute an entity of diverse histology 4,5 . Although rare, the known potential for malignant transformation of a number of these benign lesions and the opportunity for curative surgery if performed at an appropriate stage, makes it essential that our diagnostic approach is accurate, reproducible and timely and applicable to all the lesions that are encompassed within the range of PCLs 4,6 . Accurate and timely diagnoses enables appropriate management protocols to be instigated, potentially prevents the development of malignant lesions which are unlikely to be cured while avoiding unnecessary surgical procedures and the associated morbidity 4,5 …”