Imaging and Cytopathological Criteria Indicating Malignancy in Mucin-Producing Pancreatic Neoplasms

Abstract

Objectives This study aims to evaluate the performance of clinical, imaging, and cytopathological criteria in the identification of high-grade dysplasia/carcinoma (HGD/Ca) in pancreatic mucin-producing cystic neoplasms. Methods Sixty-eight consecutive, histopathologically confirmed mucin-producing cystic neoplasms, evaluated by endoscopic ultrasound-guided fine-needle aspiration, were enrolled; specifically, 39 branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), 21 main duct IPMNs, and 8 mucinous cystic neoplasms. The associations between HGD/Ca in histopathology and findings of endoscopic ultrasound and cytology, demographic, lifestyle, and clinical parameters were evaluated, separately in IPMNs and mucinous cystic neoplasms. Results Age 65 years or more was associated with HGD/Ca in IPMNs. In BD-IPMNs, cyst diameter 3 cm or greater (sensitivity, 68.8%; specificity, 65.2%), a mural nodule (sensitivity, 56.3%; specificity, 78.3%), main pancreatic duct diameter 5 to 9 mm (sensitivity, 50.0%; specificity, 87.0%), and suspicious cytology (sensitivity, 81.3%; specificity, 100%) signaled the presence of HGD/Ca. Similarly, in main duct IPMNs, suspicious cytology predicted HGD/Ca with high sensitivity (88.9%) and excellent specificity (100%). Regarding cytopathological criteria, in BD-IPMNs, HGD/Ca was associated with a high nuclear/cytoplasmic ratio, background necrosis, presence of papillary structures, hypochromatic nuclei, hyperchromatic nuclei, and major nuclear membrane irregularities (thickening and/or indentations). Conclusions Clinical, imaging, and cytopathological criteria are useful in the identification of HGD/Ca in IPMNs.

Diagnostic Performance of Pancreatic Cytology with the Papanicolaou Society of Cytopathology System: A Systematic Review, before Shifting into the Upcoming WHO International System

“…Hence, evidence suggests the proposed WHO reporting system, with its two new "pancreatic neoplasm, low-risk/grade" and "pancreatic neoplasm, high-risk/grade" categories, could potentially stratify pancreatic neoplasms (conservative management vs potential surgery) more effectively than the existing PSC system, as highrisk/grade cystic lesions have been associated with a much higher ROM. The criteria to detect HGA in pancreatic cystic fluid cytology-high nuclear/cytoplasmic ratio, nuclear membrane irregularities, hyper-or hypochromasia, and necrosis [26,27]-have been reported to be sensitive and specific to predict HGD or malignancy in histology [28], while demonstrating good interobserver reproducibility [29,30]. Notably, a recent immunohistochemical marker, the Das-1, has shown to be highly accurate detecting high-risk mucinous pancreatic cysts, especially when combined with cytology [31,32].…”

Role of Cross-sectional Imaging (CT/MRI) in Characterization and Distinguishing Benign from Malignant/Potentially Malignant Cystic Lesions of Pancreas

“…Salla et al found that the presence of mural nodule was associated with increased risk of high grade dysplasia/carcinoma in patients with branch duct IPMN. [26] In a recent multicenter study by Postelwait et al; male sex, pancreatic head, and neck location, increased size of the lesion, presence of solid component, or mural nodule, and duct dilatation were independently associated with malignancy in patients with pancreatic mucinous cystic neoplasms. [27] Several societies and associations have formulated guidelines for evaluation, management and follow-up of cystic pancreatic lesions with some differences and similarities between them.…”

Evaluating Pancreatic and Biliary Neoplasms with Small Biopsy-Based Next Generation Sequencing (NGS): Doing More with Less

“…For instance, the Fukuoka guidelines enlist distinct “high-risk stigmata” and “worrisome features”, which should be considered before deciding to surgically excise a pancreatic cystic lesion or recommend close follow-up. The presence of suspicious or positive cytology (microscopic features consistent with HGD or invasion) also triages eligible patients for surgery [ 131 , 132 ]; however, although pancreatic cyst cytology has a high specificity, its sensitivity is considered suboptimal [ 129 ]. Of interest, a recent meta-analysis on the Fukuoka and AGA guidelines found they both exhibited an inadequate diagnostic accuracy to distinguish between low- and high-risk pancreatic cysts [ 133 ].…”