Predictors of malignancy in chronic calcific pancreatitis with head mass

Abstract

AIM:To prospectively analyse the clinical, biochemical and radiological characteristics of the mass lesions arising in a background of chronic calcific pancreatitis (CCP). METHODS:Eighty three patients, who presented with chronic pancreatitis (CP) and a mass lesion in the head of pancreas between February 2005 and December 2011, were included in the study. Patients who were identified to have malignancy underwent Whipple' s procedure and patients whose investigations were suggestive of a benign lesion underwent Frey's procedure. Student t -test was used to compare the mean values of imaging findings [common bile duct (CBD), main pancreatic duct (MPD) size] and laboratory data [Serum bilirubin,] between the groups. Receiver operating characteristic curve (ROC curve) analysis was done to calculate the cutoff valves of serum bilirubin, CA 19-9, MPD and CBD size. The sensitivity, specificity, positive predictive valve (PPV) and negative predictive value (NPV) were calculated using these cut off points. Multivariate analysis was performed using logistic regression model. RESULTS:The study included 56 men (67.5%) and 27 women (32.5%). Sixty (72.3%) patients had tropical calcific pancreatitis and 23 (27.7%) had alcohol related CCP. Histologically, it was confirmed that 55 (66.3%) of the 83 patients had an inflammatory head mass and 28 (33.7%) had a malignant head mass. The mean age of individuals with benign inflammatory mass and those with malignant mass was 38.4 years and 45 years respectively. Significant clinical features that predicted a malignant head mass in CP were presence of a head mass in CCP of tropics, old age, jaundice, sudden worsening abdominal pain, gastric outlet obstruction and significant weight loss (P ≤ 0.05). The ROC curve analysis showed a cut off value of 5.8 mg/dL for serum bilirubin, 127 U/mL for CA 19-9, 11.5 mm for MPD size and 14.5 mm for CBD size. CONCLUSION:Elevated Serum bilirubin and CA 19-9, and dilated MPD and CBD were useful in predicting malignancy in patients with CCP and head mass.

Pancreatic Cancer in Chronic Pancreatitis

“…The utility of CA19-9 in differentiating an inflammatory head mass in CP from a malignant mass has been frequently investigated. Perumal et al [30] reported that CA19-9 was the single most important risk factor in predicting malignancy in CP with a head mass and a level>127 IU/ml had a sensitivity of 85.7 % and specificity of 96.5 % in predicting malignancy. However the study concluded that the CA19-9 level is best considered along with other parameters, like serum bilirubin level, CBD diameter and MPD diameter for highest predictive accuracy.…”

Diagnosis and Management of Pancreatic Adenocarcinoma in the Background of Chronic Pancreatitis: Core Issues

“…PDAC is associated with double duct sign (dilated MPD and CBD with an abrupt cutoff at the mass) more commonly in head of pancreas mass than body mass [7,8]. Ductal dilatation in PDAC is significantly more than in CP.…”

“…The sensitivity for suspecting malignancy was 100% when serum bilirubin > 5.8 mg/dL, CBD > 14.5 mm, MPD > 11.5 mm, and CA 19-9 > 127 U/mL were all present in a patient. However, this is very rarely seen in practice [8].…”

“…Ductal dilatation in PDAC is significantly more than in CP. A study has shown that MPD dilatation > 11.5 mm and common bile duct dilatation > 14.5 mm is a specific marker of PDAC in CP [8]. In PDAC, the lesion does not contain any ducts, whereas a pseudotumor contains main duct or isolated dilated side branches within, known as the duct penetrating sign seen in 85% of CP and only 4% of PDAC [18].…”

“…A malignancy in CP can be seen radiologically as a lesion in diffuse CP or mass forming focal CP [6][7][8]. An inflammatory lesion in head of pancreas, called a pseudotumor, can be seen in 10% of presumed and resected adenocarcinomas [9].…”