Cystic pancreatic neoplasms in a tertiary gastroenterologic referral center: Evaluation of the diagnostic accuracy of endoscopic ultrasound, progression rate and malignancy rate in a large unicentric cohort

Abstract

Introduction Cystic pancreatic neoplasms (CPN) are frequently diagnosed due to better diagnostic techniques and patients becoming older. However, diagnostic accuracy of endoscopic ultrasound (EUS) and value of follow-up are still unclear.

Material and Methods The aim of our retrospective study was to investigate the frequency of different cystic pancreatic neoplasms (intraductal papillary mucinous neoplasm [IPMN], serous and mucinous cystadenoma, solid pseudopapillary neoplasia), diagnostic accuracy, size progression, and rate of malignancy using EUS in a tertiary reference center in Germany. Between January 1, 2012 and December 31, 2018, 455 patients were diagnosed with cystic pancreatic lesions (798 EUS examinations).

Results Endoscopic ultrasound diagnosed 223 patients with cystic pancreatic neoplasms, including 138 (61.9%) patients with branch duct IPMN, 16 (7.2%) with main duct IPMN, and five (2.2%) with mixed-type IPMN. In the largest subgroup of branch duct IPMN, cysts were size progressive in 20 patients (38.5%). Fine needle aspiration (FNA) was performed in 21 patients, and confirmed the suspected diagnosis in 12/21 patients. 28 surgical resections were performed, in 7/28 patients (25%), high-grade dysplasia or cancer was diagnosed. Endoscopic ultrasound diagnosis of serous and mucinous cystic pancreatic neoplasms was correct in 68.4%.

Conclusions Endoscopic ultrasound differential diagnosis of CPNs is challenging. Even in a tertiary expert center, differentiation of serous and mucinous cystic neoplasia is not guaranteed. Relevant size progression of CPN, however, is rare, as is the rate of malignancy. The data of this study suggest that morphologic criteria to assess pancreatic cysts alone are not sufficient to allow a clear diagnosis. Hence, for the improved assessment of pancreatic cysts, EUS should be combined with additional tests and techniques such as MRT/MRCP, contrast-enhanced EUS, and/or FNA/fine needle biopsy including fluid analysis. The combination and correlation of imaging studies with EUS findings is mandatory.

Zusammenfassung

Einleitung Zystische pankreatische Neoplasien (ZPN) werden angesichts besserer diagnostischer Techniken und älter werdender Patienten häufiger diagnostiziert. Nichtsdestotrotz sind diagnostische Präzision und Bedeutung von Verlaufskontrollen des EUS unklar.

Material und Methodik Das Ziel der retrospektiven Studie war die Erhebung der Häufigkeit distinkter ZPNs (intraduktale papilläre muzinöse Neoplasie [IPMN], seröse und muzinöse Zystadenome, solide pseudopapilläre Neoplasie), der diagnostischen Präzision (Feinnadelpunktion, operative Resektion), der Grössenprogression sowie der Rate an maligner Entartung mittels EUS in einem tertiären Referenzzentrum in Deutschland. Hierfür wurden 455 Patienten mit zystischen pankreatischen Läsionen vom 1. Januar 2012 bis zum 31. Dezember 2018 untersucht (798 EUS Untersuchungen).

Ergebnisse 223 Patienten mit ZPN wurden diagnostiziert, davon 138 (61.9%) Patienten mit Seitengang-IPMN, 16 (7.2%) mit Hauptgang-IPMN und 5 (2.2%) mit mixed-type IPMN. In der größten Sub-Gruppe der Seitengang-IPMN waren die Zysten bei 20 Patienten (38.5%) größenprogredient. Feinnadelpunktionen wurden bei 21 Patienten durchgeführt, und bestätigten die vermutete EUS-Diagnose bei 12/21 Patienten. 28 Operationen wurden durchgeführt, dabei wurden bei 7/28 Patienten (25%) high-grade Dysplasien oder Malignome diagnostiziert. Die mittels EUS vorgenommene Einteilung in seröse und muzinöse ZPNs war in 68.4% der Patienten korrekt.

Schlußfolgerungen Die EUS-basierte Differenzialdiagnose zystischer pankreatischer Neoplasien ist ebenso wie die Differenzierung zwischen serösen und muzinösen Zysten auch in einem Referenzzentrum schwierig. Eine relevante Größenprogression der ZPN im Zeitverlauf ist insgesamt jedoch selten zu verzeichnen, die Rate an malignen Entartungen ist niedrig. Die Daten dieser Studie suggerieren, daß morphologische Kritierien allein nicht ausreichen, um eine klare Diagnose zystischer pankreatischer Neoplasien zu stellen. Deshalb sollte der EUS für eine genauere Einteilung von ZPNs mit zusätzlichen Verfahren wie zum Beispiel der MRT/MRCP, dem Kontrastmittel-Ultraschall und/oder der Feinnadelpunktion/ -biopsie inklusive einer Flüssigkeitsanalyse kombiniert werden. Eine Kombination und Korrelation bildgebender Studien mit EUS-Ergebnissen ist unbedingt zu fordern.

Schlüsselwörter

Pankreatische Zysten - Neoplasie - zystisch - muzinös - serös - Bildgebung - Endosonografie - EUS

Keywords

Pancreatic cysts - Neoplasms - Cystic - Mucinous - Serous - Diagnostic Imaging - Endosonography - EUS

Publication History

Received: 12 October 2021

Accepted after revision: 15 April 2022

Article published online:
25 July 2022

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