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Diagnostics
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Diagnosis and Management of Pancreatic Cysts
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Diagnosis and Management of Pancreatic Cysts

A special issue of Diagnostics (ISSN 2075-4418). This special issue belongs to the section "Medical Imaging and Theranostics".

Deadline for manuscript submissions: closed (15 December 2022) | Viewed by 33312

Special Issue Editor

Dr. Somashekar G. Krishna

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Guest Editor
Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA

Special Issue Information

Dear Colleagues,

Pancreatic cystic lesions (PCLs) are increasingly incidentally diagnosed due to improved and more frequent imaging studies. These lesions are mostly asymptomatic; nonetheless, they can pose challenges in their diagnosis and management. While imaging studies typically are sufficient for surveillance of cysts smaller than 1 to 2 cm in diameter, larger cysts may necessitate evaluation with endoscopic ultrasound and fine-needle aspiration. Accurate diagnosis of larger cysts is critical since some are neoplastic, with the potential for malignant transformation. Incorrect diagnosis and unwarranted surgery of an otherwise benign cyst impose significant morbidity to the patient. Due to the lack of highly accurate diagnostic techniques for PCLs, multiple consensus and society guidelines have been proposed and instituted. In addition to these guidelines and advances in imaging and endoscopy, numerous institutions discuss managing specific subjects with PCLs in multidisciplinary team meetings to arrive at a consensus. Since the overall risk of transformation to malignancy is low, experts in the management of PCLs are divided; some favor more of a conservative approach, while others prefer endoscopy-guided investigations. In this Special Issue of Diagnostics, we plan to address the complexity of managing PCLs by inviting thought leaders and published authors in this field.

Dr. Somashekar G. Krishna
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Diagnostics is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • Pancreatic cyst
  • Pancreatic cancer
  • Endoscopic ultrasound
  • Next-generation sequencing
  • Confocal endomicroscopy

Published Papers (10 papers)

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Research

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12 pages, 2236 KiB  
Article
Automated Detection of Pancreatic Cystic Lesions on CT Using Deep Learning
by Lorraine Abel, Jakob Wasserthal, Thomas Weikert, Alexander W. Sauter, Ivan Nesic, Marko Obradovic, Shan Yang, Sebastian Manneck, Carl Glessgen, Johanna M. Ospel, Bram Stieltjes, Daniel T. Boll and Björn Friebe
Diagnostics 2021, 11(5), 901; https://doi.org/10.3390/diagnostics11050901 - 19 May 2021
Cited by 12 | Viewed by 3885
Abstract
Pancreatic cystic lesions (PCL) are a frequent and underreported incidental finding on CT scans and can transform into neoplasms with devastating consequences. We developed and evaluated an algorithm based on a two-step nnU-Net architecture for automated detection of PCL on CTs. A total [...] Read more.
Pancreatic cystic lesions (PCL) are a frequent and underreported incidental finding on CT scans and can transform into neoplasms with devastating consequences. We developed and evaluated an algorithm based on a two-step nnU-Net architecture for automated detection of PCL on CTs. A total of 543 cysts on 221 abdominal CTs were manually segmented in 3D by a radiology resident in consensus with a board-certified radiologist specialized in abdominal radiology. This information was used to train a two-step nnU-Net for detection with the performance assessed depending on lesions’ volume and location in comparison to three human readers of varying experience. Mean sensitivity was 78.8 ± 0.1%. The sensitivity was highest for large lesions with 87.8% for cysts ≥220 mm3 and for lesions in the distal pancreas with up to 96.2%. The number of false-positive detections for cysts ≥220 mm3 was 0.1 per case. The algorithm’s performance was comparable to human readers. To conclude, automated detection of PCL on CTs is feasible. The proposed model could serve radiologists as a second reading tool. All imaging data and code used in this study are freely available online. Full article
(This article belongs to the Special Issue Diagnosis and Management of Pancreatic Cysts)
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Review

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15 pages, 888 KiB  
Review
Pancreatic Cystic Neoplasms: Translating Guidelines into Clinical Practice
by Sonmoon Mohapatra, Somashekar G. Krishna and Rahul Pannala
Diagnostics 2023, 13(4), 749; https://doi.org/10.3390/diagnostics13040749 - 16 Feb 2023
Viewed by 3855
Abstract
A combination of several factors, including the increasing use of cross-sectional imaging and an aging population, has led to pancreatic cystic lesions (PCLs) becoming the most detected incidental pancreatic lesions. Accurate diagnosis and risk stratification of PCLs is challenging. In the last decade, [...] Read more.
A combination of several factors, including the increasing use of cross-sectional imaging and an aging population, has led to pancreatic cystic lesions (PCLs) becoming the most detected incidental pancreatic lesions. Accurate diagnosis and risk stratification of PCLs is challenging. In the last decade, several evidence-based guidelines have been published addressing the diagnosis and management of PCLs. However, these guidelines cover different subsets of patients with PCLs and offer varying recommendations regarding diagnostic assessment, surveillance, and surgical resection. Further, recent studies comparing the accuracy of various guidelines have reported significant variations in the rate of missed cancer versus unnecessary surgical resections. In clinical practice, it is challenging to decide which guideline to follow specifically. This article reviews the varying recommendations of the major guidelines and results of comparative studies, provides an overview of newer modalities not included in the guidelines, and offers perspectives on translating the guidelines into clinical practice. Full article
(This article belongs to the Special Issue Diagnosis and Management of Pancreatic Cysts)
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14 pages, 1059 KiB  
Review
Role of Endoscopic Ultrasound in the Evaluation of Pancreatic Cystic Neoplasms: A Concise Review
by Shiva Rangwani, Wasseem Juakiem, Somashekar G. Krishna and Samer El-Dika
Diagnostics 2023, 13(4), 705; https://doi.org/10.3390/diagnostics13040705 - 13 Feb 2023
Cited by 4 | Viewed by 5196
Abstract
Pancreatic cystic lesions are being discovered as incidental lesions during cross-sectional imaging studies of the abdomen with increasing frequency. Endoscopic ultrasound is an important diagnostic modality for managing pancreatic cystic lesions. There are various types of pancreatic cystic lesions, from benign to malignant. [...] Read more.
Pancreatic cystic lesions are being discovered as incidental lesions during cross-sectional imaging studies of the abdomen with increasing frequency. Endoscopic ultrasound is an important diagnostic modality for managing pancreatic cystic lesions. There are various types of pancreatic cystic lesions, from benign to malignant. Endoscopic ultrasound has a multifactorial role in delineating the morphology of pancreatic cystic lesions, ranging from fluid and tissue acquisition for analysis—fine needle aspiration and through-the-needle biopsy, respectively—to advanced imaging techniques, such as contrast-harmonic mode endoscopic ultrasound and EUS-guided needle-based confocal laser endomicroscopy. In this review, we will summarize and provide an update on the specific role of EUS in the management of pancreatic cystic lesions. Full article
(This article belongs to the Special Issue Diagnosis and Management of Pancreatic Cysts)
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16 pages, 9334 KiB  
Review
The Role of Magnetic Resonance Imaging (MRI) in the Diagnosis of Pancreatic Cystic Lesions (PCLs)
by Elit Quingalahua, Mahmoud M. Al-Hawary and Jorge D. Machicado
Diagnostics 2023, 13(4), 585; https://doi.org/10.3390/diagnostics13040585 - 5 Feb 2023
Viewed by 2998
Abstract
Pancreatic cystic lesions (PCLs) are a common incidental finding on cross-sectional imaging. Given the high signal to noise and contrast resolution, multi-parametric capability and lack of ionizing radiation, magnetic resonance imaging (MRI) has become the non-invasive method of choice to predict cyst type, [...] Read more.
Pancreatic cystic lesions (PCLs) are a common incidental finding on cross-sectional imaging. Given the high signal to noise and contrast resolution, multi-parametric capability and lack of ionizing radiation, magnetic resonance imaging (MRI) has become the non-invasive method of choice to predict cyst type, risk stratify the presence of neoplasia, and monitor changes during surveillance. In many patients with PCLs, the combination of MRI and the patient’s history and demographics will suffice to stratify lesions and guide treatment decisions. In other patients, especially those with worrisome or high-risk features, a multimodal diagnostic approach that includes endoscopic ultrasound (EUS) with fluid analysis, digital pathomics, and/or molecular analysis is often necessary to decide on management options. The application of radiomics and artificial intelligence in MRI may improve the ability to non-invasively stratify PCLs and better guide treatment decisions. This review will summarize the evidence on the evolution of MRI for PCLs, the prevalence of PCLs using MRI, and the MRI features to diagnose specific PCL types and early malignancy. We will also describe topics such as the utility of gadolinium and secretin in MRIs of PCLs, the limitations of MRI for PCLs, and future directions. Full article
(This article belongs to the Special Issue Diagnosis and Management of Pancreatic Cysts)
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19 pages, 5908 KiB  
Review
Diagnosis and Management of Pancreatic Cysts: A Comprehensive Review of the Literature
by Ritu R. Singh, Harishankar Gopakumar and Neil R. Sharma
Diagnostics 2023, 13(3), 550; https://doi.org/10.3390/diagnostics13030550 - 2 Feb 2023
Cited by 2 | Viewed by 3167
Abstract
The prevalence of pancreatic cysts has been rising due to the widespread use of cross-sectional imaging (CT scan and MRI) of the abdomen. While most pancreatic cysts are benign and do not require treatment or surveillance, a significant minority are premalignant and rarely [...] Read more.
The prevalence of pancreatic cysts has been rising due to the widespread use of cross-sectional imaging (CT scan and MRI) of the abdomen. While most pancreatic cysts are benign and do not require treatment or surveillance, a significant minority are premalignant and rarely malignant. The risk stratification of these lesions is not straightforward, and individual risk assessment, cyst size, distribution, and alarming morphologic features (when present) can guide the next steps in management. Neoplastic pancreatic cysts are mucinous or non-mucinous. Endoscopic ultrasound with fine-needle aspiration is often required to classify pancreatic cysts into mucinous and non-mucinous cysts and to assess the malignant potential. Advances in endoscopic techniques (confocal laser endomicroscopy, microforceps biopsy) can provide a definitive diagnosis of pancreatic cysts in some cases; however, the use of these techniques involves a higher risk of adverse events. Full article
(This article belongs to the Special Issue Diagnosis and Management of Pancreatic Cysts)
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14 pages, 795 KiB  
Review
A Review on Endoscopic Ultrasound-Guided Radiofrequency Ablation (EUS-RFA) of Pancreatic Lesions
by Fred G. Karaisz, Osama O. Elkelany, Benjamin Davies, Gerard Lozanski and Somashekar G. Krishna
Diagnostics 2023, 13(3), 536; https://doi.org/10.3390/diagnostics13030536 - 1 Feb 2023
Cited by 8 | Viewed by 3585
Abstract
The morbidity associated with pancreatectomies limits surgical options for high-risk patients with pancreatic neoplasms that warrant resection. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) offers a minimally invasive and potentially definitive means to treat pancreatic neuroendocrine tumors and precancerous pancreatic cystic lesions. In addition, EUS-RFA [...] Read more.
The morbidity associated with pancreatectomies limits surgical options for high-risk patients with pancreatic neoplasms that warrant resection. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) offers a minimally invasive and potentially definitive means to treat pancreatic neuroendocrine tumors and precancerous pancreatic cystic lesions. In addition, EUS-RFA may play a role in the treatment and palliation of non-surgical cases of pancreatic adenocarcinoma. The efficacy of RFA appears to be further enhanced by systemic immunomodulatory effects. Here, we review current studies on the developing role of EUS-RFA in these pancreatic pathologies. Full article
(This article belongs to the Special Issue Diagnosis and Management of Pancreatic Cysts)
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10 pages, 1697 KiB  
Review
A Review of Endoscopic Ultrasound-Guided Chemoablative Techniques for Pancreatic Cystic Lesions
by Bryn Koehler, Da Yeon Ryoo and Somashekar G. Krishna
Diagnostics 2023, 13(3), 344; https://doi.org/10.3390/diagnostics13030344 - 17 Jan 2023
Cited by 4 | Viewed by 1461
Abstract
Pancreatic cystic lesions (PCLs) are known precursors to pancreatic cancer, one of the deadliest types of cancer worldwide. Surgical removal or pancreatectomies remain the central approach to managing precancerous high-risk PCLs. Endoscopic ultrasound (EUS)-guided therapeutic management of PCLs is a novel management strategy [...] Read more.
Pancreatic cystic lesions (PCLs) are known precursors to pancreatic cancer, one of the deadliest types of cancer worldwide. Surgical removal or pancreatectomies remain the central approach to managing precancerous high-risk PCLs. Endoscopic ultrasound (EUS)-guided therapeutic management of PCLs is a novel management strategy for patients with prohibitive surgical risks. Various ablation techniques have been explored in previous studies utilizing EUS-guided fine needle injection (FNI) of alcohol and chemotherapeutic agents. This review article focuses on EUS-FNI and chemoablation, encompassing the evolution of chemoablation, pancreatic cyst selection, chemotherapy drug selection, including novel agents, and a discussion of its safety and efficacy. Full article
(This article belongs to the Special Issue Diagnosis and Management of Pancreatic Cysts)
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17 pages, 2704 KiB  
Review
Pancreatic Cystic Neoplasms: Diagnosis and Management
by Abigail Schubach, Shivangi Kothari and Truptesh Kothari
Diagnostics 2023, 13(2), 207; https://doi.org/10.3390/diagnostics13020207 - 5 Jan 2023
Cited by 3 | Viewed by 2907
Abstract
Pancreatic cancer is one of the most lethal cancers, largely related to the difficulties with early detection, as it typically presents in later stages. Pancreatic cystic neoplasms (PCN) are commonly diagnosed as incidental findings on routine imaging. PCN is becoming more frequently detected [...] Read more.
Pancreatic cancer is one of the most lethal cancers, largely related to the difficulties with early detection, as it typically presents in later stages. Pancreatic cystic neoplasms (PCN) are commonly diagnosed as incidental findings on routine imaging. PCN is becoming more frequently detected with the increasing ease and frequency of obtaining cross-sectional images. Certain subtypes of pancreatic cysts have the potential to progress to malignancy, and therefore, clinicians are tasked with creating a patient-centered management plan. The decision of whether to undergo surgical resection or interval surveillance can be challenging given the criteria, including PCN size, pancreatic duct dilation, presence of a mural nodule, and clinical symptoms that play a potential role in risk stratification. Furthermore, the guidelines available from the major gastrointestinal societies all differ in their management recommendations. In this review, we detail an overview of the different types of PCNs and compare major guidelines for both diagnosis and management. We include emerging evidence for next-generation sequencing as well as confocal needle endomicroscopy to aid in the diagnosis and determination of malignancy potential and diagnosis. Full article
(This article belongs to the Special Issue Diagnosis and Management of Pancreatic Cysts)
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21 pages, 6627 KiB  
Review
Pancreatic Cystic Lesions: A Focused Review on Cyst Clinicopathological Features and Advanced Diagnostics
by Wei Chen, Nehaal Ahmed and Somashekar G. Krishna
Diagnostics 2023, 13(1), 65; https://doi.org/10.3390/diagnostics13010065 - 26 Dec 2022
Cited by 5 | Viewed by 2624
Abstract
Macroscopic, endomicroscopic, and histologic findings and correlation are an integral part of the diagnostic evaluation of pancreatic cystic lesions (PCLs), as complementing morphologic features seen by different specialties are combined to contribute to a final diagnosis. However, malignancy risk stratification of PCLs with [...] Read more.
Macroscopic, endomicroscopic, and histologic findings and correlation are an integral part of the diagnostic evaluation of pancreatic cystic lesions (PCLs), as complementing morphologic features seen by different specialties are combined to contribute to a final diagnosis. However, malignancy risk stratification of PCLs with worrisome features can still be challenging even after endoscopic ultrasound guided-fine needle aspiration (EUS-FNA) with cytological evaluation. This review aims to summarize cyst clinicopathological features from the pathologists’ perspective, coupled with knowledge from advanced diagnostics–confocal laser endomicroscopy and cyst fluid molecular analysis, to demonstrate the state-of-art risk stratification of PCLs. This review includes illustrative photos of surgical specimens, endomicroscopic and histologic images, and a summary of cyst fluid molecular markers. Full article
(This article belongs to the Special Issue Diagnosis and Management of Pancreatic Cysts)
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11 pages, 272 KiB  
Review
Molecular Analysis of Pancreatic Cyst Fluid for the Management of Intraductal Papillary Mucinous Neoplasms
by Ronald C. Turner, Jared T. Melnychuk, Wei Chen, Daniel Jones and Somashekar G. Krishna
Diagnostics 2022, 12(11), 2573; https://doi.org/10.3390/diagnostics12112573 - 24 Oct 2022
Cited by 6 | Viewed by 2411
Abstract
Pancreatic cancer is one of the most lethal human cancers. Early detection and diagnosis of precursor lesions for pancreatic malignancy is essential to improve the morbidity and mortality associated with this diagnosis. Of the cystic precursor lesions, branch duct intraductal papillary mucinous neoplasm [...] Read more.
Pancreatic cancer is one of the most lethal human cancers. Early detection and diagnosis of precursor lesions for pancreatic malignancy is essential to improve the morbidity and mortality associated with this diagnosis. Of the cystic precursor lesions, branch duct intraductal papillary mucinous neoplasm (IPMN) is the most frequently identified lesion and has a wide range of malignant potential. Currently, Carcinogenic embryonic antigen (CEA) levels in the cyst fluid and cytology are the two most often utilized tools to diagnose these lesions; however, their diagnostic and risk stratification capabilities are somewhat limited. Within the last decade, the use of endoscopic ultrasound-guided fine-needle aspiration has opened the door for molecular analysis of cystic fluid as an option to enhance both the diagnosis and risk stratification of these lesions. The first step is to differentiate branch duct IPMNs from other lesions. KRAS and GNAS alterations have been shown to be accurate markers for this purpose. Following cyst type identification, mutational analysis, telomere fusion, microRNAs, long non-coding RNA, and DNA methylation have been identified as potential targets for stratifying malignant potential using the cystic fluid. In this review, we will examine the various targets of cyst fluid molecular analysis and their utility in the diagnosis and risk stratification of branch duct IPMNs. Full article
(This article belongs to the Special Issue Diagnosis and Management of Pancreatic Cysts)
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