Invited Commentary: Tears of the Pancreas: Cry for Help
2021; Radiological Society of North America; Volume: 42; Issue: 1 Linguagem: Inglês
10.1148/rg.210199
ISSN1527-1323
Autores Tópico(s)Pancreatitis Pathology and Treatment
ResumoHomeRadioGraphicsVol. 42, No. 1 PreviousNext Gastrointestinal ImagingFree AccessInvited Commentary: Tears of the Pancreas: Cry for HelpAtif Zaheer Atif Zaheer Author AffiliationsFrom the Russell H. Morgan Department of Radiology and Radiological Sciences, and Pancreatitis Center, Division of Gastroenterology, Department of Medicine, The Johns Hopkins University School of Medicine, 600 North Wolfe St, Hal B164, Baltimore, MD 21287.Address correspondence to the author (e-mail: [email protected]).Atif Zaheer Published Online:Dec 2 2021https://doi.org/10.1148/rg.210199MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Miller et al in this issue.The article “Pancreatic Cystic Lesions and Malignancy: Assessment, Guidelines, and the Field Defect” by Miller et al (1) in this issue of RadioGraphics is a detailed, well-written, and beautifully illustrated review of different cystic lesions that afflict the pancreas. There is an emphasis on the features suggestive of malignancy and the biologic behavior of these lesions, as well as a description of the current guidelines for surveillance.This article provides an excellent overview of the salient pathologic and clinical features of a wide variety of cystic lesions and is a worthwhile read not just for radiologists but also for other members of institutional “cyst clinics,” including gastroenterologists, pathologists, and surgeons. It is enhanced with classic radiologic images that illustrate important scenarios that one may face as nascent cases in everyday practice. In addition, the authors discuss how radiologists play a critical role in the detection, characterization, and surveillance of these lesions.The overwhelming majority of pancreatic cysts are benign. However, it is imperative to distinguish the benign variety from the nonbenign lesions that may ultimately turn malignant. In addition, among the precancerous mucin-producing lesions there is a spectrum that encompasses lesions that range from low-grade to intermediate- and high-grade dysplasia, as well as early invasive cancer. To further complicate things, the risk of malignant transformation lies not only within the lesion itself but also elsewhere in the pancreas. Therefore, cystic lesions in a sense represent the “tears of the pancreas” or a cry for help by the organ, serving as an alarm to be on the watch for synchronous or metachronous development of pancreatic ductal adenocarcinoma elsewhere in the gland. At my institution, the difficulty in differentiating high-risk lesions from the low-risk and benign ones due to the vast overlap in their imaging appearances has taught us much humility despite years of experience (2).Miller et al (1) have done an excellent job of outlining the overall incidence and sex and age demographics of these lesions and describing the typical imaging features of those lesions that are of the nonbenign variety. At the same time, they provide a practical approach to differentiating the overlap in imaging features between nonbenign and other cystic lesions (such as cystic pancreatic neuroendocrine tumors) that may require a different approach to treatment. These authors also discuss the trigger points for additional investigation with endoscopic US with or without fine-needle aspiration, which are based on the suspicious findings established by the guidelines of various societies. Currently, there are five major expert consensus clinical guidelines for the management of pancreatic cysts, with different recommendations. The authors highlight the notable differences among the guidelines, including differences in target populations and approaches to initial and long-term surveillance, and discuss the subsequent performance of the guidelines in the target populations.Although there is some push to stop surveillance in the population of older persons with cyst stability for 5 years and in those without worrisome features or high-risk stigmata, this remains controversial, as some studies strongly suggest that there is a risk of malignancy beyond 5–10 years of follow-up despite the size stability (3). Hence, Miller et al (1) are justified in their criticism of the 2015 American Gastroenterology Association and 2017 American College of Radiology guidelines that set an end point for surveillance in cases of stable cysts. Although these guidelines are widely used and a combination of multiple features helps guide the management of these lesions, there remains a desire among physicians to have some uniformity of the guidelines for a more consistent management algorithm (4).Significant variability among radiologists exists in the reporting of the described features of pancreatic cystic lesions, with poor to moderate interobserver agreement (5). This variability may be attributed to the lack of objective definitions of these findings and the absence of widespread use of structured reporting. Furthermore, the surveillance and management of these lesions are usually provided from the point of view of larger academic centers with established pancreatic cyst clinics. A significant number of incidental lesions are identified at smaller facilities without an affiliated large-volume pancreatic center.Given the need for long-term monitoring, there is also a need to empower patients in their own care, especially now that they have immediate access to radiology reports owing to the federal Cures Act 2020 Final Rule. This access necessitates the need for wider use of recommendation-based reporting templates and perhaps the development of patient-centric software for data management that tracks the imaging features over time with every imaging examination performed and that can serve as a road map for management.Miller et al (1) recognize that owing to increasing detection at imaging and potential lifelong follow-up for patients with intraductal papillary mucinous neoplasms, there is a dire need for short noncontrast MRI protocols for surveillance of these lesions. Although not directly mentioned in the excellent review by Miller and colleagues (1), this point certainly alludes to the concern over unnecessary imaging, the increased psychologic distress of patients that is caused by apprehensive diagnosis, the additional workload of referring clinicians, and the financial burden to the health care system due to the large number and long duration of follow-ups and interventional cascades that may not lead to clinically meaningful outcomes (6).One study (7) showed a difference in cost of about $79 million between the implementation of a more sensitive guideline (2017 international consensus guideline) and the implementation of a less sensitive guideline (2015 American Gastroenterology Association guideline) for a cohort of 10 000 patients managed according to each guideline. The detection of an additional 22 malignancies was offset by a larger number of surgical deaths and higher costs. With increased detection of such lesions on cross-sectional images, some have claimed this to be a “disease of the technology” (8). This assessment of the “new disease” that was unknown until the turn of the century certainly begs the question of whether we may be doing more harm than good by subjecting a vast population to an expensive screening test that may be only a piece of a bigger puzzle that also includes clinical risk stratification, blood DNA testing, and detection of mutations in PIK3CA, SMAD4, and TP53 by means of sequencing the cyst fluid, which may lead to the identification of up to 80% of IPMNs, with high-grade dysplasia or cancer potentially abrogating the need for surveillance of low-risk lesions (9).An issue that was overlooked by Miller and colleagues (1), perhaps owing to the scope of the work presented, is the future of imaging, with automated detection of these lesions facilitated by using deep learning algorithms, and the utility of artificial intelligence in the development of risk prediction models on the radiomic features of lesions. There has been fairly rapid development in this field, and various nomograms for quantitatively predicting malignant IPMNs have been published in recent years by using logistic regression and machine learning (10). Furthermore, this information, when used alongside the clinical data on and molecular features of the cyst fluid DNA in mucin-producing cysts, which has high correlation with high-grade dysplasia and pancreatic ductal adenocarcinoma (11), may further enhance our understanding of the disease. Ultimately, these data may meet our need to identify high-risk patient populations and further stratify them for surveillance or surgical intervention, and reduce the morbidity and economic costs associated with intensive workup and unnecessary surgeries.In summary, we express our gratitude for the efforts of the pancreatologists at Northwestern Memorial Hospital for their strong contribution to advancing the care of patients with pancreatic cysts and for this well-written and beautifully illustrated review article, which is a great resource to help radiologists and other members of pancreatic cyst clinics understand approaches to assessing this disease. Although imaging is critical to the diagnosis and surveillance of high-risk lesions, the management of patients with these lesions ultimately requires comprehensive testing with several factors, including life expectancy of the patient, comorbidities, and genetic risk, taken into consideration. Further development of cyst fluid biochemical and genetic markers, as well as advancements in imaging technology, especially artificial intelligence, will greatly enhance the way personalized care is provided.The author has disclosed no relevant relationships.References1. Miller F. Pancreatic cystic lesions and malignancy: assessment, guidelines, and the field defect. RadioGraphics 2021;42(1):87–105. Google Scholar2. Zaheer A, Fishman EK, Pittman ME, Hruban RH, eds. Pancreatic imaging: a pattern-based approach to radiologic diagnosis with pathologic correlation. Cham, Switzerland: Springer, 2017. Crossref, Google Scholar3. Lee BS, Nguyen AK, Tekeste TF, et al. Long-term follow-up of branch-duct intraductal papillary mucinous neoplasms with no change in first 5 years of diagnosis. Pancreatology 2021;21(1):144–154. Crossref, Medline, Google Scholar4. Luk L, Hecht EM, Kang S, et al. Society of Abdominal Radiology Disease Focused Panel survey on clinical utilization of incidental pancreatic cyst management recommendations and template reporting. J Am Coll Radiol 2021. https://doi.org/10.1016/j.jacr.2021.04.012. Published online May 15, 2021. Google Scholar5. de Jong K, Nio CY, Mearadji B, et al. Disappointing interobserver agreement among radiologists for a classifying diagnosis of pancreatic cysts using magnetic resonance imaging. Pancreas 2012;41(2):278–282. Crossref, Medline, Google Scholar6. Ganguli I, Simpkin AL, Lupo C, et al. Cascades of care after incidental findings in a US national survey of physicians. JAMA Netw Open 2019;2(10):e1913325. Crossref, Medline, Google Scholar7. Lobo JM, Scheiman JM, Zaydfudim VM, Shami VM, Sauer BG. Clinical and economic outcomes of patients undergoing guideline-directed management of pancreatic cysts. Am J Gastroenterol 2020;115(10):1689–1697. Crossref, Medline, Google Scholar8. Budde C, Beyer G, Kuhn JP, Lerch MM, Mayerle J. The clinical and socio-economic relevance of increased IPMN detection rates and management choices. Viszeralmedizin 2015;31(1):47–52. Medline, Google Scholar9. Singhi AD, McGrath K, Brand RE, et al. Preoperative next-generation sequencing of pancreatic cyst fluid is highly accurate in cyst classification and detection of advanced neoplasia. Gut 2018;67(12):2131–2141. Crossref, Medline, Google Scholar10. Kang JS, Lee C, Song W, et al. Risk prediction for malignant intraductal papillary mucinous neoplasm of the pancreas: logistic regression versus machine learning. Sci Rep 2020;10(1):20140. Crossref, Medline, Google Scholar11. Springer S, Masica DL, Dal Molin M, et al. A multimodality test to guide the management of patients with a pancreatic cyst. Sci Transl Med 2019;11(501):eaav4772. Crossref, Medline, Google ScholarArticle HistoryReceived: Aug 5 2021Accepted: Aug 7 2021Published online: Dec 02 2021Published in print: Jan 2022 FiguresReferencesRelatedDetailsAccompanying This ArticlePancreatic Cystic Lesions and Malignancy: Assessment, Guidelines, and the Field DefectDec 2 2021RadioGraphicsRecommended Articles Pancreatic Cystic Lesions and Malignancy: Assessment, Guidelines, and the Field DefectRadioGraphics2021Volume: 42Issue: 1pp. 87-105Hereditary and Sporadic Pancreatic Ductal Adenocarcinoma: Current Update on Genetics and ImagingRadiology: Imaging Cancer2020Volume: 2Issue: 2Determining Malignant Potential of Intraductal Papillary Mucinous Neoplasm of the Pancreas: CT versus MRI by Using Revised 2017 International Consensus GuidelinesRadiology2019Volume: 293Issue: 1pp. 134-143Imaging Follow-up of Low-Risk Incidental Pancreas and Kidney Findings: Effects of Patient Age and Comorbidity on Projected Life ExpectancyRadiology2018Volume: 287Issue: 2pp. 504-514Pancreas in Hereditary Syndromes: Cross-sectional Imaging SpectrumRadioGraphics2021Volume: 41Issue: 4pp. 1082-1102See More RSNA Education Exhibits Pancreatic Cystic Lesions: What Radiologists Should Know to Assess for MalignancyDigital Posters2020Hereditary and Sporadic Pancreatic Adenocarcinoma: 2018 Genetics and Imaging UpdateDigital Posters2018You Are at the Crossroads: Where Will You Go Next? - A Comprehensive Review of Currently Available Guidelines for Diagnosis and Management of Pancreatic Cystic LesionsDigital Posters2019 RSNA Case Collection Intraductal Papillary Mucinous Neoplasm RSNA Case Collection2020Pancreatic Schwannoma RSNA Case Collection2021Pancreatic serous cystadenoma RSNA Case Collection2021 Vol. 42, No. 1 Metrics Altmetric Score PDF download
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