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Lesioni cistiche pancreatiche: linee guida diagnostiche - Gastrolearning®

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Gastrolearning II modulo/5a lezione …

Gastrolearning II modulo/5a lezione
Lesioni cistiche pancreatiche: linee guida diagnostiche
Prof.ssa E. Buscarini - Crema

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  • 1. ITALIAN CONSENSUS GUIDELINES FOR DIAGNOSTIC WORK-UP AND FOLLOW-UP OF CYSTIC PANCREATIC NEOPLASMS Elisabetta Buscarini Raffaele Pezzilli
  • 2. WHO classification of cystic pancreatic tumors, 2010  CPNs: mostly detected incidentally  High prevalence: 2.6% -19.6%  Increase of CPNs prevalence with age: 8% below 70 yrs up to 35% >90 yrs
  • 3. serous mucinous IPMN pseudopapillary Type Sex Meanageatdiagnosis serous 50 mucinous 50 IPMN >60 pseudopap 30
  • 4. AIGO and AISP have fostered consensus guidelines : – limited to the diagnostic work-up and follow-up of all CPNs according to WHO classification – based on a sound consensus methodology to allow evaluation of published data and of their quality, and to synthesize them with expert opinion – clinically oriented – taking into account also the characteristics of Italian Health Care System, with its inherent availability of different diagnostic techniques – applicable only for patients “fit for treatment” at the time of diagnosis or along the follow up Consensus guidelines CPNs
  • 5. COHORDINATORS Elisabetta Buscarini Raffaele Pezzilli Renato Cannizzaro Massimo Falconi CLINICAL Renato Cannizzaro Luca Frulloni Stefano Crippa Riccardo Casadei Alessandro Zerbi EUS Claudio De Angelis Paolo Arcidiacono Paolo Bocus Pietro Fusaroli Luca Barresi IMAGING Giovanni Morana Silvia Venturini Mirko D’Onofrio Lucia Calculli Claudio Pasquali LABORATORY Massimo Gion Daniela Basso Maurizio Ventrucci Rodolfo Rocca Gabriele Capurso PATHOLOGY Giuseppe Zamboni Vincenzo Villanacci Vincenzo Canzonieri Gianpaolo Balzano Donatella Pacchioni Consensus guidelines CPNs Teams
  • 6. Luca Albarello Lorenzo Camellini Rita Conigliaro Giuseppe Del Favero Giovanna Del Vecchio Blanco Pierluigi Di Sebastiano Carlo Fabbri Niccola Funel Andrea Galli Armando Gabbrielli Rossella Graziani Andrea Laghi Giampiero Macarri Fabrizio Magnolfi Guido Manfredi Marco Marzioni ConsensusParticipants Fabio Monica Nicola Muscatiello Massimiliano Mutignani Antonio Pisani Enrico Scarano Marco Spada Alessandro Zambelli Representative of SIED Guido Costamagna Representative of SIGE Paolo Cantù Representative of SIGENP Tiziana Guadagnini Representative of SIUMB Carla Serra Representative of the GP Marco Visconti Representative of citizen and patient rights Paolo Federici
  • 7. Levels of evidence Oxford Centre for Evidence-Based Medicine Medicine
  • 8. Grades of recommendation The strength of eachrecommendationdepends on the category of the evidencesupportingit Oxford Centre for Evidence-Based Medicine
  • 9. Consensus Guidelines CPNs Fifty-two questions 1. Clinical framework, 12 statements 2. Laboratory, circulating, 5 statements 3. Radiology, 5 statements 4. EUS, 13 statements 5. Laboratory, intracystic, 11 statements 6. Pathology, 6 statements
  • 10. CLINICAL EVALUATION
  • 11. Statement All patients with pancreatic cystic neoplasms require a diagnostic work-up EL 2a, RG B After exclusion of patients neither suitable for any treatment nor wishing a diagnostic definition, which patient with pancreatic cystic lesion needs further diagnostic work up?
  • 12. Statement Signs/symptoms include: abdominal pain, acute pancreatitis, nausea and vomiting, weight loss also due to exocrine pancreatic insufficiency with steatorrhea, anorexia, recent onset or worsening diabetes, obstructive jaundice, and palpable mass EL 4, RG D After setting definition on the basis of the presence/absence of sign/symptoms, depict accordingly clinical scenarios. In symptomatic patients which are signs/symptoms due to a pancreatic cystic lesion?
  • 13. Symptomatic Lesions
  • 14. Statement In the setting of symptomatic patients, high resolution imaging techniques including MRI with MRCP and/or MDCT scan with pancreas protocol represent the first diagnostic step EL 1a, RG A In the setting of symptomatic patients which diagnostic technique/s is/are necessary before treatment?
  • 15. Asymptomatic Lesions
  • 16. Statement A family history for pancreatic cancer and/or other malignancies and a personal and familial history consistent with Von Hippel-Lindau disease have to be searched Serum CA19-9 and glucose level have to be evaluated as well EL 2a, RG B Which data regarding personal or familial history, and which laboratory findings have to be searched for in asymptomatic patients?
  • 17. Statement An enhancing solid component within the cyst represents an indication for treatment For IPMNs the presence of a main duct > 10 mm is another indication for treatment EL 2a, RG B In asymptomatic patients are there morphological findings of the cystic pancreatic neoplasms which can address straightforward to treatment?
  • 18. In asymptomatic patients which technique/s is/are necessary to address the patient with pancreatic cystic lesion either to treatment or to follow-up? Statements In this setting pan exploring high resolution imaging techniques including MRI with MRCP and/or MDCT scan with pancreas protocol represent the first diagnostic step EL 4, RG C When “worrisome” morphological features are identified or in patients with uncertain radiologic diagnosis (i.e. small branch-duct IPMN versus small SCN) EUS with FNA for cytology is recommended EL 4, RG C
  • 19. Regarding the follow-up of patients where observation has been chosen, and bearing in mind that follow-up aims to: 1) demonstrate the size variations over the time (either as cystic lesion increase or decrease in size or disappears); 2) diagnostic confirmation (test of time), we need to answer to the following questions:Which is the test of choice for follow-up? Statement The test of choice for follow-up is MRI with MRCP. At any follow-up evaluation a careful clinical examination to look for symptoms and laboratory tests including, CA 19.9 and glucose levels has to be performed, especially in mucinous lesions EL 2a, RG B
  • 20. Which is the timing? Statement Follow-up timing should be carried out at least yearly and be related with morphological characteristics of the cystic lesion, family history of pancreatic cancer, diabetes mellitus and serum CA 19-9 levels EL 3, RG B
  • 21. Suggested follow-up timing according to the type of cystic lesion
  • 22. TEST 1 F, 32 yo, incidentaldiscovery F, 38 yo, incidentaldiscoveryduringpregnancy
  • 23. Do cystic lesions of the pancreas exclude the patient from organ transplantation? Statement No EL 4, RG C
  • 24. Which diagnostic work-up is required in organ transplant candidates with evidence of a cystic lesion of the pancreas without morphological characteristics of malignancy? Statement MRI/ MRCP and EUS with FNA are recommended. Laboratory tests including CA 19.9 and glucose level and a careful clinical evaluation for cyst-related symptoms should be carried out. EL 4, RG C
  • 25. In the organ transplanted patient does the presence of an asymptomatic cystic lesion of the pancreas without morphological aspects of malignancy require alternative follow-up strategies in diagnostic tests and timing? Statement No EL 4, RG C
  • 26. LABORATORY &CIRCULATING MARKERS
  • 27. Which is the post-test probability that an abnormal serum CA19.9 level recognizes a malignant behavior of a pancreatic cystic neoplasm? Statement CA19.9 is not a marker of CPNs malignancy. However serum CA19.9 determination provides additional information within the diagnostic work up since a positive result is associated with the presence of an invasive carcinoma with a SP ranging from 79 to 100% and a PPV of 74%. Conversely a negative result does not exclude the presence of a malignancy (SS 37-80%) EL 4, RG C
  • 28. CROSS SECTIONAL IMAGING & NUCLEAR MEDICINE
  • 29. Which is the best imaging modality among US/CEUS, MDCT, MRI - MRCP, secretin MRCP, FDG-PET for differentiating between benign and malignant cystic pancreatic lesions? Statement Conventional US of the pancreas is not able to definitively diagnose CPNs EL 5; RG C The different dynamic imaging modalities (CEUS, MDCT, MR) have similar high accuracy. EL 1b; RG A Available data do not support the use of S-MRCP in the differential diagnosis of benign versus malignant CPNs EL 5; RG D The accuracy of FDG-PET-CT is high EL 1b; RG B
  • 30. Which is the best imaging modality among US/CEUS, MDCT, MRI - MRCP, secretin MRCP, FDG-PET for differentiating between mucinous and non-mucinous cystic pancreatic lesions? Statement MDCT and MR are the best imaging modalities for differentiating mucinous and non-mucinous CPNs, both with high accuracy EL 1b; RG A There are no corresponding detailed data on CEUS and 18FDG-PET Data supporting the use of S-MRCP are not available EL 5; RG D
  • 31. Which is the role of different imaging techniques in patients with CPNs (diagnostic algorithm)? Statement MR and MDCT are first level techniques in the differentiating benign from malignant CPNs. CEUS has similar performances than MR and MDCT, when CPNs is visible at US MR with MRCP is the best imaging modality to evaluate the communication of CPNs with the main pancreatic duct EL 1b; RG A Based on the above statements, MR with MRCP is the imaging method of choice for the study of CPNs 18FDG-PET must be considered as a second level, if clinical suspicion for malignancy is high and other imaging modalities are inconclusive or if other imaging modalities are suspicious for malignancy but with a low level of confidence. EL 5; RG D
  • 32. Which is the role of different imaging techniques (US/CEUS, MDCT, MRI - MRCP, secretin MRCP, 18FDG-PET- CT) for the follow up of patients with asymptomatic CPNs? Statement The role of single method is depending on both the size and the number of CPNs Single cyst: Small (< 1 cm) • visible at US: US preferred until size change occurs. • not visible at US: MR/MRCP Large (≥ 1 cm) • visible at US: US preferred until size change occurs. If size change occurs, • not visible at US: MR with MRCP or MDCT (the latter with the above limitations). In case of strict follow-up (e.g. 3 months), MDCT should be used only in older patients without renal insufficiency or in patients with absolute contraindications to MR Multiple cysts: •MR with MRCP
  • 33. ENDOSONOGRAPHY & ERCP
  • 34. Statement EUS can identify morphological features which increase the suspicion for malignancy in CPNs. However EUS morphologic features alone cannot exclude the presence of malignancy in CPNs EL 2b, RG B What is the role of EUS in differentiating between benign and malignant CPNs?
  • 35. Statement Although EUS morphology alone cannot provide a definite differential diagnosis between mucinous and non-mucinous CPNs, some EUS features offer useful information on the type of lesion EL 4, RG C What is the role of EUS in differentiating between mucinous and non-mucinous pancreatic cystic lesions?
  • 36. Statement Contrast enhanced EUS may be helpful in differential diagnosis of CPNs and in ruling out neoplastic degeneration. Analysis of intracystic nodules at contrast enhanced EUS may help in differentiating neoplastic vegetations from mucus and debris EL 4, RG C Does the use of contrast during EUS increase the diagnostic accuracy of EUS for CPNs?
  • 37. Statement EUS-FNA is indicated when a previous diagnostic modality has depicted CPNs with worrisome features other than an enhancing solid component or when the other diagnostic modalities fail to give either a definite diagnosis or in cases of advanced malignant cystic lesions when chemotherapy is considered EL 2a, RG B When is EUS-FNA recommended for differentiating between benign and malignant CPNs?
  • 38. Statement EUS-FNA is indicated when the other diagnostic modalities fail to give a definite differential diagnosis EL 2a, RG B When is EUS-FNA recommended for differential diagnosis between mucinous and non–mucinous CPNs?
  • 39. TEST 2 F, 74 yo, recurrentepigastricpain&recentdiabetesonset
  • 40. M, 64 yo, incidentaldiscovery TEST 3
  • 41. Statement Diagnostic ERCP for the evaluation of CPNs is indicated only if endoscopic views of the papillary area, pancreatoscopy, or intraductal ultrasound are still required at the end of the diagnostic work-up for a definite diagnosis in patients with suspected IPMN EL 4, RG C Which is the diagnostic role of ERCP in patients with CPNs?
  • 42. Statement EUS-FNA of CPNs entails a rate of intra-cyst hemorrhagearound 4%. Usually bleeding is self-limiting. No death has been reported after EUS- FNA performed in the standard modality with standard needles. Different risks of complications have been reported with different technical modalities of FNA or using different devices. EL 4, RG C Which is the expected complication rate due to EUS- FNA?
  • 43. Statement There are not sufficient data to show that antibiotic prophylaxis reduces the rate of infectious complications. EL5, RG D Does antibiotic prophylaxis reduce the infectious complication rate of EUS-FNA of CPNs?
  • 44. LABORATORY- MARKERS IN CYST FLUID
  • 45. Is the determination of intracystic CEA useful in the differential diagnosis between benign and malignant cystic pancreatic lesions? Statement Intracystic CEA is not accurate in recognizing malignant from non- malignant lesions EL 2a, RG B
  • 46. Is the determination of intracystic CEA useful in the differential diagnosis between mucinous and non-mucinous cystic pancreatic lesions? Statement Increased CEA levels in cyst fluid are helpfulindistinguishing mucinous from not mucinous CPNs EL 2a, RG B
  • 47. Is the determination of intracystic amylase useful in the differential diagnosis of cystic pancreatic lesions? Statement The determination of amylase in cyst fluid is helpful to determine the differential diagnosis among CPNs. High amylase levels are usually associated with a communication between pancreatic duct and cystic lesion, as for the majority of IPMNs EL 2c, RG B
  • 48. How much does a combination of intracystic tests increase their performances? Statement The determination of both CEA and amylase is recommended to help in distinguishing mucinous from non-mucinous cyst lesions EL 2c, RG B
  • 49. Are there specific recommendations for the assessment of positive/negative cutoff point of CEA, Amylase and CA19.9 in cyst fluid ? Statement No evidence exist on cutoff to be used in the clinical practice. In addition, cutoff values are partially related to the used assay method EL 5, RG D
  • 50. PATHOLOGY
  • 51. Can cytological examination differentiate between benign and malignant cystic pancreatic lesions? Statement The cytological examination is useful in the differential diagnosis between benign and malignant cystic pancreatic lesions EL 2a, RG B
  • 52. How could be differentiated a mucinous from a non- mucinous cystic lesion by cytological examination? Statement The presence of extracellular, thick mucus, and the recognition of an atypical epithelial cell component with intracytoplasmic mucin, represent the diagnostic hallmark of mucinous cystic lesions EL 2c, RG B
  • 53. Which is the diagnostic value of high-grade cellular atypia? Statement The presence of cells with high grade atypia is the best cytological marker of a malignant cystic neoplasms EL 2b, RG B
  • 54. TEST 4
  • 55. TEST 5 F, 75 yo, incidentaldiscovery
  • 56. TEST 5 CEA > 150,000 ng/ml Amylase 84 U/ml No malignantcells
  • 57. Future developments The consensus process has highlighted some areas particularly in need of study: 1. Available data on natural history of CPNs are still very limited 2. Studies of CPNs with transcutaneous imaging are barely comparable to EUS studies as the latter generally deal with smaller CPNs or more difficult to interpret: studies comparing the yield and impact of these techniques in similar CPNs are thus desirable 3. The laboratory examination of CPN fluid still requires a standardization 4. AIGO and AISP will validate present guidelines with a prospective data collection in order to evaluate the improvement of both patient management and efficiency in resource utilization

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