Frequent detection of pancreatic lesions in asymptomatic high-risk individuals

Abstract

Background & aims: The risk of pancreatic cancer is increased in patients with a strong family history of pancreatic cancer or a predisposing germline mutation. Screening can detect curable, noninvasive pancreatic neoplasms, but the optimal imaging approach is not known. We determined the baseline prevalence and characteristics of pancreatic abnormalities using 3 imaging tests to screen asymptomatic, high-risk individuals (HRIs).

Methods: We screened 225 asymptomatic adult HRIs at 5 academic US medical centers once, using computed tomography (CT), magnetic resonance imaging (MRI), and endoscopic ultrasonography (EUS). We compared results in a blinded, independent fashion.

Results: Ninety-two of 216 HRIs (42%) were found to have at least 1 pancreatic mass (84 cystic, 3 solid) or a dilated pancreatic duct (n = 5) by any of the imaging modalities. Fifty-one of the 84 HRIs with a cyst (60.7%) had multiple lesions, typically small (mean, 0.55 cm; range, 2-39 mm), in multiple locations. The prevalence of pancreatic lesions increased with age; they were detected in 14% of subjects younger than 50 years old, 34% of subjects 50-59 years old, and 53% of subjects 60-69 years old (P < .0001). CT, MRI, and EUS detected a pancreatic abnormality in 11%, 33.3%, and 42.6% of the HRIs, respectively. Among these abnormalities, proven or suspected neoplasms were identified in 85 HRIs (82 intraductal papillary mucinous neoplasms and 3 pancreatic endocrine tumors). Three of 5 HRIs who underwent pancreatic resection had high-grade dysplasia in less than 3 cm intraductal papillary mucinous neoplasms and in multiple intraepithelial neoplasias.

Conclusions: Screening of asymptomatic HRIs frequently detects small pancreatic cysts, including curable, noninvasive high-grade neoplasms. EUS and MRI detect pancreatic lesions better than CT.

Figure 1

Study Schema

Figure 2

Asymptomatic prevalent combined (main duct and multiple branch duct) IPMNs in a 74 year old healthy Ashkenazi Jewish woman with 2 affected first-degree and relatives; pancreatic protocol CT (3A, right image), MRI/MRCP (2A left image), and EUS (2B, right image) all showed multiple pancreatic cysts 3-15 mm (arrows indicate suspected BD-IPMNs) and a mildly dilated main pancreatic duct up to 3.8 mm. Endoscopic examination of the ampulla at the time of EUS showed a patulous pancreatic duct orifice with active mucin extrusion (2B, left image). EUS also showed echogenic mucin and polypoid mural nodules in the main duct and multiple cysts typical of mixed IPMN (2B, right image, arrow). See video (for online submission).

Figure 2

Asymptomatic prevalent combined (main duct and multiple branch duct) IPMNs in a 74 year old healthy Ashkenazi Jewish woman with 2 affected first-degree and relatives; pancreatic protocol CT (3A, right image), MRI/MRCP (2A left image), and EUS (2B, right image) all showed multiple pancreatic cysts 3-15 mm (arrows indicate suspected BD-IPMNs) and a mildly dilated main pancreatic duct up to 3.8 mm. Endoscopic examination of the ampulla at the time of EUS showed a patulous pancreatic duct orifice with active mucin extrusion (2B, left image). EUS also showed echogenic mucin and polypoid mural nodules in the main duct and multiple cysts typical of mixed IPMN (2B, right image, arrow). See video (for online submission).

Figure 2

Asymptomatic prevalent combined (main duct and multiple branch duct) IPMNs in a 74 year old healthy Ashkenazi Jewish woman with 2 affected first-degree and relatives; pancreatic protocol CT (3A, right image), MRI/MRCP (2A left image), and EUS (2B, right image) all showed multiple pancreatic cysts 3-15 mm (arrows indicate suspected BD-IPMNs) and a mildly dilated main pancreatic duct up to 3.8 mm. Endoscopic examination of the ampulla at the time of EUS showed a patulous pancreatic duct orifice with active mucin extrusion (2B, left image). EUS also showed echogenic mucin and polypoid mural nodules in the main duct and multiple cysts typical of mixed IPMN (2B, right image, arrow). See video (for online submission).

Figure 3

Histologic sections from the distal pancreatectomy performed on Patient 1. The main duct intraductal papillary neoplasm (IPMN) harbored high-grade dysplasia (Figure 3A), and the adjacent pancreatic parenchyma pancreatic intraepithelial with high-grade dysplasia (PanIN-3) (Figure 3B).

Figure 3

Histologic sections from the distal pancreatectomy performed on Patient 1. The main duct intraductal papillary neoplasm (IPMN) harbored high-grade dysplasia (Figure 3A), and the adjacent pancreatic parenchyma pancreatic intraepithelial with high-grade dysplasia (PanIN-3) (Figure 3B).