Imaging investigation of pancreatic cystic lesions and proposal for therapeutic guidelines

Abstract

Aim: To propose a diagnostic algorithm for preoperatively predicting the need for surgical intervention.

Methods: The study included 56 patients (27 men and 29 women) with a final diagnosis of cystic pancreatic lesions. The following materials were used: ultrasonic equipment with 3.5 and 7 MHz linear, convex and biopsical transducers. Multidetector computed tomography (MDCT) investigations were performed using a 16-slice scanner. Images were obtained following the oral administration of 200 mL water and 100 mL intravenous iopamidol (300 mg/mL) administered by pump injector at a rate of 3 mL/s (40 and 60 s post-injection, respectively) using 0.5 mm detectors, reconstructed at 1 mm (pancreatic phase) or 2 mm (portal venous phase) increments. The table feed was 10 mm per rotation. Images were acquired in the pancreatic and portal venous phases of contrast enhancement. The "Chiba" needles 18, 20, 22, 23 G and an automatic aspiration system were used in conjunction with the following methods of guiding the interventional procedures: (1)"free-hand" biopsy and puncture method under ultrasound (US) or computed tomography (CT) control; (2) guiding method using biopsical transducer.

Results: All 56 patients in this study underwent at least two cuts imaging survey methods, such as US, CT or magnetic resonance imaging (MRI). The most common preoperative diagnostic examination was US scan - 56 patients (100%). MDCT studies were conducted in 49 (87.50%) and MRI in 13 (23.21%). More than half of patients surveyed (37) underwent some type of interventional procedure: 25-fine-needle aspiration and 29-fine needle aspiration biopsy (FNAB), as part of the examination. Thirty-four patients of all 56 patients underwent surgery because of histological evidence of malignancy after the FNAB for cystic lesions of the pancreas. Distal pancreatectomy with splenectomy was the most common operative approach in 13 patients, followed by Whipple resection in 11 and distal pancreatectomy without splenectomy in 7. Three patients were treated with total pancreatectomy due to the presence of a multifocal mucinous neoplasm. Comparing the diagnostic results of US examination with those of MDCT examination and histological verification true positive results were found in 31 patients, true negative in 11 patients, false positive in 5 and false negative in 9 patients. Accordingly we estimated the power of the diagnostic imaging methods for cystic lesions of the pancreas. A specificity of 68.75%, sensitivity of 79.48%, accuracy of 75.00%, positive predictive value of 86.11% and negative predictive value of 55% were obtained. The power increased after applying invasive procedures with immunohistochemical analysis of CEA and P-53 (Fig. 4). In 15 patients with cytological feature of malignant tumour cells, the tumour markers were positive. In our opinion the higher the percentage of reacting cells the higher the percent of malignancy. In patients with clear symptoms and/or clear imaging features of malignant or premalignant cystic neoplasm, the need for surgery was confirmed by histological verification in 34 (60.71%) of cases.

Conclusion: By using the proposed algorithm, cystic mucinous tumors of the pancreas were detected and proper operative interventions would have been rendered with fewer diagnostic examinations.

Keywords: Diagnostic intervention; Fine-needle biopsy; Pancreatic cystic neoplasm.

Figure 1

Computed tomography and ultrasound images of microcystic pancreatic lesions/serous cystic neoplasm.

Figure 2

Ultrasound and computed tomography image of septated macrocyst-mucinous cystic neoplasm/mucinous cystic neoplasm.

Figure 3

Multidetector computed tomography coronal reconstruction and ultrasound images of multiple branch duct type of intraductal papillary mucinous tumors. Note the dilated pancreatic duct on ultrasound image.

Figure 4

Cytological preparation with immuno-reactivity to P-53 in 80%-95% of the cells.

Figure 5

Proposed diagnostic algorithm and therapeutic behavior of suspected pancreatic cystic neoplasms. US: Ultrasound; CT: Computed tomography; MRI: Magnetic resonance imaging; ERCP: Endoscopic retrograde cholangiopancreatography; FNAB: fine needle aspiration biopsy.