The Feasibility of Serum Multiple Tumor Markers Test Between Patients with Primary Pancreatic Cancer and Those with Benign Pancreatic Cystic Disease.

BACKGROUND: Although CA 19-9 is the primary marker used in the diagnosis and treatment of pancreatic cancer, other serum tumor markers have also been utilized in the follow-up of pancreatic cancer. We investigated the clinical utility of CYFRA 21-1, AFP, CEA, CA 19-9, CA 125, NSE, and combinations of these markers in patients with pancreatic cancer. METHODS: We enrolled patients with primary pancreatic cancer and benign pancreatic cystic disease (n = 163). We performed sensitivity tests for multiple tumor markers, plotted receiver operating characteristic curves, and conducted multivariate analysis using the Cox proportional hazard method. Survival data were evaluated using Kaplan-Meier analysis of overall survival. RESULTS: Among multiple tumor markers assessed in this study, CA 19-9 showed good diagnostic performance, with an area under the curve of 0.86 ± 0.04 in ROC analysis. Based on two different cutoff values, CYFRA 21-1 (≥ 2.0 and 1.83 ng/mL) had a respective sensitivity of 80.4% and 82.3% and was also more significant than the other tumor markers in a parallel test. There was a weak significant relationship between tumoral fluorodeoxyglucose uptake and CYFRA 21-1 or CA 19-9. Initial CA 125, CYFRA 21-1, and CEA could be utilized to categorize subgroups with different overall survival. In multivariate analyses, CA 125 (HR 18.8, p < 0.001) and CYFRA 21-1 levels (HR 0.962, p = 0.006) demonstrated independent prognostic significance for predicting overall survival. CONCLUSIONS: In addition to CA 19-9, the present study suggested that various tumor markers could be used in the diagnosis and prognosis of pancreatic cancer. Further studies are warranted to confirm the clinical usefulness of diverse biological markers in pancreatic cancer.

Can outcome of pancreatic pseudocysts be predicted? Proposal for a new scoring system.

BACKGROUND: The spontaneous resolution rate of pancreatic pseudocysts (PPs) is 86%, and the serious complication rate is 3-9%. The aim of the present study was to develop a scoring system that would predict spontaneous resolution of PPs. METHODS: Medical records of 70 patients were retrospectively reviewed. Two patients were excluded. Demographic data and laboratory measurements were obtained from patient records. RESULTS: Mean age of the 68 patients included was 56.6 years. Female:male ratio was 1.34:1. Causes of pancreatitis were stones (48.5%), alcohol consumption (26.5%), and unknown etiology (25%). Mean size of PP was 71 mm. Pseudocysts disappeared in 32 patients (47.1%). With univariate analysis, serum direct bilirubin level (>0.95 mg/dL), cyst carcinoembryonic antigen (CEA) level (>1.5), and cyst diameter (>55 mm) were found to be significantly different between patients with and without spontaneous resolution. In multivariate analysis, these variables were statistically significant. Scores were calculated with points assigned to each variable. Final scores predicted spontaneous resolution in approximately 80% of patients. CONCLUSION: The scoring system developed to predict resolution of PPs is simple and useful, but requires validation.

[DYNAMICS OF CHANGES OF PROINFLAMMATORY AND ANTIINFLAMMATORY CYTOKINES, AS WELL AS SOME INDICES OF THE BLOOD PEROXIDATION SYSTEM, IN THE PATIENTS WITH VARIOUS PANCREATIC PSEUDOCYST TYPES].

The investigation was performed in 47 patients, operated on for pancreatic pseudocysts (PP). The PP type was established in accordance to A. D'Egidio, M. Schein (1991) classification. The blood plasma contents of proinflammatory and antiinflammatory cytokines, including interleukins (IL): IL-6, IL-8, IL-10, IL-18, as well as malonic dialdehyde and activity of glutationperoxidase, were determined for estimation of the immune state disorders. Mostly expressed changes in IL-8 content were registered in complicated PP in 72 h postoperatively, what was have characterized by more expressed raising of its level in systemic blood flow, than in a splanchnic one, in all types of PP and witnessed a hepatic capacity to guarantee a cytokine's clearance in all the patients. The contents of glutationperoxidase and IL-18 in the blood serum in various types of PP have correlated immediately with pancreatitis severity. Close correlative connection between these indices while unfavorable prognosis of postoperative period course was established.

Calcium level may be a predictive factor for pseudocyst formation after acute pancreatitis.

Pancreatic pseudocysts (PPs) are defined as fluid collections more than 4 weeks old that are surrounded by a nonepithelial wall of fibrous or granulation tissue. Many risk factors have been associated with pseudocyst development but predictive factors remain to be explored. The aim of this study was to investigate the clinical, and biochemical parameters that may predict the development of a PPs after an attack of acute pancreatitis (AP). The medical charts of 102 patients diagnosed with AP were enrolled into the study. Demographic, clinical and laboratory details were recorded at admission and at the 48(th) hour. There were several risk factors on admission and at the 48(th) hour that was predictive of PP formation when evaluated by univariate analysis such as: Alanine aminotransferase level at 48 hrs, calcium level at admission, base excess at 48 hrs, calcium level at 48 hrs, and albumin level at 48 hrs. In multivariate analysis, low calcium level at admission was the only variable that was shown to predict formation of PPs. Lower serum calcium level may be a predictive factor for the development of PPs after AP attack. We advise that patients with calcium levels below 8 mg/dl, after AP should be followed more closely.

[Acute pancreatitis in pediatric age: our experience in 52 cases]. / Pancreatite acuta in età pediatrica: nostra esperienza su 52 casi.

AIM: The aim of this study was to report our experience about clinical presentation and management in children with mild and sever acute pancreatitis (PA). METHODS: At the onset of clinical manifestations the following laboratory and instrumental tests were performed to all patients: abdominal ultrasonography, measurement of blood amylase and lipase and PCR; preventive antibiotic therapy, gabexate mesylate and proton pump inhibitors were also administrated to all patients. During the follow-up CT and dosage amylase and lipase in blood were performed. RESULTS: Results summarize data of 52 patients with suspected diagnosis of acute pancreatitis admitted to our hospital within 24 h of symptoms (from January 2008 to December 2011). Age ranged between 4-18 years, and the study included 30 females and 22 males. According to Santorini Consensus Conference, 40 patients were defined having a mild and 12 a severe pancreatitis. All patients with mild PA underwent a medical and/or surgical treatment (endoscopic retrograde cholangiopancreatography, laparoscopic cholecystectomy); there were 2 fatalities between patients with severe PA and 2 cases of pancreatic pseudocyst treated with guided CT drainage and therapy with octreotide. All patients had abdominal pain but the location, severity and duration of pain were extremely variable. Blood dosage of amylase was altered in 83% of cases and of lipase in 100%. Ultrasonography showed abnormalities in 89% of the patients and TC showed alterations of pancreatic parenchyma in 100% of the cases when performed at 48 h. CONCLUSION: In absence of randomized controlled studies, systematic review or guidelines for diagnosis and management of PA in pediatric age we used our experiences on adult patients, aware of this approach limitation.

Pancreatic pseudocysts in children: treatment by endoscopic cyst gastrostomy.

AIM: The aim of the present study was to review the use of endoscopic cyst gastrostomy (E-CG) as a treatment option for pancreatic pseudocysts referred to a tertiary paediatric surgical centre. METHODS: Retrospective review during a 10-year period (January 2001-December 2010). Cyst gastrostomies were performed using 1 or 2 double pigtailed Zimmon stents (7-10 Fr) under general anaesthesia. Data are quoted as median (range). RESULTS: E-CG was performed in 7 (5 males) children (median age at presentation 11.7 [8.2-15.8] years). Pancreatic pseudocysts were caused by acute pancreatitis in 5 (gallstones n = 1, hereditary pancreatitis n = 1, pancreatic divisum n = 1, asparaginase induced n = 1, and idiopathic n = 1) and pancreatic trauma in 2 (motor vehicle accident n = 1, and handlebar injury n = 1). All of the cases were associated with a rise in serum amylase level, median 1028 (276-2077) IU/L at the peak of symptoms. Three children had pancreatic duct stent placement during endoscopic retrograde cholangiopancreatography as the initial therapeutic intervention, but went on to have E-CG later. One who had a huge pseudocyst at presentation had already undergone an open cyst gastrostomy, which had recurred at 1 month. Rescue E-CG was performed 38 days later. All of the stents were removed endoscopically at 8 (6-40) weeks. E-CG was uncomplicated and pseudocysts resolved completely in 5. One required repeat placement at 15 days due to catheter slippage with later full resolution. One child required open cyst gastrostomy due to reaccumulation two months following removal of the stent. Median hospital stay post E-CG was 3 (1-23) days. There has been no recurrence at median follow-up of 18 (5-108) months. CONCLUSIONS: Endoscopic cyst gastrostomy is a safe and effective alternative for the management of pancreatic pseudocysts in children and should now be considered as treatment of choice.

Molecular analysis of cyst fluid aspiration in the diagnosis and risk assessment of cystic lesions of the pancreas.

Pancreatic cyst detection is increasing largely due to increasing use of cross-sectional imaging. The management of pancreatic cysts differs for true cysts, pseudocysts, mucinous cysts, nonmucinous cysts, and malignant lesions. Depending on the setting, diagnostic tests, such as cross-sectional imaging, endoscopic ultrasound, cyst fluid chemistry, and cytology, have moderate accuracy in characterizing the cyst subtype. Molecular analysis of cyst fluid aspirates has shown promise in preliminary studies and may require smaller fluid volumes than is needed for carcinoembryonic antigen level and cytology. This article reviews published studies in which molecular analysis was performed in the evaluation of pancreatic cysts. The molecular studies are compared with the conventional tests. Most studies have had moderate sample sizes (16-124) and have characterized a high proportion of patients with malignant cysts. Evaluation of molecular analysis as a diagnostic tool merits larger prospective trials with long-term follow-up of patients who are not sent to surgery. Larger cysts may meet size criteria for resection, and it is the smaller cysts for which molecular analysis may be of benefit if additional molecular testing results in a change in management.

[Diagnosis of purulent-necrotic complications of pancreatic pseudocysts].

The data on causes and rate of purulent-necrotic complications (PNC) occurrence of pancreatic cysts (PC) are adduced. Difficulties of these complications diagnosis and treatment were noted. Diagnostic markers for the PC PNC course and the treatment efficacy were proposed.

How useful are clinical, biochemical, and cross-sectional imaging features in predicting potentially malignant or malignant cystic lesions of the pancreas? Results from a single institution experience with 220 surgically treated patients.

BACKGROUND: This study aims to determine the use of preoperative clinical, biochemical, and cross-sectional imaging features for predicting malignancy in cystic lesions of the pancreas (CLP). STUDY DESIGN: Two hundred twenty patients who underwent operations for CLP or suspected CLP were reviewed. Patients were divided into two groups, patients undergoing operations for pseudocysts and patients undergoing operations for suspected cystic neoplasms. The predictive effect of various preoperative factors on the malignant potential of CLP was evaluated. RESULTS: Forty-four patients with a preoperative diagnosis of pseudocysts underwent operations for complications of pseudocyst. Forty-two were confirmed pathologically to have pseudocysts, but two were found, unexpectedly, to harbor malignant lesions. One hundred seventy-six patients underwent operations for suspected pancreatic cystic neoplasms. There were 70 benign, 51 potentially malignant, and 55 malignant CLP. On multivariate analysis, three factors, ie, elevated serum carcinoembryonic antigen (CEA) or carbohydrate antigen 19-9; cyst size > 3 cm; and presence of one or more of three morphologic features, such as solid component; peripheral calcification; and main duct dilation on cross-sectional imaging were independent predictors of malignancy. Presence of two or three of these factors had a positive predictive value of 88% in predicting a premalignant or malignant CLP. CONCLUSIONS: Most pancreatic pseudocysts can be accurately diagnosed preoperatively. In patients with suspected pancreatic cystic neoplasms, elevated serum CEA or carbohydrate antigen 19-9, cyst size > 3 cm, and presence of suspicious morphologic features on imaging are predictors of potentially malignant or malignant CLP. Patients with a high likelihood of a potentially malignant or malignant lesion based on these three factors should undergo operation without additional investigations.

Autoimmune pancreatitis with pseudocysts.

A 47-year-old woman was admitted to our hospital with complaints of fever, upper abdominal pain, and back pain. The serum amylase, C-reactive protein (CRP), and IgG (especially IgG4) were elevated, and abdominal computed tomography (CT) revealed diffuse enlargement of the pancreas and pseudocysts. Endoscopic retrograde pancreatography (ERP) revealed diffuse irregular narrowing of the main pancreatic duct. Histopathological examination of the pancreatic tissue showed fibrotic change with lymphocytic infiltration. Based on these findings, we diagnosed this case as a case of autoimmune pancreatitis. This case also fully satisfied the diagnostic criteria for autoimmune pancreatitis established by the Japan Pancreas Society in 2002. Few reports have been published on cases of autoimmune pancreatitis complicated by the formation of pseudocysts in the pancreas. We, therefore, report this case here to emphasize that cases of autoimmune pancreatitis can be complicated by the development of pseudocysts.

Serum amylase and lipase alone are not cost-effective screening methods for pediatric pancreatic trauma.

BACKGROUND: Injury to the pancreas is rare in pediatric trauma. Identification of pancreatic injury relies on clinical, radiographic, and laboratory data. Serum screening for pancreatic injury frequently is used but has not proven to correlate well with pancreatic injury. This study investigated utility and cost effectiveness of serum assessment of amylase and lipase. METHODS: A retrospective study of 1,821 pediatric trauma patients over 64 months was conducted. A total of 293 (16%) of these patients suffered trauma to the torso 195 (11%) of whom had confirmed intraabdominal injury. Eight pancreatic injuries (4% of abdominal injuries) were identified; 5 underwent surgery for pancreatic ductal injury. One patient not operated on had a pseudocyst that required late drainage. RESULTS: Serum amylase or lipase levels (AMY/LIP) were measured in 507 (28%) patients. A total of 116 (23%) had elevated AMY/LIP levels. Six of 8 with proven pancreatic injury underwent AMY/LIP testing; 5 had elevated values. Forty-eight percent of patients with elevated AMY/LIP levels had no evidence of intraabdominal injury. Seventy-four of 116 (64%) with elevated AMY/LIP levels underwent abdominal and pelvic computed tomography (CT) scanning, yet 38 (51%) of these had completely normal scans. Many patients with elevated AMY/LIP levels (cost, $6 per test) underwent screening CT scans (cost, $592 per test) based on AMY/LIP alone. No patient with elevated AMY/LIP levels but without clinical suspicion was proven to have pancreatic injury. Cost data are presented. CONCLUSIONS: Serum amylase and lipase determinations may support clinical suspicion in the diagnosis of pediatric pancreatic trauma but are not reliable or cost effective as screening tools. Costs incurred from routine serum amylase and lipase or from imaging tests subsequent to elevated serum values may be significant and unjustified.

Extraordinarily elevated CA19-9 in benign conditions: a case report and review of the literature.

Carbohydrate antigen CA19-9 is commonly used in the diagnosis of pancreatic and biliary malignancies. However, increases in its level in benign conditions such as acute cholangitis or pancreatitis have also been reported. A 79-year-old woman presented with cholangitis and a pancreatic pseudocyst while showing elevation of CA19-9 up to 35,500 U/mL. The patient was adequately treated and at two months' follow-up the CA19-9 level had returned to normal.

Three truncated forms of serum albumin associated with pancreatic pseudocyst.

Plasma from a patient with chronic pancreatic pseudocyst showed an additional more negative albumin band (18%) on agarose gel electrophoresis. Both components bound (63)Ni(2+), indicating intact N-terminals; however, electrospray ionisation analysis of the intact proteins showed the mass of more negative albumin was 1254 Da less than the control and that the apparently normal band was 112 Da less. Reverse phase mapping and mass analysis of CNBr peptides showed three proteolytically modified forms of the C-terminal peptide indicating that some 81% of the albumin molecules lacked the C-terminal Leu residue, that 18% lacked the C-terminal KKLVAASQAALGL and that approximately 1% lacked the QAALGL sequence. These findings were further verified by tryptic mapping of the aberrant CNBr peptides. The truncations probably result from exposure of the albumin to 'leaking' pancreatic endo and exoproteases. During less acute phases of the disease, the 13 and 6 residue truncated forms together decreased to less than 1%, while the des-Leu(585) form made up the balance; no normal albumin was detected. This suggested that the des-Leu(585) form might be present at low levels in the plasma of normal individuals and CNBr mapping confirmed that it constituted 4-15% of the albumin from normal plasma.

Acute pancreatitis complicating a bone marrow harvest.

A patient developing acute pancreatitis with pseudocyst formation after an uncomplicated bone marrow harvest is reported. The diagnosis was confirmed by elevated serum amylase and lipase, and by CT scan. We suggest that the pancreatitis may have been precipitated by spasm of the sphincter of Oddi secondary to opiates administered as premedication and for pain relief.

[Bisalbuminemia disclosing primary hyperparathyroidism with fistulized pancreatic false cyst]. / Bisalbuminémie révélant une hyperparathyroïdie primaire avec faux kyste du pancréas fistulisé.

Discovery on a protein electrophoregram of a bisalbuminemia can orientate according to its migration fast or slow to an hereditary mutation of an amino acid, or an acquired form by excess of beta lactamines due to renal insufficiency or by the rupture of a pancreatic pseudocyst in the peritoneum. This is this late mechanism that we report in this case of bisalbuminemia related to an opened pancreatic pseudocyst secondary to an adenoma of the parathyroid gland.

Serum tumor markers and cyst fluid analysis are useful for the diagnosis of pancreatic cystic tumors.

BACKGROUND: This study was performed to evaluate the utility of serum and cyst fluid analysis for enzymes (amylase and lipase) and tumor markers (carcinoembryonic antigen, CA 19-9, CA 125, and CA 72-4) in the differential diagnosis of cystic pancreatic lesions. METHODS: Serum and cyst fluid were obtained from 48 patients with pancreatic cysts (21 pseudocysts, 14 mucinous cystic neoplasms, 6 ductal carcinomas, and 7 serous cystadenomas), observed between 1989 and 1994. RESULTS: Serum CA 19-9 levels were significantly higher in ductal carcinomas (all > 100 U/mL) and mucinous cystic neoplasms (P < 0.05). CA 72-4 cyst fluid levels were significantly higher in mucinous cystic tumors (P < 0.005), with 95% specificity and 80% sensitivity in detecting mucinous or malignant cysts. A combined assay of serum CA 19-9 and cyst fluid CA 72-4 correctly identified 19 of 20 (pre-) malignant lesions (95%), with only 1 false-positive result (3.6%). Cytology showed a sensitivity of 48% and specificity of 100%. CONCLUSIONS: Any pancreatic cyst with high serum CA 19-9 values, positive cytology, or high CA 72-4 in the fluid should be considered for resection.