Cistoadenoma seroso de pâncreas. por que a acurácia é baixa aos exames de imagem? / Serous cystadenoma of pancreas: why there is low accuracy in imaging exams?

RESUMO - RACIONAL: Apesar da recomendação atual que o cistoadenoma seroso deva ser tratado de forma conservadora, significativa parte dos pacientes com essa condição ainda é operada por dúvida diagnóstica. OBJETIVO: Analisar causas da baixa acurácia diagnóstica do cistoadenoma seroso. MÉTODOS: Estudo retrospectivo de portadores de cistoadenoma seroso de um banco de dados de dois ambulatórios de cirurgia hepatopancreaticobiliar entre 2006 e 2020. Foram incluídos pacientes com lesões típicas de cistoadenoma seroso aos exames de imagem (tomografia computadorizada, ressonância magnética e ecoendoscopia) e pacientes que o anatomopatológico confirmasse esse diagnóstico. RESULTADOS: 27 pacientes foram incluídos. 85,18% eram do sexo feminino. A idade média foi de 63,4 anos. Apenas um apresentava sintomas típicos de pancreatite. A Ressonância magnética foi o exame mais realizado (62,9%). A lesão era única em 88,9% e o tamanho médio foi 4 cm. O aspecto típico microcístico foi encontrado em 66,6% dos casos, os demais foram considerados atípicos. A ecoendoscopia foi realizada em 29,6%. O valor médio de antígeno carcinoembrionário nos pacientes submetidos à punção do cisto foi de 198,25 ng/mL. O tratamento cirúrgico foi realizado em 10 casos (37%). Em 7, a causa cirúrgica foi a suspeita do cistoadenoma mucinoso mediante identificação de lesões atípicas (unilocular com ou sem septos e macrocística). Em 2, a suspeita de neoplasia papilar intraductal mucinosa com "fatores preocupantes" foi a indicação cirúrgica. O último foi submetido à cirurgia por lesão de aspecto sólido e suspeita de câncer. O índice de complicações > ou = Clavien-Dindo 2 foi 30%, o índice de fístula pancreática clinicamente relevante (B e C) foi 30%. A mortalidade foi nula. CONCLUSÃO: A apresentação morfológica atípica do cistoadenoma seroso, particularmente lesões uniloculares e macrocísticas, é a principal responsável pela indicação cirúrgica. Apenas a implementação de novos, eficientes e reprodutíveis métodos diagnósticos poderá reduzir o número de cirurgias desnecessárias nesses pacientes.

ABSTRACT - BACKGROUND: Many patients with serous cystadenoma of the pancreas (SCP) underwent surgery due to diagnostic doubt. AIM: The aim of this study was to analyze the causes of low accuracy in diagnosing SCP. METHODS: This is a retrospective study of patients with SCP from a database of two hepatopancreatic biliary surgery outpatient clinics between 2006 and 2020. Patients with typical SCP lesions in imaging exams (e.g., tomography, magnetic resonance imaging [MRI], and endoscopic ultrasound [EUS]) and patients whose pathological testing confirmed this diagnosis were included. RESULTS: A total of 27 patients were included in this study. Most patients were women (85.18%), and the mean age was 63.4 years. Only one patient had typical pancreatitis symptoms. MRI was the most performed method (62.9%). The lesion was single in 88.9%, and the average size was 4 cm. The typical microcystic aspect was found in 66.6%. EUS was performed in 29.6% of cases. The mean carcinoembryonic antigen value in patients undergoing cyst puncture was 198.25 ng/mL. Surgical treatment was performed in 10 cases (37%). The cause of surgery in seven of these cases was due to a suspicion of mucinous cystadenoma based on an identification of atypical lesions (unilocular with or without septa and macrocystic) in imaging exams. A suspicion of intraductal papillary mucinous neoplasm with "worrying factors" was the indication for surgery in two cases. The last case underwent surgical treatment for a solid-looking lesion which was suspected of cancer. The complication rate ≥Clavien-Dindo 2 was 30%, and the clinically relevant pancreatic fistula rate (B and C) was 30%. Mortality was nil. CONCLUSION: The atypical morphological presentation of SCP, particularly unilocular and macrocystic lesions, is the main indication for surgery. Only the implementation of new, efficient, and reproducible diagnostic methods can reduce the number of unnecessary surgeries among these patients.

Radiomic of enhanced CT for identification of benign and borderline serous tumors of ovary / 中国介入影像与治疗学

Objective: To establish radiomic model based on enhanced CT, and to observe the value of the model for distinguishing benign and borderline serous tumors of ovary. Methods: Data of CT imaging of 49 patients with ovary serous cystadenoma (SC) and 31 patients with serous borderline tumors (SBT) confirmed by pathology were retrospectively analyzed. AK software was used by 2 radiologists to delineate ROI of the tumors, and radiomic parameters were extracted. Then multiple Logistic regression was applied to identify optimal radiomic features and construct the prediction model. ROC curve was used to analyze the diagnostic efficacy of radiomic parameters and model on ovarian SC and SBT. Results: A total of 396 image radiomics parameters were extracted, and 5 feature parameters were obtained after dimensionality reduction, namely Percentile10, Percentile15, SA, LRHGLEa90, o1 and LRHGLEa90, o7, respectively. The results of reproducibility analysis of 2 radiologists had good consistency (all intraclass correlation coefficient> 0.75). Radscore prediction model was constructed with the above 5 characteristic parameters, and the AUC, sensitivity and specificity of Radscore model for differentiating ovarian SC and SBT in the training set was 0.90, 0.91 and 0.79, while in the testing set was 0.86, 0.90 and 0.73, respectively. Conclusion: Radiomic model based on enhanced CT can be used for identifying SC and SBT of ovary.

Diagnostic value of CT texture analysis in the quantification of radiological phenotype for pancreatic cystadenoma / 中华胰腺病杂志

Objective To provide objective parameters for differentiating pancreatic cystic tumors via using computed tomography texture analysis (CTTA) to quantify the special imaging features of pancreatic cystadenomas.Methods Enhanced CT images of pancreas from patients who were admitted in Department of Radiology in First Hospital affiliated with Zhejiang University and First People's Hospital of Hangzhou City and pathologically diagnosed as pancreatic serous cystadenomas (n =48) and mucinous cystadenomas (n =34) from January 2009 to December 2016 were retrospectively analyzed.Regions of interest were drawn on the parenchymal phase CT images in 5 slices according to the border of the tumors.Mean grey level intensity (M),variance (V),entropy (E),skewness (Ske) and kurtosis (Kur) were obtained from fine texture (σ =1.0) to coarse texture (σ =2.5).Receiver operating characteristic (ROC) curve for texture parameters with statistically difference was drawn,and the area under curve (AUC),diagnostic sensitivity and specificity were calculated.The diagnostic accuracy of senior and junior doctors was compared with the traditional CT analysis method.Results Reliability coefficient of the two radiologists was 0.809 ～ 0.997 with high consistency.Compared with mucinous cystic tumors,serous cystadenomas had a significantly different V (5.93 ± 9.02 vs 1.29±0.62),E (2.39±0.61 vs2.02±0.39) and Kur(30.18 ±42.55 vs 8.80-±4.34) in Ske0 of 2.5 (P ＜0.05),and there were no statistically significant differences on other parameters.The AUC of differential parameters for diagnosing two kinds of cystic tumors ranged from 0.56 to 0.84.The diagnostic accuracy of the traditional CT analysis method by junior doctor and senior radiologist was 60％ and 71％,respectively.Conclusions CTTA can not only effectively quantify the heterogeneity of pancreatic cystadenomas,but also is effective in the differentiation.

An appraisal of pancreatic cyst fluid molecular markers

Pancreatic malignancy is the third leading cause of cancer related death in the United States with limited viable screening options. By the end of this decade, cancers are poised to become the leading cause of death with pancreatic cancer projected to be the second leading cause of cancer related mortality. Pancreatic cystic lesions (PCLs) are found in approximately 5%–14% of patients due to the increased utilization of cross-sectional imaging, with approximately 8%–10% of pancreatic cancers originating as PCLs. Current screening guidelines have shown discrepancies between morphologic characteristics of PCLs and identifying advanced pancreatic disease. Molecular analysis has emerged as a novel technology to aid in adequate diagnosis and management decisions of PCLs. Mucinous cysts including intraductal papillary mucinous neoplasms (IPMNs) or mucinous cystic neoplasms have similar oncogenic mutations including KRAS, TP53, SMAD4, PIK3CA, PTEN, or CKDN2A, while GNAS and RNF43 mutations are specific only to IPMNs. Serous cystadenomas have been associated with a loss of tumor suppressor gene VHL, while solid-psuedopapillary neoplasms have an oncogenic mutation CTNNB1. A specific molecular marker to diagnose existing high-grade dysplasia or impending malignant transformation is yet to be identified. Moving forward it is important to advance technology in isolating and identifying high-risk molecular markers from cyst fluid while considering their increased utilization in the evaluation of PCLs.

Analysis of VEGF/PlGF heterodimer level in pancreatic cyst fluid as a biomarker for serous cystadenoma.

INTRODUCTION: Pancreatic cyst fluid (PCF) analysis provides valuable information in the preoperative evaluation of pancreatic cysts. Vascular endothelial growth factors (VEGF) and other proangiogenesis factors such a placental growth factor (PlGF) are promising biomarkers for identifying serous cystadenoma (SCA). VEGF-A has recently been reported as a SCA marker. We sought to assess the value of the VEGF-A/PlGF heterodimer as a potential biomarker of SCA in PCF. MATERIALS AND METHODS: PCF was analyzed for VEGF/PlGF and 7 additional proangiogenic markers including VEGF-A, VEGF-C, VEGF-D, TEK tyrosine kinase, endothelial (TIE-2), soluble fms-like tyrosine kinase-1 (sFlt-1), PlGF, and basic fibroblast growth factor (bFGF). True-positive or false-negative results were determined by histological confirmation of SCA and false-positive or true-negative results with confirmation of a non-SCA cyst by either cytology or histology, elevated carcinoembryonic antigen ≥192 ng/mL, elevated amylase ≥5000 U/L, or detected KRAS/GNAS mutations. RESULTS: Forty-eight PCFs were analyzed; 1 was technically inadequate. Of the remaining 47, 3 (6%) contained measurable (>60 pg/mL) concentrations of VEGF/PlGF heterodimer: 1 pseudocyst, 1 cystic adenocarcinoma, and 1 SCA. Of 6 histologically confirmed SCAs, there was only 1 (17%) true positive. Six PCFs were not classifiable due to insufficient data, leaving 41 PCFs for performance calculations (33 true negative, 5 false negative, 1 true positive, and 2 false positive) yielding a sensitivity of 17% and specificity of 94%. CONCLUSIONS: VEGF/PlGF heterodimer is present in low concentrations in PCF and is an insensitive biomarker for SCA. Additional study is required to determine clinical utility of heterodimeric VEGF/PlGF in combination with other proangiogenic markers.

Ultrasonic diagnosis and pathological comparison of pancreatic serous and mucinous cystadenoma / 重庆医学

Objective To explore the value of ultrasound in diagnosis and differential diagnosis of pancreatic mucinous cystade‐noma and serous cystadenoma .Methods Data of tumor features of sixty seven cases of pancreatic cystadenoma ultrasonographic was retrospectively analyzed .The tumor location ,tumor size ,tumor boundary ,tumor shape ,cavity number and calcification were re‐corded .Then all the data was statistically analyzed .Results Pancreatic cystadenoma occured mostly in middle‐aged women ,there was no significant difference between pancreatic mucinous cystadenoma and serous cystadenoma of the pancreas in age ,gender ,le‐sion location ,lesion size ,shape ,boundary ,cystic wall ,cystic wall nodules(P>0 .05) ,while there were significant differences in with and without clinical symptoms ,cavity number ,diameter of the largest cyst and calcification(P<0 .05) .Conclusion Ultrasonic man‐ifestations of pancreatic cystadenoma has certain characteristics ,when there are clinical symptoms ,cavity number is less than 6 , maximum sac diameter is bigger than 2 cm and there is marginal calcification ,it tends to mucinous cystadenoma;when there is no clinical symptoms ,cavity number is equal to or more than 6 ,maximum sac diameter is equal to or smaller than 2 cm and there is cen‐tral calcification ,it tends to serous cystadenoma .

Serous cystadenoma of the pancreas: a report of 18 cases / 中华普通外科杂志

Objective To investigate the diagnosis and treatment of serous cystadenoma of the pancreas. Methods The clinical data of 18 patients with serous cystadenoma of the pancreas which were admitted into the First Affiliated Hospital of China Medical University from October 1999 to October 2010 were retrospectively analyzed. Results There were 15 females(83.3%) and 3 males (16.7%).Tumors were present in the pancreatic body and tail in 12 cases ( 66. 7% ), in the pancreatic head in 3 cases ( 16. 7% ) and in the pancreatic neck in 3 cases( 16. 7% ). The mean maximum diameter of the tumor was 6. 5 cm. No specific clinical features were indentified. The size of the tumor was significantly correlated with clinical symptoms. CT was main examination with correct diagnosing rate of 61.1%. All 18 patients received surgical resection. Pancreaticoduodenectomy was performed in 3 patients, distal pancreatectomy in 5 cases,spleen-preserving distal pancreatectomy in 5 cases, middle pancreatectomy in 3 cases, and tumor enucleation in 2 cases. Postoperative pancreatic fistula developed in 10 cases (55.6%);Fistula was healed by conservative therapy in all these 10 cases. Postoperative followed up from 6 to 125 months (mean,48. 3months) found no recurrence or metastasis. Conclusions CT was main imaging examination for serous cystadenoma of the pancreas. Surgical resection should be adopted for serous cystadenoma of the pancreas with clinical symptoms but uncertain malignancy.

Cistoadenoma seroso gigante de ovario: reporte de un caso / Giant ovarian serous cystadenoma: a case report

El cistoadenoma seroso de ovario es un tipo de tumor derivado del epitelio superficial (celómico), formado por áreas quísticas. La razón del predominio de estos tumores en el ovario es un misterio. Se presenta el caso de una paciente con cistoadenoma seroso de ovario; que fue referida al Servicio de Cirugía del Hospital Provincial Docente Dr Antonio Luaces Iraola por presentar un gran aumento del volumen abdominal, de 12 meses de evolución, cuyo diagnóstico fue sospechado por hallazgo de ultrasonografía pélvica; se encontró en la sala de operaciones una tumoración gigante de 10 kg de peso que fue confirmado por anatomopatología como un cistoadenoma seroso de ovario.

Giant ovarian serous cystadenoma is a type of tumor derived from the surface epithelium (celomic), formed by cystic areas. The reason for the prevalence of these ovarian tumors is a mystery. It is reported the case of a patient with ovary serous cystadenoma that was referred to the Surgery Service of the Teaching Provincial Hospital Dr Antonio Luaces Iraola for presenting a large increase volume in abdominal, 12 months evolution, whose diagnosis was suspected by pelvic ultrasonography; a giant of 10 kg was found during surgery and diagnosis was confirmed by histopathology as an ovarian serous cystadenoma.

Macrocystic Form of Serous Cystadenoma of the Pancreas: Two Cases Report

The macrocystic form of serous cystadenoma of the pancreas is an uncommon benign neoplasm composed of few, relatively large cysts that are lined by uniform, glycogen-rich, cuboidal epithelial cells. We report here on two cases of pathologically proven macrocystic serous cystadenoma of the pancreas in a 45-year-old female patient and a 53-year-old female patient. Both these cysts were lined by low cuboidal epithelia without any evidence of mucin production. There was also no evidence of pancreatitis. These tumors were radiologically suspected as being mucinous cystic neoplasm or pseudocysts. Although the microscopic and immunohistochemical studies of the macrocystic variant are not different from the conventional serous microcystic cystadenoma, their unusual macroscopic features can lead to confusion for the clinicians and radiologists.

Morphological Classification of Serous Cystic Tumor (SCT) of Pancreas and its Clinical Significance / 한국간담췌외과학회지

PURPOSE: Honeycomb microcystic tumor is typical for SCT, but various SCTs including oligocystic tumor have been frequently reported. We classified SCT morphologically according to the gross and radiologic feature, and we analyzed the clinical features for the subtypes of SCT. We also suggest the guidelines for the differential diagnosis from mucinous cystic tumors (MCT) and the appropriate management. METHODS: This study enrolled 31 patients with SCT and 37 patients with MCT of the pancreas that were treated from Jan. 1992 to Oct. 2003 at Seoul National University Hospital. When the SCTs were classified according to cyst size and multiplicity, 13 were microcystic tumor and 18 were macrocystic tumor. We then compared microcystic SCT with mcrocystic SCT and we also compared macrocystic SCT with MCT. RESULTS: The mean age of patients with SCT was 50 (range: 31~77) and the male : female ratio was 1 : 3. The head : tail ratio was 14 : 18. There was no malignant SCT and no tumor recurrence. There was no difference between the microcystic and macrocystic type tumors according to the patients' age, gender and symptoms, and for the tumors' location and size. But preoperative misdiagnosis occurred 15.4% of the time for the microcystic type and 61.1% of the time for the macrocystic type (p=0.01). When we compared macrocystic SCT with MCT, there was no difference in the patients' age and symptoms, or for the tumors' size and the CA19-9 level in the serum. However, a difference was found for the tumors' location and the patients' gender ratio. There was a difference for the tumor location (p=0.043) and the patients' gender ratio (p=0.082). CONCLUSION: According to morphological features, we could classify SCT into two types (microcystic vs. macrocystic). Microcystic SCT can be accurately diagnosed at the preoperative stage, so conservative treatment and observation is possible. Macrocystic SCT is difficult to differentiate from the other pancreatic cystic tumors with malignant potential, so resection is recommended.