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Objective: To retrospectively compare inter- and intra-reader agreement of abbreviated MRCP (aMRCP) with comprehensive MRI (cMRCP) protocol for detection of worrisome features, high-risk stigmata, and concomitant pancreatic cancer in pancreatic cyst surveillance., Methods: 151 patients (104 women, mean age: 69[10] years) with baseline and follow-up contrast-enhanced MRIs were included. This comprised 138 patients under cyst surveillance with 5-year follow-up showing no pancreatic ductal adenocarcinoma (PDAC), 6 with pancreatic cystic lesion-derived malignancy, and 7 with concomitant PDAC. The aMRCP protocol used four sequences (axial and coronal Half-Fourier Single-shot Turbo-spin-Echo, axial T1 fat-saturated pre-contrast, and 3D-MRCP), while cMRCP included all standard sequences, including post-contrast. Three blinded abdominal radiologists assessed baseline cyst characteristics, worrisome features, high-risk stigmata, and PDAC signs using both aMRCP and cMRCP, with a 2-week washout period. Intra- and inter-reader agreement were calculated using Fleiss' multi-rater kappa and Intra-class Correlation Coefficient (ICC). 95% confidence intervals (CI) were calculated., Results: Cyst size, growth, and abrupt main pancreatic duct transition had strong intra- and inter-reader agreement. Intra-reader agreement was ICC = 0.93-0.99 for cyst size, ICC = 0.71-1.00 for cyst growth, and kappa = 0.83-1.00 for abrupt duct transition. Inter-reader agreement for cyst size was ICC = 0.86 (aMRCP) and ICC = 0.83 (cMRCP), and for abrupt duct transition was kappa = 0.84 (aMRCP) and kappa = 0.69 (cMRCP). Thickened cyst wall, mural nodule and cyst-duct communication demonstrated varying intra-reader agreements and poor inter-reader agreements., Conclusion: aMRCP showed high intra- and inter-reader agreement for most pancreatic cyst parameters that highly rely on T2-weighted sequences., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Pancreatic cystic lesions (PCLs) are frequent on MRI and are thought to be associated with pancreatic adenocarcinoma (PDAC) necessitating long-term surveillance based on older studies suffering from selection bias., Purpose: To establish the percentage of patients with PCLs on MRI with a present or future PDAC., Study Type: Systematic review, meta-analysis., Population: Adults with PCLs on MRI and a present or future diagnosis of PDAC were eligible. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus were searched to April 2022 (PROSPERO:CRD42022320502). Studies limited to PCLs not requiring surveillance, <100 patients, or those with a history/genetic risk of PDAC were excluded., Field Strength/sequence: ≥1.5 T with ≥1 T2-weighted sequence., Assessment: Two investigators extracted data, with discrepancies resolved by a third. QUADAS-2 assessed bias. PDAC was diagnosed using a composite reference standard., Statistical Tests: A meta-analysis of proportions was performed at the patient-level with 95% confidence intervals (95% CI)., Results: Eight studies with 1289 patients contributed to the percentage of patients with a present diagnosis of PDAC, and 10 studies with 3422 patients to the percentage with a future diagnosis. Of patients with PCLs on MRI, 14.8% (95% CI 2.4-34.9) had a PDAC at initial MRI, which decreased to 6.0% (2.2-11.3) for studies at low risk of bias. For patients without PDAC on initial MRI, 2.0% (1.1-3.2) developed PDAC during surveillance, similar for low risk of bias studies at 1.9% (0.7-3.6), with no clear trend of increased PDAC for longer surveillance durations. For patients without worrisome features or high-risk stigmata, 0.9% (0.1-2.2) developed PDAC during surveillance. Of 10, eight studies had a median surveillance ≥3 years (range 3-157 months). Sources of bias included retrospectively limiting PCLs to those with histopathology and inconsistent surveillance protocols., Data Conclusion: A low percentage of patients with PCLs on MRI develop PDAC while on surveillance. The first MRI revealing a PCL should be scrutinized for PDAC., Level of Evidence: 3 TECHNICAL EFFICACY: Stage 2., (© 2023 The Authors. Journal of Magnetic Resonance Imaging published by Wiley Periodicals LLC on behalf of International Society for Magnetic Resonance in Medicine.)

Abstract: This study aimed to assess the detection rate of small (<10 mm) pancreas cyst and intrareader reliability for cyst size measurements on transabdominal ultrasonography (US). From 2020 to 2022, 194 pancreas cysts in 173 patients, incidentally detected on computed tomography or magnetic resonance imaging, were evaluated on US by 1 of 2 radiologists (readers 1 and 2). Intrareader agreements of cyst size measurements on US were assessed by intraclass correlation coefficient (ICC). Bland-Altman plot was used to visualize the differences between the first and second size measurements in each reader. In this study, readers 1 and 2 evaluated 86 cysts in 76 patients and 108 cysts in 97 patients, respectively. Most of the cysts (191 of 194) were located in the nontail portion of the pancreas. Overall detection rate of pancreas cysts by US was 92.3% (179 of 194). The mean size of measured 179 pancreas cysts was 4.7 ± 1.5 mm. The readers showed excellent intrareader agreements (ICC = 0.925 and 0.960) for cyst size measurements, except for the cysts with size ≤5 mm, where both readers showed good intrareader agreements (ICC = 0.848 and 0.873). The 95% limits of agreement of readers 1 and 2 were 13.8% and 14.9% of the mean, respectively. Therefore, transabdominal US could be a reliable follow-up imaging modality for small (<10 mm) nontail pancreas cysts incidentally detected on computed tomography or magnetic resonance imaging, especially for the cysts with size between 5 and 10 mm. Size changes of the pancreas cysts approximately less than 15% may be within the measurement error., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The ACR Incidental Findings Committee (IFC) presents recommendations for managing pancreatic cysts that are incidentally detected on CT or MRI. These recommendations represent an update from the pancreatic component of the JACR 2010 white paper on managing incidental findings in the adrenal glands, kidneys, liver, and pancreas. The Pancreas Subcommittee-which included abdominal radiologists, a gastroenterologist, and a pancreatic surgeon-developed this algorithm. The recommendations draw from published evidence and expert opinion, and were finalized by informal iterative consensus. Algorithm branches successively categorize pancreatic cysts based on patient characteristics and imaging features. They terminate with an ascertainment of benignity and/or indolence (sufficient to discontinue follow-up), or a management recommendation. The algorithm addresses most, but not all, pathologies and clinical scenarios. Our goal is to improve quality of care by providing guidance on how to manage incidentally detected pancreatic cysts., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background and Aim: Endoscopic ultrasound-guided through-the-needle biopsy (EUS-TTNB) has been used over the past few years to increase diagnostic accuracy for pancreatic cystic lesions (PCLs). However, many concerns remain regarding its widespread use. This systematic review and meta-analysis aimed to pool the data from high-quality studies to evaluate the utility of EUS-TTNB in diagnosing PCLs., Methods: Electronic databases (PubMed, Embase, and Cochrane Library) from January 2010 through October 2022 were searched for publications addressing the diagnostic performance of EUS-TTNB in the diagnosis of pancreatic cystic lesions. Pooled proportions were calculated using fixed (inverse variance) and random-effects (DerSimonian-Laird) models., Results: The initial search identified 635 studies, of which 35 relevant articles were reviewed. We extracted data from 11 studies that met the inclusion criterion, comprising a total of 575 patients. Mean patient age was 62.25 years ± 6.12 with females constituting 61.39% of the study population. Pooled sensitivity of EUS-TTNB in differentiating a PCL as neoplastic or non-neoplastic was 76.60% (95% CI = 72.60-80. 30). For the same indication, EUS TTNB had a pooled specificity of 98.90% (95% CI = 93.80-100.00). The positive likelihood ratio was 10.28 (95% CI = 4.77-22.15), and the negative likelihood ratio was 0.26 (95% CI = 0.22-0.31). The pooled diagnostic odds ratio for EUS-TTNB in diagnosing PCLs as malignant/pre-malignant vs. non-malignant was 41.34 (95% CI = 17.42-98.08). Pooled adverse event rates were 3.04% (95% CI = 1.83-4.54) for pancreatitis, 4.02% (95% CI = 2.61-5.72) for intra-cystic bleeding, 0.94% (95% CI = 0.33-1.86) for fever, and 1.73% (95% CI = 0.85-2.91) for other minor events., Conclusions: EUS-TTNB has good sensitivity with excellent specificity in accurately classifying PCLs as neoplastic or non-neoplastic. Adding EUS-TTNB to EUS-FNA increases the accuracy of EUS-guided approach in diagnosing PCLs. However, it could significantly increase the risk of post-procedural pancreatitis., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: To evaluate the efficacy of low-dose CT (LDCT) with deep learning image reconstruction (DLIR) for the surveillance of pancreatic cystic lesions (PCLs) compared with standard-dose CT (SDCT) with adaptive statistical iterative reconstruction (ASIR-V)., Methods: The study enrolled 103 patients who underwent pancreatic CT for follow-up of incidentally detected PCLs. The CT protocol included LDCT in the pancreatic phase with 40% ASIR-V, DLIR at medium (DLIR-M) and high levels (DLIR-H), and SDCT in the portal-venous phase with 40% ASIR-V. The overall image quality and conspicuity of PCLs were qualitatively assessed using five-point scales by two radiologists. The size of PCLs, presence of thickened/enhancing walls, enhancing mural nodules, and main pancreatic duct dilatation were reviewed. CT noise and cyst-to-pancreas contrast-to-noise ratio (CNR) were measured. Qualitative and quantitative parameters were analyzed using the chi-squared test, one-way ANOVA, and t-test. Additionally, interobserver agreement was analyzed using the kappa and weighted-kappa statistics., Results: The volume CT dose-indexes in LDCT and SDCT were 3.0 ± 0.6 mGy and 8.4 ± 2.9 mGy, respectively. LDCT with DLIR-H showed the highest overall image quality, the lowest noise, and the highest CNR. The PCL conspicuity in LDCT with either DLIR-M or DLIR-H was not significantly different from that in SDCT with ASIR-V. Other findings depicting PCLs also revealed no significant differences between LDCT with DLIR and SDCT with ASIR-V. Moreover, the results revealed good or excellent interobserver agreement., Conclusion: LDCT with DLIR has a comparable performance with SDCT for the follow-up of incidentally detected PCLs., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Pancreatic cystic lesions (PCLs) are followed for years due to older and likely biased works demonstrating a strong association with pancreatic carcinoma; more recent data are needed clarifying this relationship., Purpose: To determine the association between PCLs on MRI and a synchronous or future diagnosis of pancreatic carcinoma., Study Type: Single-center retrospective cohort., Population: A total of 192 patients (111 female, 58%) with median age 66 years (range 26-87 years) with PCLs on abdominal MRI from 2011 to 2016., Field Strength/sequences: 1.5 T and 3 T, including T 2 WI, T 1 WI, diffusion weighted imaging and contrast-enhanced T 1 WI., Assessment: Each PCL was reviewed independently by 2 of 10 fellowship-trained abdominal radiologists. Fukuoka guideline worrisome features and high-risk stigmata were evaluated. Follow-up imaging and clinical notes were reviewed within a system that captures pancreatic carcinoma for the region, for a median follow-up of 67 months (interquartile range: 43-88 months)., Statistical Tests: Pancreatic carcinoma prevalence and incidence rate for future carcinoma with 95% confidence intervals (95% CI). Fisher exact test, logistic regression with odds ratios (OR) and the Wilcoxon rank-sum test were used to assess PCL morphologic features with the Kolmogorov-Smirnov test used to assess for normality. P < 0.05 defined statistical significance., Results: The prevalence of pancreatic carcinoma on initial MRI showing a PCL was 2.4% (95% CI: 0.9%, 5.2%). Thickened/enhancing cyst wall was associated with pancreatic carcinoma, OR 52 (95% CI: 4.5, 1203). Of 189 patients with a PCL but without pancreatic carcinoma at the time of initial MRI, one developed high-grade dysplasia and none developed invasive carcinoma for an incidence rate of 0.97 (95% CI: 0.02, 5.43) and 0 (95% CI: 0, 3.59) cases per 1000 person-years, respectively., Data Conclusion: A low percentage of patients with a PCL on MRI had a pancreatic carcinoma at the time of initial evaluation and none developed carcinoma over a median 67 months of follow-up., Evidence Level: 3 TECHNICAL EFFICACY: 5., (© 2022 International Society for Magnetic Resonance in Medicine.)

Purpose: We aimed to answer several clinically relevant questions; (1) the interobserver agreement, (2) diagnostic performance of MRI with MRCP for (a) branch duct intraductal papillary mucinous neoplasms (BD-IPMN), mucinous cystic neoplasms (MCN) and serous cystic neoplasms (SCN), (b) distinguishing mucinous (BD-IPMN and MCN) from non-mucinous cysts, and (c) distinguishing three pancreatic cystic neoplasms (PCN) from post-inflammatory cysts (PIC)., Methods: A retrospective analysis was performed at a tertiary referral center for pancreatic diseases on 71 patients including 44 PCNs and 27 PICs. All PCNs were confirmed by surgical pathology to be 17 BD-IPMNs, 13 MCNs, and 14 SCNs. Main duct and mixed type IPMNs were excluded. Two experienced abdominal radiologists blindly reviewed all the images., Results: Sensitivity of two radiologists for BD-IPMN, MCN and SCN was 88-94%, 62-69% and 57-64%, specificity of 67-78%, 67-78% and 67-78%, and accuracy of 77-82%, 65-75% and 63-73%, respectively. There was 80% sensitivity, 63-73% specificity, 70-76% accuracy for distinguishing mucinous from non-mucinous neoplasms, and 73-75% sensitivity, 67-78% specificity, 70-76% accuracy for distinguishing all PCNs from PICs. There was moderate-to-substantial interobserver agreement (Cohen's kappa: 0.65)., Conclusion: Two experienced abdominal radiologists had moderate-to-high sensitivity, specificity, and accuracy for BD-IPMN, MCN, and SCN. The interobserver agreement was moderate-to-substantial. MRI with MRCP can help workup of incidental pancreatic cysts by distinguishing PCNs from PICs, and premalignant mucinous neoplasms from cysts with no malignant potential., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Pancreatic cystic neoplasms (PCN) comprise of a diverse array of pancreatic cysts, including intraductal papillary mucinous neoplasms (IPMN), mucinous cystic neoplasms (MCN), serous cystic neoplasms (SCN), cystic neuroendocrine tumors (cNET), and many others. Increasing use of cross-sectional imaging has resulted in greater numbers of PCNs discovered incidentally. The overall risk of malignancy is low, but can vary considerably between different classes of PCNs. Furthermore, many pancreatic cysts are indeterminate on imaging, and the inability to reliably predict the course of disease remains a challenge for radiologists. Due to the variability in disease course and a lack of high-quality studies on PCNs, there is no universal consensus when it comes to balancing optimal surveillance while avoiding the risk for overtreatment. Currently, there are three widely accepted international guidelines outlining guidelines for surveillance and management of PCNs: the American Gastroenterological Association (AGA) in 2015, the International Association of Pancreatology (IAP) last revised in 2017, and the European Study Group on Cystic Tumours of the Pancreas (European) last revised in 2018. In 2017, the American College of Radiology released its own comprehensive set of recommendations for managing indeterminate pancreatic cysts that are detected incidentally on CT or MRI. The purpose of this paper is to describe the key differences between the ACR recommendations and the aforementioned three sets of guidelines regarding cyst management, imaging surveillance, performance, and cost-effectiveness., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Cystic pancreatic lesions (CPLs) are common and increasingly encountered in clinical radiology practice. The appropriate imaging surveillance strategy for lower-risk CPLs (branch duct-intraductal papillary mucinous neoplasms and indeterminant small cystic lesions) has been a topic of intense study and debate in recent years. MRI is considered the investigation of choice for initial characterisation and follow-up of CPLs. Follow-up intervals for CPLs vary from 6 months to 2 years and surveillance may be lifelong or until the patient is no longer considered fit for potential surgical intervention. This creates a significant burden on MRI resources as a standard protocol pancreatic MRI may have an acquisition time of up to 35-50 min. However, the necessity of contrast-enhanced sequences and diffusion weighted imaging (DWI) for routine follow-up of CPLs has been questioned in recent years., Methods: We reviewed the available evidence to determine whether an abbreviated MRI (A-MRI) protocol may be safely adopted for surveillance of CPLs, as has been implemented in other clinical scenarios., Results: A number of recent retrospective studies have indicated that an A-MRI, omitting contrast-enhanced and DWI, may be used for CPL surveillance without any suspicious features or cases of malignancy being missed. Although small number of cases may need to be recalled for additional MR sequences based on the A-MRI findings, there is still a significant overall timesaving., Conclusion: The best available evidence currently suggests that an A-MRI protocol should be considered for routine surveillance of CPLs. Prospective studies are required to ensure the findings reported in these retrospective case studies are backed up in ongoing clinical practice.

Rationale: Serous cystic neoplasms (SCNs) are treated as benign lesions. It is widely known that SCN rarely have a connection with the main pancreatic duct (MPD), which helps differentiate them from other cystic lesions, such as intraductal papillary mucinous neoplasm (IPMN). However, very rare cases where the SCN appears connected to the MPD cause diagnostic confusion., Patient Concerns: We present 2 patients with SCN (1 male, 54, and 1 female, 42). Both patients were asymptomatic, without abnormal laboratory results., Diagnosis: In both cases, abdominopelvic computed tomography and pancreatic magnetic resonance imaging scans revealed a multilobulated cystic lesion in communication with the MPD. Since the size of each patient's lesion was >3 cm and there was connectivity with the MPD, it was strongly suspected to be a branch duct-type IPMN with worrisome features rather than SCN and surgical intervention was considered., Interventions: Both neoplasms were misdiagnosed as IPMN due to appearing connected with the MPD on radiologic imaging. Surgery was performed., Outcomes: A final diagnosis of microcystic serous cystadenoma of the pancreas without connectivity of MPD was confirmed in both patients., Lessons: An unnecessary surgery was performed due to atypical radiologic features in which the pancreatic duct seems to be connected to the pancreatic cystic lesion on magnetic resonance imaging, leading to misdiagnosis of SCN as IPMN. Particular attention should be paid to interpretation of clinicoradiologic findings of pancreatic cystic lesions, especially to the decision of surgical intervention. Also, awareness of presence of the atypical radiologic features of SCN may broaden the knowledge base of radiologists., Lessons: An unnecessary surgery was performed due to atypical radiologic features in which the pancreatic duct seems to be connected to the pancreatic cystic lesion on magnetic resonance imaging, leading to misdiagnosis of SCN as IPMN. Particular attention should be paid to interpretation of clinicoradiologic findings of pancreatic cystic lesions, especially to the decision of surgical intervention. Also, awareness of presence of the atypical radiologic features of SCN may broaden the knowledge base of radiologists., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: In contrast to pancreatic ductal adenocarcinoma (PDAC), the risks of pancreatectomy for mucinous pancreatic cysts (MCs) are balanced against the putative goal of removing potentially malignant tumors. Despite undergoing similar operations, different rates of perioperative complications and morbidity between MC and PDAC patient populations may affect recommendations for resection. We therefore sought to compare the rates of postoperative complications between patients undergoing pancreatectomies for MCs or PDAC., Methods: A prospectively maintained institutional database was used to identify patients who underwent surgical resection for MCs or PDAC from July 2011 to August 2019. Patient demographics, complications, and perioperative data were compared between groups., Results: A total of 103 patients underwent surgical resection for MCs and 428 patients underwent resection for PDAC. Combined major 90-day postoperative complications were similar between MC and PDAC patients undergoing pancreaticoduodenectomy (PD, 32.5% vs. 20.0%, p = 0.068) or distal pancreatectomy (DP, 30.2% vs. 20.5%, p = 0.172). The most frequent complications were postoperative pancreatic fistula (POPF), abscess, and postoperative bleeding. The incidence of 90-day ISGPS Grade B/C POPF was higher in cyst patients undergoing PD (17.5% vs. 4.1%, p = 0.003) but not DP (25.4% vs. 20.5%, p = 0.473). No significant differences in operative time or length of stay between MCs and PDAC cohorts were observed., Conclusions: POPFs occur more frequently and at higher grades in patients undergoing PD for MCs than for PDAC and should inform patient selection. Accordingly, the perioperative management of MC patients undergoing PD should emphasize POPF risk mitigation., (© 2022. The Society for Surgery of the Alimentary Tract.)

Background: Computed tomography (CT) imaging is routinely obtained for diagnostics, especially in trauma and emergency rooms, often identifying incidental findings. We utilized a natural language processing (NLP) algorithm to quantify the incidence of clinically relevant pancreatic lesions in CT imaging., Patients and Methods: We utilized the electronic medical record to perform a retrospective chart review of adult patients admitted for trauma to a level 1 tertiary care center between 2010 and 2020 who underwent abdominal CT imaging. An open-source NLP software was used to identify patients with intrapapillary mucinous neoplasms (IPMN), pancreatic cysts, pancreatic ductal dilation, or pancreatic masses after optimizing the algorithm using a test group of patients who underwent pancreatic surgery., Results: The algorithm identified pancreatic lesions in 27 of 28 patients who underwent pancreatic surgery and excluded 1 patient who had a pure ampullary mass. The study cohort consisted of 18,769 patients who met our inclusion criteria admitted to the hospital. Of this population, 232 were found to have pancreatic lesions of interest. There were 48 (20.7%) patients with concern for IPMN, pancreatic cysts in 36 (15.5%), concerning masses in 30 (12.9%), traumatic findings in 44 (19.0%), pancreatitis in 41 (17.7%), and ductal abnormalities in 19 (18.2%) patients. Prior pancreatic surgery and other findings were identified in 14 (6.0%) patients., Conclusions: In this study, we propose a novel use of NLP software to identify potentially malignant pancreatic lesions annotated in CT imaging performed for other purposes. This methodology can significantly increase the screening and automated referral for the management of precancerous lesions., (© 2022. Society of Surgical Oncology.)

Purpose: The aims of this study are to compare the performance of various preoperative imaging modalities for assessing the malignant potential of pancreatic cystic lesions (PCLs) through a network meta-analysis (NMA) and to clarify the role of 18 F-FDG PET in the management of patients with PCL., Methods: PubMed, EMBASE, and Cochrane Library were searched for the studies evaluating the performance of preoperative imaging modalities for identifying malignant PCLs. The NMA was performed for 4 representative categories of various imaging modalities in terms of diagnostic performance for differentiating malignant from benign PCL and intraductal papillary mucinous neoplasms only as a subgroup analysis. To calculate the probability of each imaging modality being the most effective diagnostic method, the surface under the cumulative ranking curve values were obtained., Results: A total of 1018 patients from 17 direct comparison studies using 2 or more preoperative imaging modalities were included for differentiating malignant from benign PCL. The positive predictive value (PPV) and accuracy of 18 F-FDG PET were significantly higher than that of CT (PPV: odds ratio [OR], 2.66; 95% credible interval [CrI], 1.21-6.17; accuracy: OR, 2.63; 95% CrI, 1.41-5.38) or MRI (PPV: OR, 2.50; 95% CrI, 1.09-6.26; accuracy: OR, 2.50; 95% CrI, 1.28-5.47) in all PCLs, as well as in the subgroup analysis for intraductal papillary mucinous neoplasm only. 18 F-FDG PET showed the highest surface under the cumulative ranking curve values in all diagnostic performance areas of sensitivity, specificity, PPV, negative predictive value, and accuracy, followed by MRI or CT., Conclusions: The results from this NMA suggest that 18 F-FDG PET is the best preoperative imaging modality for differentiating malignant from benign PCLs and that it can be used for the preoperative evaluation of PCLs., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To develop a deep learning model (DLM) to improve readers' interpretation and speed in the differentiation of pancreatic cystic lesions (PCLs) on dual-phase enhanced CT, and a low contrast media dose, external testing set validated the model., Materials and Methods: Dual-phase enhanced CT images of 363 patients with 368 PCLs obtained from two centers were retrospectively assessed. Based on the examination date, a training and validation set of 266 PCLs, an internal testing set of 52 PCLs were designated from center 1. An external testing set included 50 PCLs from center 2. Clinical and radiological characteristics were compared. The DLM was developed using 3D specially designed densely connected convolutional networks for PCL differentiation. Radiomic features were extracted to build a traditional radiomics model (RM). Performance of the DLM, traditional RM, and three readers was compared., Results: The accuracy for differential diagnosis was 0.904 with DLM, which was the highest in the internal testing set. Accuracy differences between the DLM and senior radiologist were not significant both in the internal and external testing set (both p > 0.05). With the help of the DLM, the accuracy and specificity of the junior radiologist were significantly improved (all p < 0.05), and all readers' diagnostic time was shortened (all p < 0.05)., Conclusion: The DLM achieved senior radiologist-level performance in differentiating benign and malignant PCLs which could improve the junior radiologist's interpretation and speed of PCLs on CT., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: To assess the long-term malignancy risk of incidental small pancreatic cysts., Materials and Methods: In this HIPAA-compliant, IRB-approved, retrospective, multi-institutional study, the long-term incidence of pancreatic cancer was compared between patients with and without small pancreatic cysts. Patients with incidental pancreatic cysts ≥ 0.5 and < 2.0 cm in maximal diameter, detected on MRI performed between 1999 and 2011, represented the "small pancreatic cyst" group. Patients that underwent MRI between 2005 and 2011 and had no reported pancreatic cysts represented the comparison "no cyst" group., Results: The "small pancreatic cyst" group included 267 patients, ages 63.4 ± 11.8 years, 166/267 (62%) women with a mean follow-up of 8.6 ± 4.3 years, median 9.2 years; the "no cyst" group included 1,459 patients, ages 64.6 ± 12 years, 794/1,459 (54%) women with a mean follow-up of 7.0 ± 4.2 years, median 7.8 (p values 0.12, 0.02, < 0.001, respectively). Two/267 (0.7%) patients developed pancreatic cancer at a separate location from the known cyst in the "small pancreatic cyst" group, with a cancer rate of 0.9 (95% CI 0.1-3.1) cases per 1,000 patient-years. In the "no cyst" cohort, 18/1,459 (1.2%) patients developed pancreatic cancer, with a cancer rate of 1.8 (95% CI 1.2-3.1) cases per 1,000 patient-years (p = 0.6). The all-cause mortality was similar in both groups: 57/267 (21%) vs. 384/1,459 (26%) (p = 0.09)., Conclusion: The long-term risk of pancreatic malignancy in asymptomatic patients with incidental pancreatic cysts less than 2 cm is 0.9 cases per 1,000 patient-years of follow-up, similar to those without pancreatic cysts. These very few pancreatic cancers developed at a separate location from the known cyst., Key Points: • After a median of 9.2 years of follow-up, the risk of pancreatic malignancy in patients with an asymptomatic small pancreatic cyst was 0.9 cases per 1,000 patient-years of follow-up, similar to those without pancreatic cysts. • Very few pancreatic cancer cases developed in the location separate from the known pancreatic cyst., (© 2021. The Author(s), under exclusive licence to European Society of Radiology.)

Purpose: To determine if gadolinium is necessary for the diagnosis of a pancreatic cystic lesion (PCL) as benign or malignant by assessing inter- and intra-observer agreement and diagnostic accuracy for the presence of worrisome features/high-risk stigmata on non-contrast MRI compared to MRI with and without contrast, with cytopathology as a reference standard., Methods: The institutional database was searched to identify consecutive patients that underwent EUS/FNA or surgical resection of an asymptomatic PCL performed from 01/01/2015 to 01/01/2019. Two abdominal radiologists independently evaluated PCLs on MRI with all sequences except for contrast-enhanced sequences followed by a second reading with data from the entire MRI including pre- and post-contrast sequences. Cyst size, growth, and the presence of worrisome features/high-risk stigmata were assessed for each cyst on both datasets., Results: There were 87 patients with 87 pancreatic cysts; 76(87.4%) were benign and 11 (12.7%) were malignant. The presence of any worrisome features/high-risk stigmata for reader 1 was concordant on both MRIs in 95.4% (83/87; k = 0.874) of cases and for reader 2 was concordant in 96.6% (84/87; k = 0.920) of cases. The diagnostic accuracy of the two datasets when the presence of any worrisome feature/high-risk stigmata was predictive of malignancy was identical for reader 1 (AUC = 0.622 for both; p = 1.0) and similar for reader 2 (AUC 0.569 and 0.589; p = 0.08) for both MRI datasets., Conclusion: The addition of gadolinium had no significant impact in the diagnosis of a benign versus malignant PCL, with similar intra-observer agreement and diagnostic accuracy for both readers when using contrast-enhanced and unenhanced MRI datasets., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Differentiation of benign and malignant pancreatic cystic lesions on MRI, computed tomography (CT), and endoscopic ultrasound (EUS) is critical for determining management., Purpose: To perform a systematic review evaluating the diagnostic accuracy of MRI for diagnosing malignant pancreatic cystic lesions, and to compare the accuracy of MRI to CT and EUS., Study Type: Systematic review and meta-analysis., Data Sources: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus were searched until February 2020 for studies reporting MRI accuracy for assessing pancreatic cystic lesions., Field Strength: 1.5T or 3.0T., Assessment: Methodologic and outcome data were extracted by two reviewers (AU and MA, 2 years of experience each). All studies of pancreatic cystic lesions on MRI were identified. Studies with incomplete MRI technique were excluded. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool., Statistical Tests: Sensitivity/specificity was pooled using bivariate random-effects meta-analysis with 95% confidence intervals (95%CI). Pairwise-comparison of MRI to CT and EUS was performed. The impact of gadolinium-based contrast agents, mucinous lesions, and risk of bias were explored using meta-regression., Results: MRI pooled sensitivity was 76% (95%CI 67% to 84%) and specificity was 80% (95%CI 74% to 85%) for distinguishing benign and malignant lesions. MRI and CT had similar sensitivity (P = 0.822) and specificity (P = 0.096), but MRI was more specific than EUS (80% vs. 75%, P < 0.05). Studies including only contrast-enhanced MRI were more sensitive than those including unenhanced exams (P < 0.05). MRI sensitivity and specificity did not differ for mucinous lesions (P = 0.537 and P = 0.384, respectively) or for studies at risk of bias (P = 0.789 and P = 0.791, respectively)., Data Conclusion: MRI and CT demonstrate comparable accuracy for diagnosing malignant pancreatic cystic lesions. EUS is less specific than MRI, which suggests that, in some cases, management should be guided by MRI findings rather than EUS., Level of Evidence: 3 TECHNICAL EFFICACY STAGE: 2., (© 2021 International Society for Magnetic Resonance in Medicine.)

Objectives: To assess sonographic characteristics and outcome of patients with pancreatic cystic lesions seen by ultrasound., Methods: From our ultrasound electronic reporting database we identified all patients in which "pancreatic cyst" or "pancreatic cysts" were reported from 1995 to 2018. In patients with more than one sonogram, the first was used for our study. For each case, we recorded sonographic characteristics, maximal diameter, cyst location, and results of follow-up ultrasound, CT or magnetic resonance imaging, as well as patient sex, age, relative clinical history, and endoscopic ultrasound (EUS) or surgical findings when available., Results: Our study included 177 patients of whom 121 were female (68.4%). Mean age at diagnosis was 65 (±16, SD, range 22-99). Ultrasound was the initial diagnostic test in 122 (68.9%). Mean diameter of the index cyst was 13.7 mm (±11.5 mm, SD, range 2-91 mm). Among 177 index cysts, 155 were simple and 22 complex. Three complex cysts were surgically resected, yielding a primary pancreatic malignancy, a metastasis, and an epithelial-lined cyst. One simple cyst was resected, yielding a benign intraductal papillary mucinous neoplasm. Seventeen patients underwent EUS showing six mucinous cysts and 11 nonmucinous cysts. One hundred-eighteen patients had follow-up imaging for a mean time of 5.6 years (±3.8, range 0.25-21 years). One patient was presumed to have primary pancreatic cancer. The overall rate for primary pancreatic malignancy was 1.7% (2/118)., Conclusions: Cystic pancreatic lesions seen on ultrasound are most often benign, with a low risk of pancreatic malignancy. Ultrasound is an excellent method to follow-up these cysts., (© 2020 Wiley Periodicals LLC.)

Objectives: Imaging features of pancreatic acinar cystic transformation (ACT) have been published. We aimed to describe the clinical and radiological characteristics of patients with a presumed pancreatic ACT diagnosis, reappraising the value of these published imaging criteria., Materials and Methods: Single-center retrospective study (2003-2021) of consecutive patients with a presumed diagnosis of ACT as suggested by the local expert multidisciplinary case review board. Patients without available imaging (CT or MRI) for review were excluded. Patients were classified into "certain" ACT (if ≥ 2 imaging criteria and no differential diagnosis) or "uncertain" ACT (if ≥ 1 imaging criteria and suggested differential diagnoses)., Results: Sixty-four patients (35 males, [55%]) were included. ACT was considered "certain" for 34 patients (53%) and "uncertain" for 30 patients (47%). The number of ACT criteria did not differ between groups, with 91.2% of patients with ≥ 3 ACT imaging criteria in the "certain" group vs 93.3% in the "uncertain" group (p = 0.88). In the "uncertain" group, the main suggested differentials were branch-duct intraductal papillary mucinous neoplasm (18/30 patients, 60%), calcifying chronic pancreatitis (8/30 patients, 27%), both (three patients, 10%) and serous cystadenoma (one patient, 3%). Calcifications were significantly more frequent in the "uncertain" group (89% vs 63% in the "certain" group, p = 0.02)., Conclusion: Published ACT imaging criteria are frequently associated with features suggesting differential diagnoses. They appear insufficient to reach a final diagnosis in a subset of patients., Clinical Relevance Statement: ACT displays a heterogeneous morphological imaging presentation challenging the non-invasive diagnostic work-up. Physicians' and radiologists' awareness of this entity is important to better understand its natural history and improve non-invasive diagnostic criteria., Key Points: The criteria to help diagnose ACT are frequently associated with features suggestive of differentials. The main alternatives suggested when ACT diagnosis was "uncertain" were branch-duct intraductal papillary mucinous neoplasm and calcifying chronic pancreatitis. Published ACT diagnostic imaging criteria can be insufficient for a definite non-invasive diagnosis., Competing Interests: Compliance with ethical standards Guarantor The scientific guarantor of this publication is Vinciane Rebours. Conflict of interest Maxime Ronot is a member of the European Radiology Editorial Board. He has not taken part in the review or selection process of this article. The other authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. Statistics and biometry No complex statistical methods were necessary for this paper. Informed consent Written informed consent was obtained from all subjects (patients) in this study. Ethical approval Institutional Review Board approval was not required because this is a retrospective study and it did not imply an interaction or intervention with the subjects included (the data collected and the examinations performed were done in the context of standard care). Study subjects or cohorts overlap Some study subjects have been previously reported in Aguilera Munoz L, Boros C, Bonvalet F, et al (2023) Pancreatic Acinar Cystic Transformation: Familial Forms Do Exist. Pancreas. https://doi.org/10.1097/MPA.0000000000002233 Methodology RetrospectiveObservationalPerformed at one institution, (© 2024. The Author(s), under exclusive licence to European Society of Radiology.)

Purpose: To calculate the prevalence of pancreatic cysts on photon counting CT (PCCT) and compare with that of 128-slice conventional energy-integrating detector CT (EIDCT)., Method: A retrospective single institution database search identified all contrast-enhanced abdominal CT examinations performed at an outpatient facility that has both a PCCT and EIDCT between 4/11/2022 and 7/26/2022. The presence and size of pancreatic cysts were recorded. In patients with PCCT reported pancreatic cysts, prior CT imaging (EIDCT) was reviewed for reported pancreatic cysts. Fisher's exact test was used to compare the pancreatic cyst detection rate for PCCT and EIDCT. Wilcoxon rank sum test was used to compare cyst size and patient age. A p <.05 indicated statistical significance., Results: 2494 patients were included. Our pancreatic cyst detection rate was 4.9 % (49/1009) with PCCT and 3.0 % (44/1485) for EIDCT (p =.017). For CT angiograms, pancreatic cysts were detected in 6.6 % (21/319) with PCCT and 0.0 % (0/141) with EIDCT (p <.001). Pancreatic cyst detection rate was not statistically different for portal venous, enterography, renal mass, pancreas, 3-phase liver, or venogram protocols (all p >.05). Mean[SD] pancreatic cyst size was 13.7[9.7]mm for PCCT and 15.3[14.7] for EIDCT (p =.95). 55.1 % (27/49) of PCCT and 61.4 % (27/44) of EIDCT that described pancreatic cysts had prior contrast-enhanced EIDCTs. Of these, 40.7 % (11/27) of PCCT and 14.8 % (4/27) of EIDCT described pancreatic cysts were not previously reported (p =.027)., Conclusions: Photon-counting CT afforded greater pancreatic cyst detection than conventional energy-integrating detector CT, particularly with CT angiograms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Cystic lesions of the pancreas (PCLs) may be inflammatory or proliferative and making an accurate and timely pre-operative diagnosis remains a significant clinical challenge. This is principally due to the heterogeneity of the pathological processes involved. PCLs constitute an entity with diverse histology and although infrequent, the possible potential for malignant transformation of these lesions and the opportunity for curative surgery mandates that our diagnostic approaches are up to date and evidence based. In addition, improved diagnostic accuracy is crucial to prevent unnecessary surgical procedures with the inevitable associated morbidity., Methods: This narrative review examines the current diagnostic benchmarks and identifies novel diagnostic techniques that warrant further consideration, a number of which are beginning to be included in routine clinical practice when these PCLs are being investigated. A computerized search was made of MEDLINE, EMBASE and PubMed using the search words 'diagnostic approaches to pancreatic cystic lesions'. All relevant articles in English language or with an English abstract were retrieved and additionally cross referenced., Conclusion: The increasing accuracy of available imaging techniques together with the wider availability of endoluminal ultrasound and the development of additional novel methods to assess PCLs presents an opportunity to significantly improve the pre-operative diagnosis rate. This is essential to classify the type of PCL and hence guide the management particularly with lesions where there is a likelihood of progression to more serious pathology. We have highlighted the need for a comprehensive and standardized algorithm for the diagnosis and management of PCLs., (© 2020 Royal Australasian College of Surgeons.)

Purpose of Review: Pancreatic cancer is the third leading cause of cancer death and with a dismal 5-year survival of 10%. Poor survival of pancreatic cancer is mostly due to its presentation and diagnosis at a late stage. The present article aims to update clinicians with recent progress in the field of early detection of pancreatic cancer., Recent Findings: Pancreatic cancer screening is not recommended in the general population due to its low prevalence. In this review, we discuss high-risk groups for pancreatic cancer, including inherited predisposition to pancreatic cancer, new-onset diabetes, mucinous pancreatic cyst, and chronic pancreatitis. We discuss methods of enrichment of high-risk groups with clinical models using electronic health records and biomarkers. We also discuss improvements in imaging modalities and emerging role of machine learning and artificial intelligence in the field of imaging and biomarker to aid in early identification of pancreatic cancer., Summary: There are still vast challenges in the field of early detection of pancreatic cancer. We need to develop noninvasive prediagnostic validated biomarkers for longitudinal surveillance of high-risk individuals and imaging modalities that can identify pancreatic cancer early.

Background and Aim: The clinical significance of incidental pancreatic cystic lesions (PCLs) remains unclear in those that are not accompanied by worrisome features or high-risk stigmata. We aimed to investigate the natural course of PCLs without any risk features and examine the clinical factors associated with their progression., Methods: We conducted a retrospective cohort study of 427 patients with PCLs, which were incidentally detected by computed tomography between January 2003 and December 2012. Progression of PCLs without any risk features and the clinical factors associated with their progression were investigated. The length of time to significant growth was also evaluated., Results: Ninety-four (22.0%) of the 427 patients had asymptomatic PCLs that showed significant growth after a median surveillance period of 5.3 years; approximately 27.7% of the patients showed significant size changes in the first 5 years, while the remaining 72.3% showed significant changes after 5 years. The cumulative rate of patients with significant growth was associated with initial cyst size and high body mass index. In the growth group, additional treatments were required for 12 patients, one of whom developed malignancy. Four patients in the stable group underwent additional treatment and showed no malignant change., Conclusions: One-fifth of the asymptomatic PCLs significantly increased in size after a long-term follow-up period, which was associated with initial cyst size and obesity. The size of PCLs mostly increased after 5 years; although the malignancy risk of PCLs was low, it was still a concern., (© 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Owing to increased detection rates, the diagnosis and management of incidental pancreatic cysts has become a common predicament. Up to 13% of patients undergoing cross-sectional imaging studies for other indications are found to have pancreatic cystic lesions. Although most cystic lesions are benign, the malignant potential of several types of pancreatic cysts makes accurate classification vital to directing therapy. To this end, advances in the last decade led to better characterization of pancreatic cyst morphology and hence enhanced the ability to predict underlying histopathology, and biological behavior. Although accurate classification remains a challenge, the utilization of complementary diagnostic tools is the optimal approach to dictate management. The following review includes a description of pancreatic cysts, a critical review of current and emerging diagnostic techniques and a review of recent guidelines in the management of incidental pancreatic cysts.

Rationale and Objectives: According to current guidelines, pancreatic cystic lesions (PCLs) with worrisome or high-risk features may have overtreatment. The purpose of this study was to build a clinical and radiological based machine-learning (ML) model to identify malignant PCLs for surgery among preoperative PCLs with worrisome or high-risk features., Materials and Methods: Clinical and radiological details of 317 pathologically confirmed PCLs with worrisome or high-risk features were retrospectively analyzed and applied to ML models including Support Vector Machine, Logistic Regression (LR), Decision Tree, Bernoulli NB, Gaussian NB, K Nearest Neighbors and Linear Discriminant Analysis. The diagnostic ability for malignancy of the optimal model with the highest diagnostic AUC in the cross-validation procedure was further evaluated in internal (n = 77) and external (n = 50) testing cohorts, and was compared to two published guidelines in internal mucinous cyst cohort., Results: Ten clinical and radiological feature-based LR model was the optimal model with the highest AUC (0.951) in the cross-validation procedure. In the internal testing cohort, LR model reached an AUC, accuracy, sensitivity, and specificity of 0.927, 0.909, 0.914, and 0.905; in the external testing cohort, LR model reached 0.948, 0.900, 0.963, and 0.826. When compared to the European guidelines and the ACG guidelines, LR model demonstrated significantly better accuracy and specificity in identifying malignancy, while maintaining the same high sensitivity., Conclusion: Clinical- and radiological-based LR model can accurately identify malignant PCLs in patients with worrisome or high-risk features, possessing diagnostic performance better than the European guidelines as well as ACG guidelines., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Purpose: Radiological detection and follow-up of pancreatic cysts in multisequence MRI studies are required to assess the likelihood of their malignancy and to determine their treatment. The evaluation requires expertise and has not been automated. This paper presents MC3DU-Net, a novel multisequence cascaded pipeline for the detection and segmentation of pancreatic cysts in MRI studies consisting of coronal MRCP and axial TSE MRI sequences., Methods: MC3DU-Net leverages the information in both sequences by computing a pancreas Region of Interest (ROI) segmentation in the TSE MRI scan, transferring it to MRCP scan, and then detecting and segmenting the cysts in the ROI of the MRCP scan. Both the voxel-level ROI of the pancreas and the segmentation of the cysts are performed with 3D U-Nets trained with Hard Negative Patch Mining, a new technique for class imbalance correction and for the reduction in false positives., Results: MC3DU-Net was evaluated on a dataset of 158 MRI patient studies with a training/validation/testing split of 118/17/23. Ground truth segmentations of a total of 840 cysts were manually obtained by expert clinicians. MC3DU-Net achieves a mean recall of 0.80 ± 0.19, a mean precision of 0.75 ± 0.26, a mean Dice score of 0.80 ± 0.19 and a mean ASSD of 0.60 ± 0.53 for pancreatic cysts of diameter > 5 mm, which is the clinically relevant endpoint., Conclusion: MC3DU-Net is the first fully automatic method for detection and segmentation of pancreatic cysts in MRI. Automatic detection and segmentation of pancreatic cysts in MRI can be performed accurately and reliably. It may provide a method for precise disease evaluation and may serve as a second expert reader., (© 2023. CARS.)

Pancreas pathology is constantly evolving and can present various challenges for pathologists. This paper is focused on providing helpful hints for daily routine diagnostics. During histopathological analysis of pancreas biopsies, pancreatic ductal adenocarcinoma must be distinguished not only from other solid neoplasms, but especially from its mimicker, autoimmune pancreatitis. This can be achieved by a systematic workup following clear diagnostic criteria. When analyzing samples from cystic pancreatic lesions, mucin-producing neoplasms must be detected due to their role as pancreatic cancer precursors; molecular analyses can help considerably with their detection and distinction. During frozen section examination, evaluation of the pancreatic neck margin and analysis of unclear lesions of the liver are two important tasks, which are explained further in this article. A special challenge is the evaluation of neoadjuvant treated pancreatic cancer, which requires a detailed macroscopic and microscopic workup. Finally, current advances in precision oncology and emerging approaches for pancreatic cancer within this field are discussed. With the advancement of technical possibilities and their increasingly broad implementation, the classification systems in pancreatic pathology will continue to gain in complexity, but also in accuracy., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Lymphoepithelial cysts (LECs) of the pancreas are a rare type of true pancreatic cysts and represent an estimated 0.5% of all pancreatic cystic lesions. They are benign lesions and have no malignant potential. However, they are hard to differentiate from malignant lesions because their imaging and clinical presentation vary greatly. Seeing as these are benign lesions which are increasingly found incidentally during imaging for other indications, correct diagnosis is important to prevent unnecessary intervention and morbidity., Case Report: We report the case of a 41-year-old female who presented with abdominal discomfort, bloating and dyspepsia. An abdominal computed tomography (CT) showed a large mass in the left fossa. We describe the diagnostic and therapeutic measures taken in this case., Methods: We reviewed the literature for common features of the LEC. We grouped common imaging and histological features of the LEC of the pancreas to provide easily identifiable characteristics to facilitate diagnosis. For the review, we focused on papers, mostly case reports, presenting these common characteristics. We also reviewed the literature for key topics that should be taken into account when considering therapeutic interventions in a patient with a possible diagnosis of a LEC., Conclusion: Cysts of the pancreas are increasingly identified due to widespread use and improved resolution of cross-sectional imaging. To obtain the correct diagnosis, it is sometimes necessary to combine advanced imaging, i.e. CT and MRI-imaging, and endoscopic ultrasound with fine needle aspiration (EUS/FNA), while CA 19-9 also has diagnostic value. We summarize all diagnostic characteristics in a table for ease of use. Furthermore we summarized possible therapeutic interventions.

Pancreatic cystic lesions (PCLs) are both common and often incidental. These encompass a range of pathologies with varying degrees of concern for malignancy. Although establishing a diagnosis is helpful for determining malignant potential, many PCLs are either too small to characterize or demonstrate nonspecific morphologic features. The most salient modalities involved in diagnosis and surveillance are magnetic resonance imaging, multidetector computerized tomography, and endoscopic ultrasound. Fine needle aspiration has a role in conjunction with molecular markers as a diagnostic tool, particularly for identifying malignant lesions. Although several major consensus guidelines exist internationally, there remains uncertainty in establishing the strength of the association between all PCLs and pancreatic adenocarcinoma, and in showing a benefit from extended periods of imaging surveillance. No consensus exists between the major guidelines, particularly regarding surveillance duration, frequency, or endpoints. This review paper discusses PCL subtypes, diagnosis, and compares the major consensus guidelines with considerations for local adaptability along with questions regarding current and future priorities for research.

The role of endoscopic ultrasound (EUS) in the last two decades has shifted from a diagnostic tool to an important therapeutic tool treating mainly pancreato-biliary disorders. In recent years, its applications for treating pancreatic diseases have broadened, including the implementation of radiofrequency ablation (RFA), which has been traditionally used for treating solid tumors. In this critical in-depth review, we summarized all the papers throughout the literature regarding EUS-RFA for pancreatic neuroendocrine neoplasms, adenocarcinoma, and pancreatic cystic lesions. Overall, for pancreatic neuroendocrine neoplasms we identified 16 papers that reported 96 patients who underwent EUS-RFA, with acceptable adverse events that were rated mild to moderate and a high complete radiological resolution rate of 90%. For pancreatic adenocarcinoma, we identified 8 papers with 121 patients. Adverse events occurred in 13% of patients, mostly rated mild. However, no clear survival benefit was demonstrated. For pancreatic cystic lesions, we identified 4 papers with 38 patients. The adverse events were mostly mild and occurred in 9.1% of patients, and complete or partial radiological resolution of the cysts was reported in 36.8%. Notably, the procedure was technically feasible for most of the patients. Nevertheless, a long road remains before this technique finds its definite place in guidelines due to several controversies. EUS-RFA for pancreatic tumors seems to be safe and effective, especially for pancreatic neuroendocrine neoplasms, but multicenter prospective trials are needed to consider this treatment as a gold standard., Competing Interests: Conflict-of-interest statement: All the authors report having no relevant conflicts of interest for this article., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

With the progress of imaging technology and the popularization of healthy examination, the detection rate of pancreatic cystic neoplasm(PCN) has increased significantly. PCN has complex disease spectrum, strong heterogeneity, and diverse surgical treatment strategies. Surgical timing and methods directly affect patients' prognosis. Therefore, how to identify malignant tumors and formulate reasonable treatment strategies are the keys to treat PCN. Many guidelines for clinical diagnosis and treatment of PCN have been released, but there are still many disputes about its surgical indications. Hence, fully assessing the surgical indications is of great significance to improve the PCN patients' prognosis. This paper deeply discusses on the surgical indications of PCN by reviewing the current clinical diagnosis, treatment and research progress of PCN, in order to standardize the diagnosis and treatment of PCN.

Background: Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) can be used for the differential diagnosis of pancreatic lesions by evaluating microvascular circulation and patterns of contrast enhancement. However, routine use of CEH-EUS is limited by its high cost, the lack of contrast agent availability and the absence of expertise with this technique. Directional eFLOW (D-eFLOW) (Aloka Co., Ltd., Tokyo, Japan) was introduced as a new high-definition modality that detects blood flow in microvessels. Because it uses built-in functions, it entails no additional cost and reduces time for examination. The present study compared the usefulness of D-eFLOW and CEH-EUS for differential diagnosis of pancreatic and peripancreatic lesions., Methods: This retrospective study analyzed 130 patients who underwent EUS and D-eFLOW examinations from January 2016 to March 2020 to evaluate pancreatic and peripancreatic masses., Results: All 130 patients underwent D-eFLOW and CEH-EUS examinations. Histological diagnoses were confirmed in 130 patients by EUS-FNA and/or surgery. D-eFLOW and CEH-EUS showed good correlation in evaluating the vascularity of pancreatic and peripancreatic tumors (Fisher's exact test, p < 0.05)., Conclusions: In evaluating the characteristics of tumorous lesions, vascularity detected by D-eFLOW showed good correlation with enhancement patterns of CEH-EUS. D-eFLOW can be considered a good alternative to CEH-EUS in diagnosing pancreatic and peripancreatic masses., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021. Published by Elsevier B.V.)

Introduction: The present study aims to compare low-kV CT reconstructed with MBIR technique with MRI in detecting high-risk stigmata and worrisome features in patients with pancreatic cystic lesions., Methods: We retrospective enrolled 75 patients who underwent low-kV CT with contrast media injection for general abdominal disorders and MRI with MRCP sequences. The reviewer, blinded to clinical and histopathological data, recorded the overall number of pancreatic cystic lesions, size, location, presence of calcifications, septa, or solid enhancing or non-enhancing components, main pancreatic duct (MPD) communication, and MPD dilatation. Mean differences with 95% limits of agreement, ICC, and κ statistics were used to compare CT and MRI., Results: More pancreatic cystic lesions were detected with MRI than with CT, however, the ICC value of 0.81 suggested a good agreement. According to the evaluated target lesion, a very good agreement (ICC = 0.98) was found regarding the diameter (21.4 mm CT vs 21.8 mm MRI), the location (κ = 0.90), the detection of MPD dilatation (κ = 1), the presence of septa (κ = 0.86) and the MPD communication (κ = 0.87). A moderate agreement on the assessment of enhanced components was noted (κ = 0.44), while there was only a fair agreement about the presence of calcifications (κ = 0.87)., Conclusion: MDCT can be considered almost equivalent to MRI with MRCP in the evaluation of worrisome features and high-risk stigmata, offering detailed morphologic features helpful for their characterization., Implications for Practice: Even if MRI is considered the reference standard in pancreatic cystic lesions characterization, CT can be considered a useful tool as a first-line imaging technique to identify worrisome features and high-risk stigmata., Competing Interests: Conflict of interest statement The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.)

Contrast-enhanced ultrasonography (CEUS) is increasingly being performed in Italy and Europe, particularly in the field of hepato-gastroenterology. Initially, it was mainly carried out to characterize focal hepatic lesions, but, since then, numerous studies have demonstrated its efficacy in the differential diagnosis of focal pancreatic pathologies (D'Onofrio et al. in Expert Rev Med Devices 7(2):257-273, 2010; Vidili et al. in J Ultrasound 22(1):41-51, 2019). The purpose of this paper is to provide Italian Medical Doctors with recommendations and thereby practical guidelines on the management of these patients. The present paper reports the final conclusions reached by the SIUMB guideline commission. This paper addresses particularly percutaneous ultrasound (US) examination (transabdominal US) and is drawn up specifically for publication.

Pancreatic cystic lesions (PCLs) have been increasingly identified over the past 2 decades due to the widespread use of high-resolution non-invasive abdominal imaging. They cover a vast spectrum, from benign to malignant and invasive lesions, thus they constitute a significant clinical entity. Among PCLs, mucin-producing lesions are those at risk of progression to malignancy. They include mucinous cystic neoplasms (MCN) and intraductal papillary mucinous neoplasms (IPMN). The diagnosis and management of these cystic lesions are a dilemma since there is a significant overlap in the morphology of benign and premalignant lesions. At the moment, there is no single test that will allow a correct diagnosis in all cases. Magnetic resonance (MR) and endoscopic ultrasound (EUS) morphology, with cyst fluid analysis and cytohistology done with EUS-guided procedure are the best techniques that can narrow the differential diagnosis and identify potentially malignant lesions requiring resection from those requiring follow-up only. The purpose of this paper is to present an updated review of MR imaging findings of mucinous PCLs and to provide a new morphological approach that can serve as a practical guide for the diagnosis of these lesions, allowing a more confident characterization and avoiding relevant misdiagnosis. Furthermore, we provide some information about EUS and cystic fluid analysis and cytohistology, since they are diagnostic modalities that radiologists and surgeons should be familiar with.

Purpose of Review: Pancreatic cystic lesions represent a growing public health dilemma, particularly as our population ages and cross-sectional imaging becomes more sensitive. Mucinous cysts carry a clinically significant risk of developing pancreatic cancer, which carries an extremely poor prognosis. Determining which cysts will develop cancer may be challenging, and surgical resection of the pancreas carries significant morbidity. The goal of this paper is to review the rationale for cyst ablation and discuss prior and current research on cyst ablation techniques and efficacy. Indications, contraindications, and factors related to optimal patient selection are outlined., Recent Findings: Endoscopic ultrasound-guided chemoablation of pancreatic cysts has been performed in neoplastic cysts, with varying levels of efficacy. Safety concerns arose due to the risk of pancreatitis in alcohol-based treatments; however, the most recent data using a non-alcohol chemoablation cocktail suggests that ablation is effective without the need for alcohol, resulting in a significantly more favorable adverse event profile. Endoscopic ultrasound-guided chemoablation of neoplastic pancreatic cysts is a promising, minimally invasive approach for treatment of cysts, with recent significant advances in safety and efficacy, suggesting that it should play a role in the treatment algorithm.

Background: Pancreatic cystic lesions found in the literature are estimated between 2.6-19.6%. These neoplasms are almost exclusively benign tumors, and rarely become malignant. The aim of this paper was to report a feasible total pancreatectomy with portal resection in a giant pancreatic serous cystadenoma mimicking a malignant tumor., Case Presentation: A healthy 52-year-old female patient presented to us with a giant pancreatic cyst with unknown preoperative diagnosis and a secondary dilatation of the Wirsung duct, and unclear vascular invasion. The imaging assessment was not conclusive for malignancy. Furthermore, it was decided to perform a total pancreatectomy with portal vein resection and splenectomy. The pathological findings revealed a microcystic serous cystadenoma of 10 cm with abundant myxoid stromal degeneration and focal papillary proliferation without atypia., Conclusion: Unless the diagnosis of serous cystadenoma is certain, cystic tumors with inconclusive clinical and imaging features should be radically treated.

Pancreatic serous cystadenomas are uncommon benign tumours that are often found incidentally on routine imaging examinations. Radiological imaging techniques alone have proven to be suboptimal to fully characterize cystic pancreatic lesions. Endoscopic ultrasound, with the addition of fine-needle aspiration in difficult cases, has showed greater diagnostic accuracy than conventional imaging techniques. The best management strategy of these neoplasms is still debated. Surgery should be limited only to symptomatic and highly selected cases and most of the patients should only be strictly monitored. In the current paper, we provide an updated overview on pancreatic serous cystadenomas, focusing our attention on epidemiology, clinical characteristics and diagnostic evaluation; finally, we also discuss different management strategies and areas for future research.

Objective: Pancreatic cystic tumors are relatively rare tumors and only 1% of them are malignant. They are often asymptomatic and detected as incidental findings through diagnostic imaging. Currently there are no universal guide lines for the correct clinical approach to pancreatic cystic lesions. Cross-sectional imaging demonstrates some typical morphological features that determine the pre-operative diagnosis of the pancreatic cystic lesions (serous or mucinous cystadenoma, intraductal papillary mucinous neoplasms). In addition, endoscopic ultrasonography permits the collection and analysis of the fluid content. The aim of this paper is to describe our case load in the management of pancreatic cystic neoplasms and propose some criteria for choosing between surgical or conservative approaches., Patients and Methods: 12 patients with pancreatic cystic neoplasms were retrospectively evaluated. They were studied using cross-sectional imaging modalities (computed tomography and magnetic resonance); endoscopic ultrasonography was performed in 7 patients., Results: In each patient a careful evaluation of several factors (age, comorbidity, imaging features, symptoms, life expectancy) conditioned our clinical decision. Among our 12 patients, surgical resection was performed in 7 cases., Discussion: The treatment of pancreatic cystic lesions is still a dilemma because even in the presence of malignant potential, pancreatic surgery remains very complicated and demolitive. Many factors need to be considered in the management of cystic pancreatic tumors. The most important include histological type, location, size, age and clinical condition of the patient., Conclusions: A correct multidisciplinary pre-operative diagnosis is mandatory. Surgery should only be performed in selected cases.

Background/aims: Von Hippel-Lindau disease is an autosomal dominant genetic disorder characterized by neoplasms developing in multiple organs. Although the pancreas is one of the most frequently involved organs, the frequency of pancreatic cysts, cystadenomas, neuroendocrine tumors and diabetes has not been sufficiently evaluated due to the low prevalence of this disease. In this paper, we review and retrospectively analyze 11 patients with von Hippel-Lindau disease., Methodology: Eleven patients (6 males, 5 females) who underwent CT or MRI scans at Okayama University Hospital between 2002 and 2009 were enrolled in this study. Their pancreatic CT scans, MRI scans, biochemical test results and clinical histories were retrospectively reviewed., Results: All patients had one or more pancreatic involvements. Nine of the 11 patients had multiple pancreatic cysts, 2 had dilatation of the main pancreatic duct, 3 had a non-functioning pancreatic endocrine tumor (one patient required pancreatoduodenectomy due to the endocrine carcinoma) and 3 had diabetes mellitus. Pancreatic cystadenomas were not detected in this case series., Conclusions: The prevalence of pancreatic involvement was 100% in this study. Regular screening and scheduled follow-up for pancreatic lesions and diabetes should be performed on individuals predisposed to von Hippel-Lindau disease.

Pancreatic true cysts represent a rare, heterogeneous group of pancreatic tumors; therapeutic strategy is based on patient's general status, cyst topography, and especially the estimated risk of malignancy. This paper aim is to present 7 cases of pancreatic true cysts, operated on a six years period (January 2004-January 2010) in our surgical clinic: 2 men and 5 women, aged between 24-61 years old; cyst diameter varies between 3.5-15 cm, tumor location being pancreatic head in two cases and the distal pancreas in 5 cases. Surgical treatment consisted in cyst enucleation (two cases), splenopancreatectomy (three cases), duodenopancreatectomy (one case), and subtotal splenopancreatectomy (one case). Histology was represented by serous cystadenoma (one case), mucinous cystadenoma (2 cases), intraductal papillary mucinous cystadenoma (one case), and papillary cystadenocarcinoma (3 cases).Postoperative results were good in all cases, with 3 postoperative pancreatic external fistulas, resolved conservatory; no case of post-pancreatectomy diabetes mellitus was registered. In conclusion, surgical removal of the pancreatic cystic tumors is necessary, especially due to the risk of malignancy, at least in the absence of rigorous histological proofs of benignancy. Postoperative results are favorable in terms of postoperative morbidity and mortality.

Although many reports have described laparoscopic pancreatic surgery, laparoscopic pancreaticoduodenectomy (PD) has not been widely employed because of technical difficulties. This paper describes a totally laparoscopic pylorus-preserving PD performed for an intraductal papillary-mucinous neoplasm. After the laparoscopic resection, an end-to-side pancreaticojejunostomy including duct-to-mucosa anastomosis without a stenting tube, an approximation of the pancreas stump and jejunal wall, an end-to-side hepaticojejunostomy, and an end-to-side duodenojejunostomy were performed intracorporeally. The patient recovered without any complications and was discharged on the 14th postoperative day. The surgical margin was free of neoplastic changes. Although the experience is limited and the appropriate indications must await future studies, this case indicates that a laparoscopic pylorus-preserving PD can be feasible, safe, and effective in highly selected patients.

This paper presents our experience on the characterization of cystic pancreatic lesions using CT and MRI. First of all, true cystic pancreatic neoplasms should be differentiated from pseudocysts. Noninvasive characterization of cystic pancreatic neoplasms continues to rely principally on CT and MRI. Despite the presence of classic radiological characteristics of various cystic pancreatic neoplasms, these lesions continue to be problematic for the radiologist. They are most frequently incidental findings that are not related to the reason for imaging the patients in whom they are discovered. The radiological and clinical challenges are to determine the benign or malignant nature of the lesion and its potential resectability. The heterogeneity among cystic lesions and overlap in imaging characteristics should cause radiologists to approach the specific characterization of cystic pancreatic masses with a substantial degree of humility. Recommending an appropriate management approach based on imaging findings, in conjunction with clinical information and clinical consultation, may therefore be more important than attempting to assign a specific diagnosis to a cystic pancreatic lesion.

Cystic lesions of the pancreas are encountered frequently in clinical practice. Cystic neoplasms of the pancreas are much less common. In order to diagnose and most effectively treat these lesions, the surgeon must understand their clinical presentation in order to plan appropriate preoperative evaluation and therapeutic intervention. The following is a descriptive outline of the most common types of cystic neoplasms of the pancreas and a discussion of their preoperative, intraoperative, and postoperative management. The goal of the paper is to provide a functional understanding of cystic neoplasms of the pancreas so that they may be recognized and appropriately treated.

The paper focuses on different classifications of cystic affections of the pancreas. The most simplified classification is proposed to be used in routine practice, which facilitates clinical recognition and permits the selection of optimum, in the first place, surgical, tactics.

This paper reports the malignant transformation of a benign pancreatic cyst treated by internal drainage in a 30-year-old woman. The initial lesion was diagnosed on surgical biopsy of the cyst wall. The diagnosis of pancreatic carcinoma was made after one year of satisfactory course, by fine needle cytologic aspiration of the fibrous retraction of the cyst; at that time the patient had severe pancreatic pain with multinodular liver on ultrasonography. The conclusion is the recommendation of total excision of pancreatic cysts whenever the diagnosis is incomplete or imprecise.

This paper reports an extremely rare case of lymphoepithelial cyst of the pancreas. The patient, a 58-year-old man with no subjective symptoms, was found to have a pancreatic tumor during a physical examination. He visited our clinic and was admitted for a follow-up examination. Based on the ultrasonographic findings, superselective angiography, and aspiration biopsy, an epidermoid cyst was diagnosed. Enucleation was easily performed. Macroscopically, this cyst resembled an atheroma. Histologically, the cavity of the cyst was lined with a squamous epithelium with a nucleated layer and below that, lymphatic tissue. No malignancy was found. Tumors of the pancreas with a squamous epithelial covering are extremely rare; only a few such cases have been reported in the literature. As of 1991, only 12 cases, including the present case, had been reported. With the advances in diagnostic techniques, the detection of pancreatic tumors is expected to improve. This paper reports a case in which the use of an aspiration biopsy and superselective angiography proved to be useful in making an accurate diagnosis.

This paper reports on the technique and results of cystogastric catheter drainage, as described by Hancke, in eight patients with post-acute pseudocysts, and in one patient with acute necrotising pancreatitis. With this procedure, the catheter is passed, under gastroscopic and ultrasonographic control, percutaneously through the stomach into the pseudocyst in such a manner that the contents of the cyst drain into the stomach. Too small a residual stomach following surgery, and too small, or immature, cysts, represent the limitations of the technique. In five patients, complete, lasting emptying of the cyst was accomplished without any complications. The intervention can be carried out under local anesthesia.

This paper describes a case of pancreatic pseudocyst involving the mediastinum. Diagnosis was made by CT, which demonstrated the cystic nature of the lesion and its communication with an intra abdominal pseudocyst.