Introduction

PNET is an important determinant of survival in MEN1 patients and the most important cause of MEN1-related death. Early identification of pNETs in MEN1 is important since these represent a common cause of morbidity and mortality of the syndrome. Prognosis is associated with tumour size. Many pNETs are small subcentimetre lesions and only become symptomatic when the tumour is large. Conventional radiology is usually suboptimal in detecting small tumours (< 2cm), thus missing the window to remove them at an earlier stage. We aim to compare EUS detection of pNETs in patients with confirmed MEN1 compared to cross-sectional imaging including CT and/or MRI pancreas and assess the incremental benefit of EUS.

Aims & Methods

Over a span of 7 years, a total of 20 patients with clinically confirmed MEN1 had surveillance of pNET performed with EUS, CT/MRI and biochemical screening. Data were retrospectively retrieved from the hospital electronic records database. EUS and CT/MRI done within 3-6 months of each other were compared to minimize discrepancy in findings due to pNET size progression and new lesions over time. Statistical analysis was performed using SPSS v20 on the size and number of pNET detection by EUS and CT/MRI using the Wilcoxon Signed Rank Test and McNemar Chi-square.

Results

A total of 28 EUS procedures and an equal number of cross sectional imaging (CT/MRI) were performed. pNETs were identified in 95% of all 20 MEN1 cases. Overall median pNET size was 7.1mm on EUS and 14.5mm on CT/MRI (p=0.007). Mean value for smallest PNETs detected by EUS was 4.6mm and 12.7mm on CT/MRI (p=0.001). EUS detected more pancreatic lesions/pNETs compared to CT/MRI (p<0.001) in 25 of the 28 procedures (89.3% more). The remaining 3 procedures showed equal numbers of pNETs detection by both modalities. The interquartile range (IQR) for smallest pNET detected by EUS was 3.0-5.0mm while IQR for CT/MRI lies between 8.3mm-14.8mm. EUS detected all 100% cases of pNETs in our series of MEN1 compared to CT/MRI imaging alone which detected 57.9% cases (p=0.008). 14 of 20 patients had FNA performed with a positive yield of 85.7%. In 50% of patients, pNET measured ≤10 mm. 45% of patients underwent surgery for pNETs while the rest had surveillance.

Conclusion

In MEN1 patients, CT/MRI underestimated the presence of pancreatic lesions/pNETs in 42.1% compared to EUS (p=0.008) and was not able to identify pNETs < 8mm in all but one case.
EUS offers higher sensitivity than cross sectional imaging (CT/MRI) in terms of detecting the number of positive pNET cases as well as a greater number of pancreatic lesions especially subcentimetre lesions in MEN1. EUS should be considered a standard tool in the algorithm for MEN1 workup, instead of an adjunct reserved for diagnostic dilemmas.

References

NCCN Guidelines 2015 version 1.2015 Neuroendocrine Tumours.

Introduction

Therapeutic management of acute biliary pancreatitis (ABP) includes endoscopic sphincterotomy and cholecystectomy. However, the optimal feeding strategy prior to cholecystectomy—early oral intake or exclusive enteral nutrition—remains debated, particularly given the risk of recurrent biliary events (BEs) before surgery, especially when surgery is delayed.

Aims & Methods

The primary objective was to evaluate the likehood of BEs (biliary colic/migration, stone impaction, cholangitis, recurrent acute pancreatitis, and acute cholecystitis) prior to cholecystectomy, comparing feeding methods: oral vs. exclusive enteral nutrition. The secondary objective was to evaluate cholecystectomy rates during the initial hospitalization and the reasons for non-performance. Data were collected during hospitalization, at 3 months, and at 6 months if surgery had not been performed by month 3. BEs and feeding modalities at those times were documented. Analyses included Cox models and Chi-square tests.

Results

From October 2022 to December 2023, 1,172 patients with ABP were prospectively enrolled by 60 French hospitals, with 1,167 included in the final analysis. Sixty patients (5%) were lost to follow-up, and 34 deaths (3%) were reported. Severe ABP was observed in 27.2% (n=317) of patients. After 48–72 hours, oral feeding was resumed in 62% (n=724), enteral feeding in 16% (n=192), and fasting/parenteral feeding in 21% (n=249). During follow-up, 236 BEs occurred in 172 patients, meaning 15.5% experienced at least one event, with a median onset time of 26 days (range: 9–57 days). Specifically, 6% had at least one episode of biliary colic/migration, 2.1% experienced stone impaction, 2.3% developed cholangitis, 6.1% had recurrent AP (9% of which were severe), and 1.6% developed acute cholecystitis.
Univariate analysis identified several factors associated with a higher risk of BE recurrence (p < 0.10): age ≥52 years (p=0.093), obesity (BMI ≥30, p=0.032), ASA score >2 (p=0.097), total bilirubin ≥60 µmol/L (p=0.010), CRP >150 mg/L, diagnostic delay ≥21 days (p=0.009), and prior sphincterotomy (p=0.136). No difference in BE incidence was observed between severe and non-severe ABP (p=0.497) when analyzing the first 172 BEs.
Over the full follow-up period, despite the 87 BEs analyzed and potential biases, there remained no significant association between nutrition type (oral vs. exclusive enteral nutrition ) and the likelihood of BE occurrence (p=0.447).
In patients with non-severe ABP, cholecystectomy was performed during the initial hospitalization in only 33% of cases. The main reasons for non-performance were structural (e.g., lack of availability or surgeon refusal), accounting for 45% of cases.

Conclusion

BEs are frequent and clinically relevant: 15.5% of patients experienced at least one before surgery, with 6% developing recurrent ABP (9% of which were severe). Cholecystectomy remains underutilized; only one-third of patients with non-severe ABP underwent it during their initial stay, often due to modifiable reasons. Neither ABP severity nor nutritional type-oral vs enteral nutrition (despite potential biases, missing data, and ongoing analysis)-appeared to be associated with the occurrence of BEs prior to surgery. Early cholecystectomy, when possible, remains the only reliable strategy for preventing BEs.

Disclosure

This study received a research grant from Fresenius Kabi.

Introduction

Mucinous cystic neoplasms (MCN) are rare cystic pancreatic lesions with an evidenced malignant potential. Although the population who bear MCN is well characterized, the natural history of these lesions has not been elucidated as well as the risk features of malignancy. In a recent single centre study (Vullierme et al., 2021), we identified imaging features suggesting malignant MCN on MRI:
1) ≥ 5mm wall thickness,
2) mural nodule size ≥ 9 mm,
3) enhancing intra-cystic septa and/or
4) heterogenous signal on T2-weighted imaging.

Aims & Methods

The aims of this study were to identify clinical malignancy predictive factors and to validate in a multicentre cohort, the imaging malignancy predictive factors identified previously. In this multicentre retrospective study, patients who underwent pancreatic resection between January 2008 and December 2021 for MCN were included. Pathological review confirmed the presence of ovarian-type stroma. The preoperative imaging (CT and/or MRI) had to be available for a centralized expert radiological review. A multivariable logistic regression was performed to identify predictive factors of malignancy.

Results

A total of 198 patients were included from 13 participant centres. The cohort was constituted of 196 female patients (99%) with a median age of 46 (IQR 37-55) years. At diagnosis, 97 patients (49%) were asymptomatic. Low-grade dysplasia (LGD) was observed in 166 (84%) patients and at least high-grade dysplasia (≥HGD) in 32 (16%) patients, from which 14/32 had invasive carcinoma. An age of diagnosis of ≥55 years and the presence of symptoms at diagnosis was significantly associated with ≥HGD (p=0.028 and p=0.01, respectively). Regarding imaging features: ≥ 5mm wall thickness, a mural nodule size of ≥ 9 mm, presence of enhancing intra-cystic septa, and heterogenous cyst signal on T2-weighted imaging, were all significantly associated with ≥HGD (p=0.005, p=0.009, p=0.006, and p=0.003, respectively). In multivariate analysis, symptoms at diagnosis (OR 2.78, CI95% 1.13-6.89; p=0.027), lesion size ≥4cm (OR 3.29, CI95% 1.05-10.4; p=0.041) and presence of mural nodule (OR 6.58, CI95% 2.77-15.64; p<0.001) were independent predictive factors of ≥HGD.

Conclusion

MCN causing symptoms at diagnosis, measuring ≥ 4cm and with a mural nodule in imaging, should be addressed for surgical resection. The imaging features predictive of malignancy, that are confirmed in this cohort, should also be considered in surgical management decisions.

References

Vullierme MP, Gregory J, Rebours V, Cros J, Abelhady-Attia Y, Vilgrain V, Aguilera Munoz L, Laurent L, Levy P, Sauvanet A, Ronot M. MRI is useful to suggest and exclude malignancy in mucinous cystic neoplasms of the pancreas. Eur Radiol. 2021 Aug 10; PMID: 34374801

Disclosure

No conflict of interest to disclose