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Approach to the Patient with a Pancreatic Mass

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Hepato-Pancreato-Biliary Malignancies

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Abstract

“Pancreatic mass” is a term that instantly terrifies patients. However, the list of possible etiologies is broad, and includes even benign lesions (for instance, pancreatic cysts incorrectly referred to as a mass). Using a systematic, algorithmic approach for evaluating focal pancreatic lesions, a physician can not only select the proper diagnostic tests but also involve the appropriate multispecialty services in a timely manner.

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References

  1. Basturk O, Askan G. Benign tumors and Tumorlike lesions of the pancreas. Surg Pathol Clin. 2016;9(4):619–41.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Sachs T, Pratt WB, Callery MP, Vollmer CM Jr. The incidental asymptomatic pancreatic lesion: nuisance or threat? J Gastrointest Surg. 2009;13(3):405–15.

    Article  PubMed  Google Scholar 

  3. Lee KS, Sekhar A, Rofsky NM, Pedrosa I. Prevalence of incidental pancreatic cysts in the adult population on MR imaging. Am J Gastroenterol. 2010;105(9):2079–84.

    Article  PubMed  Google Scholar 

  4. Hart PA, Zen Y, Chari ST. Recent advances in autoimmune pancreatitis. Gastroenterology. 2015;149(1):39–51.

    Article  CAS  PubMed  Google Scholar 

  5. O’Reilly DA, Malde DJ, Duncan T, Rao M, Filobbos R. Review of the diagnosis, classification and management of autoimmune pancreatitis. World J Gastrointest Pathophysiol. 2014;5(2):71–81.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Sugumar A, Takahashi N, Chari ST. Distinguishing pancreatic cancer from autoimmune pancreatitis. Curr Gastroenterol Rep. 2010;12(2):91–7.

    Article  PubMed  Google Scholar 

  7. Wakabayashi T, Kawaura Y, Satomura Y, et al. Clinical and imaging features of autoimmune pancreatitis with focal pancreatic swelling or mass formation: comparison with so-called tumor-forming pancreatitis and pancreatic carcinoma. Am J Gastroenterol. 2003;98(12):2679–87.

    Article  PubMed  Google Scholar 

  8. Ghazale A, Chari ST, Smyrk TC, et al. Value of serum IgG4 in the diagnosis of autoimmune pancreatitis and in distinguishing it from pancreatic cancer. Am J Gastroenterol. 2007;102(8):1646–53.

    Article  CAS  PubMed  Google Scholar 

  9. Chari ST, Smyrk TC, Levy MJ, et al. Diagnosis of autoimmune pancreatitis: the Mayo Clinic experience. Clin Gastroenterol Hepatol. 2006;4(8):1010–6. quiz 934

    Article  PubMed  Google Scholar 

  10. Sandanayake NS, Church NI, Chapman MH, et al. Presentation and management of post-treatment relapse in autoimmune pancreatitis/immunoglobulin G4-associated cholangitis. Clin Gastroenterol Hepatol. 2009;7(10):1089–96.

    Article  CAS  PubMed  Google Scholar 

  11. Shimosegawa T, Chari ST, Frulloni L, et al. International consensus diagnostic criteria for autoimmune pancreatitis: guidelines of the International Association of Pancreatology. Pancreas. 2011;40(3):352–8.

    Article  PubMed  Google Scholar 

  12. Kirkegard J, Mortensen FV, Cronin-Fenton D. Chronic pancreatitis and pancreatic cancer risk: a systematic review and meta-analysis. Am J Gastroenterol. 2017;112(9):1366–72.

    Article  PubMed  Google Scholar 

  13. Raimondi S, Lowenfels AB, Morselli-Labate AM, Maisonneuve P, Pezzilli R. Pancreatic cancer in chronic pancreatitis; aetiology, incidence, and early detection. Best Pract Res Clin Gastroenterol. 2010;24(3):349–58.

    Article  PubMed  Google Scholar 

  14. Ballehaninna UK, Chamberlain RS. The clinical utility of serum CA 19-9 in the diagnosis, prognosis and management of pancreatic adenocarcinoma: an evidence based appraisal. J Gastrointest Oncol. 2012;3(2):105–19.

    CAS  PubMed  PubMed Central  Google Scholar 

  15. Forsmark CE. Management of chronic pancreatitis. Gastroenterology. 2013;144(6):1282–91 e3.

    Article  PubMed  Google Scholar 

  16. Wolske KM, Ponnatapura J, Kolokythas O, Burke LMB, Tappouni R, Lalwani N. Chronic pancreatitis or pancreatic tumor? A problem-solving approach. Radiographics. 2019;39(7):1965–82.

    Article  PubMed  Google Scholar 

  17. Yamada Y, Mori H, Matsumoto S, Kiyosue H, Hori Y, Hongo N. Pancreatic adenocarcinoma versus chronic pancreatitis: differentiation with triple-phase helical CT. Abdom Imaging. 2010;35(2):163–71.

    Article  PubMed  Google Scholar 

  18. Tajima Y, Kuroki T, Tsutsumi R, Isomoto I, Uetani M, Kanematsu T. Pancreatic carcinoma coexisting with chronic pancreatitis versus tumor-forming pancreatitis: diagnostic utility of the time-signal intensity curve from dynamic contrast-enhanced MR imaging. World J Gastroenterol. 2007;13(6):858–65.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Kim JK, Altun E, Elias J Jr, Pamuklar E, Rivero H, Semelka RC. Focal pancreatic mass: distinction of pancreatic cancer from chronic pancreatitis using gadolinium-enhanced 3D-gradient-echo MRI. J Magn Reson Imaging. 2007;26(2):313–22.

    Article  PubMed  Google Scholar 

  20. Adler DG, Diehl DL. Missed lesions in endoscopic ultrasound. Endoscopic Ultrasound. 2015;4(3):165–7.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Ardengh JC, Lopes CV, Campos AD, Pereira de Lima LF, Venco F, Modena JL. Endoscopic ultrasound and fine needle aspiration in chronic pancreatitis: differential diagnosis between pseudotumoral masses and pancreatic cancer. JOP. 2007;8(4):413–21.

    PubMed  Google Scholar 

  22. de la Fuente SG, Ceppa EP, Reddy SK, Clary BM, Tyler DS, Pappas TN. Incidence of benign disease in patients that underwent resection for presumed pancreatic cancer diagnosed by endoscopic ultrasonography (EUS) and fine-needle aspiration (FNA). J Gastrointest Surg. 2010;14(7):1139–42.

    Article  PubMed  Google Scholar 

  23. Bournet B, Souque A, Senesse P, et al. Endoscopic ultrasound-guided fine-needle aspiration biopsy coupled with KRAS mutation assay to distinguish pancreatic cancer from pseudotumoral chronic pancreatitis. Endoscopy. 2009;41(6):552–7.

    Article  CAS  PubMed  Google Scholar 

  24. Xu WSJ, Li X, et al. Endoscopic ultrasound elastography for differentiation of benign and malignant pancreatic masses: a systemic review and meta-analysis. Eur J Gastroenterol Hepatol. 2013;25(2):218–24.

    Article  PubMed  Google Scholar 

  25. Gong TTHD, Zhu Q. Contrast-enhanced EUS for differential diagnosis of pancreatic mass lesions: a meta-analysis. Gastrointest Endosc. 2012;76:301–9.

    Article  PubMed  Google Scholar 

  26. Yamashita YST, Napoleon B, et al. Value of contrast-enhanced harmonic endoscopic ultrasonography with enhancement pattern for diagnosis of pancreatic cancer: a meta-analysis. Dig Endosc. 2019;31(2):125–33.

    Article  PubMed  Google Scholar 

  27. Harmsen F-JR, Domagk D, Dietrich CF, Hocke M. Discriminating chronic pancreatitis from pancreatic cancer: contrast-enhanced EUS and multidetector computed tomography in direct comparison. Endoscopic ultrasound. 2018;7(6):395–403.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Rückert F, Brussig T, Kuhn M, et al. Malignancy in chronic pancreatitis: analysis of diagnostic procedures and proposal of a clinical algorithm. Pancreatology. 2013;13(3):243–9.

    Article  PubMed  Google Scholar 

  29. American Cancer Society Cancer Facts and Figures. Atlanta. GA: American Cancer Society; 2020. p. 2020.

    Google Scholar 

  30. Siegel RMK, Jemal A. Cancer statistics, 2020. CA Cancer J Lin. 2020;70(1):7–30.

    Article  Google Scholar 

  31. Howlader N, Noone AM, Krapcho M, et al. SEER cancer statistics review, 1975–2017. Bethesda, MD: National Cancer Institute; 2020.

    Google Scholar 

  32. Decker GA, Batheja MJ, Collins JM, et al. Risk factors for pancreatic adenocarcinoma and prospects for screening. Gastroenterol Hepatol (N Y). 2010;6(4):246–54.

    Google Scholar 

  33. Porta M, Fabregat X, Malats N, et al. Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage. Clin Transl Oncol. 2005;7(5):189–97.

    Article  PubMed  Google Scholar 

  34. Matsuyama M, Ishii H, Kuraoka K, et al. Ultrasound-guided vs endoscopic ultrasound-guided fine-needle aspiration for pancreatic cancer diagnosis. World J Gastroenterol. 2013;19(15):2368–73.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Hruban RH, Klimstra DS. Adenocarcinoma of the pancreas. Semin Diagn Pathol. 2014;31(6):443–51.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Lanke G, Ali FS, Lee JH. Clinical update on the management of pseudopapillary tumor of pancreas. World J Gastrointest Endosc. 2018;10(9):145–55.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Romics L Jr, Olah A, Belagyi T, Hajdu N, Gyurus P, Ruszinko V. Solid pseudopapillary neoplasm of the pancreas – proposed algorithms for diagnosis and surgical treatment. Langenbeck’s Arch Surg. 2010;395(6):747–55.

    Article  Google Scholar 

  38. Cai H, Zhou M, Hu Y, et al. Solid-pseudopapillary neoplasms of the pancreas: clinical and pathological features of 33 cases. Surg Today. 2013;43(2):148–54.

    Article  CAS  PubMed  Google Scholar 

  39. Jiang L, Cui L, Wang J, Chen W, Miao L, Jia J. Solid pseudopapillary tumors of the pancreas: findings from routine screening sonographic examination and the value of contrast-enhanced ultrasound. J Clin Ultrasound. 2015;43(5):277–82.

    Article  PubMed  Google Scholar 

  40. Holen KD, Klimstra DS, Hummer A, et al. Clinical characteristics and outcomes from an institutional series of acinar cell carcinoma of the pancreas and related tumors. J Clin Oncol. 2002;20(24):4673–8.

    Article  PubMed  Google Scholar 

  41. Mortenson MM, Katz MH, Tamm EP, et al. Current diagnosis and management of unusual pancreatic tumors. Am J Surg. 2008;196(1):100–13.

    Article  PubMed  Google Scholar 

  42. Zundler S, Erber R, Agaimy A, et al. Pancreatic panniculitis in a patient with pancreatic-type acinar cell carcinoma of the liver – case report and review of literature. BMC Cancer. 2016;16:130.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Chiou YY, Chiang JH, Hwang JI, Yen CH, Tsay SH, Chang CY. Acinar cell carcinoma of the pancreas: clinical and computed tomography manifestations. J Comput Assist Tomogr. 2004;28(2):180–6.

    Article  PubMed  Google Scholar 

  44. Tatli S, Mortele KJ, Levy AD, et al. CT and MRI features of pure acinar cell carcinoma of the pancreas in adults. Am J Roentgenol. 2005;184(2):511–9.

    Article  Google Scholar 

  45. Klimstra DS. Nonductal neoplasms of the pancreas. Mod Pathol. 2007;20(Suppl 1):S94–112.

    Article  PubMed  Google Scholar 

  46. Nishimura R, Takakuwa T, Hoshida Y, Tsujimoto M, Aozasa K. Primary pancreatic lymphoma: clinicopathological analysis of 19 cases from Japan and review of the literature. Oncology. 2001;60(4):322–9.

    Article  CAS  PubMed  Google Scholar 

  47. Sadot E, Yahalom J, Do RK, et al. Clinical features and outcome of primary pancreatic lymphoma. Ann Surg Oncol. 2015;22(4):1176–84.

    Article  PubMed  Google Scholar 

  48. Koniaris LG, Lillemoe KD, Yeo CJ, et al. Is there a role for surgical resection in the treatment of early-stage pancreatic lymphoma? J Am Coll Surg. 2000;190(3):319–30.

    Article  CAS  PubMed  Google Scholar 

  49. Merkle EM, Bender GN, Brambs HJ. Imaging findings in pancreatic lymphoma: differential aspects. AJR Am J Roentgenol. 2000;174(3):671–5.

    Article  CAS  PubMed  Google Scholar 

  50. Nagtegaal ID, Odze RD, Klimstra D, et al. The 2019 WHO classification of tumours of the digestive system. Histopathology. 2020;76(2):182–8.

    Article  PubMed  Google Scholar 

  51. Nayer H, Weir EG, Sheth S, Ali SZ. Primary pancreatic lymphomas: a cytopathologic analysis of a rare malignancy. Cancer. 2004;102(5):315–21.

    Article  PubMed  Google Scholar 

  52. Salman B, Brat G, Yoon YS, et al. The diagnosis and surgical treatment of pancreatoblastoma in adults: a case series and review of the literature. J Gastrointest Surg. 2013;17(12):2153–61.

    Article  PubMed  Google Scholar 

  53. Montemarano H, Lonergan GJ, Bulas DI, Selby DM. Pancreatoblastoma: imaging findings in 10 patients and review of the literature. Radiology. 2000;214(2):476–82.

    Article  CAS  PubMed  Google Scholar 

  54. Ohike N, La Rosa S. Pancreatoblastoma. In: WHO Classification of Tumours Editorial Board, editor. WHO classification of tumors: digestive system tumours. 5th ed. Lyon: International Agency for Research on Cancer; 2019. p. 337.

    Google Scholar 

  55. Adsay NV, Andea A, Basturk O, Kilinc N, Nassar H, Cheng JD. Secondary tumors of the pancreas: an analysis of a surgical and autopsy database and review of the literature. Virchows Arch. 2004;444(6):527–35.

    Article  PubMed  Google Scholar 

  56. Adler H, Redmond CE, Heneghan HM, et al. Pancreatectomy for metastatic disease: a systematic review. Eur J Surg Oncol. 2014;40(4):379–86.

    Article  CAS  PubMed  Google Scholar 

  57. Wente MN, Kleeff J, Esposito I, et al. Renal cancer cell metastasis into the pancreas: a single-center experience and overview of the literature. Pancreas. 2005;30(3):218–22.

    Article  PubMed  Google Scholar 

  58. Triantopoulou C, Kolliakou E, Karoumpalis I, Yarmenitis S, Dervenis C. Metastatic disease to the pancreas: an imaging challenge. Insights Imaging. 2012;3(2):165–72.

    Article  PubMed  Google Scholar 

  59. van der Pol CB, Lee S, Tsai S, et al. Differentiation of pancreatic neuroendocrine tumors from pancreas renal cell carcinoma metastases on CT using qualitative and quantitative features. Abdom Radiol (NY). 2019;44(3):992–9.

    Article  Google Scholar 

  60. Fesinmeyer MD, Austin MA, Li CI, De Roos AJ, Bowen DJ. Differences in survival by histologic type of pancreatic cancer. Cancer Epidemiol Biomark Prev. 2005;14(7):1766–73.

    Article  Google Scholar 

  61. Kasumova GG, Tabatabaie O, Eskander MF, Tadikonda A, Ng SC, Tseng JF. National Rise of primary pancreatic carcinoid tumors: comparison to functional and nonfunctional pancreatic neuroendocrine tumors. J Am Coll Surg. 2017;224(6):1057–64.

    Article  PubMed  Google Scholar 

  62. Philips P, Kooby DA, Maithel S, et al. Grading using Ki-67 index and mitotic rate increases the prognostic accuracy of pancreatic neuroendocrine tumors. Pancreas. 2018;47(3):326–31.

    Article  PubMed  Google Scholar 

  63. Fraenkel M, Kim MK, Faggiano A, Valk GD. Epidemiology of gastroenteropancreatic neuroendocrine tumours. Best Pract Res Clin Gastroenterol. 2012;26(6):691–703.

    Article  CAS  PubMed  Google Scholar 

  64. Grozinsky-Glasberg S, Mazeh H, Gross DJ. Clinical features of pancreatic neuroendocrine tumors. J Hepatobiliary Pancreat Sci. 2015;22(8):578–85.

    Article  PubMed  Google Scholar 

  65. Madura JA, Cummings OW, Wiebke EA, Broadie TA, Goulet RL Jr, Howard TJ. Nonfunctioning islet cell tumors of the pancreas: a difficult diagnosis but one worth the effort. Am Surg. 1997;63(7):573–7; discussion 7–8

    CAS  PubMed  Google Scholar 

  66. Eriksson B, Oberg K, Stridsberg M. Tumor markers in neuroendocrine tumors. Digestion. 2000;62(Suppl 1):33–8.

    Article  CAS  PubMed  Google Scholar 

  67. Guarneri G, Gasparini G, Crippa S, Andreasi V, Falconi M. Diagnostic strategy with a solid pancreatic mass. Presse Med. 2019;48(3 Pt 2):e125–e45.

    Article  PubMed  Google Scholar 

  68. Best LM, Rawji V, Pereira SP, Davidson BR, Gurusamy KS. Imaging modalities for characterising focal pancreatic lesions. Cochrane Database Syst Rev. 2017;4(4):Cd010213.

    PubMed  Google Scholar 

  69. Tummala MP, Rao MS, Agarwal MB. Differential diagnosis of focal non-cystic pancreatic lesions with and without proximal dilation of pancreatic duct noted on CT scan. Clin Transl Gastroenterol. 2013;4(11):e42.

    Article  Google Scholar 

  70. Macgregor-Das A, Goggins M. Diagnostic biomarkers. In: Neoptolemos JP, Urrutia R, Abbruzzese JL, Büchler MW, editors. Pancreatic cancer. New York, Springer; 2018. p. 659–80.

    Chapter  Google Scholar 

  71. Zhang TT, Wang L, Liu HH, et al. Differentiation of pancreatic carcinoma and mass-forming focal pancreatitis: qualitative and quantitative assessment by dynamic contrast-enhanced MRI combined with diffusion-weighted imaging. Oncotarget. 2017;8(1):1744–59.

    Article  PubMed  Google Scholar 

  72. Network NCC. Pancreatic adenocarcinoma (Version 1.2020). 2020.

    Google Scholar 

  73. James PD, Tsolakis AV, Zhang M, et al. Incremental benefit of preoperative EUS for the detection of pancreatic neuroendocrine tumors: a meta-analysis. Gastrointest Endosc. 2015;81(4):848–56 e1.

    Article  PubMed  Google Scholar 

  74. Jeon SK, Lee JM, Joo I, et al. Nonhypervascular pancreatic neuroendocrine tumors: differential diagnosis from pancreatic ductal adenocarcinomas at MR imaging-retrospective cross-sectional study. Radiology. 2017;284(1):77–87.

    Article  PubMed  Google Scholar 

  75. Al-Hawary MM, Kaza RK, Azar SF, Ruma JA, Francis IR. Mimics of pancreatic ductal adenocarcinoma. Cancer Imaging. 2013;13(3):342–9.

    Article  PubMed  PubMed Central  Google Scholar 

  76. Iwashita T, Yasuda I, Doi S, et al. Use of samples from endoscopic ultrasound-guided 19-gauge fine-needle aspiration in diagnosis of autoimmune pancreatitis. Clin Gastroenterol Hepatol. 2012;10(3):316-22.

    Article  PubMed  Google Scholar 

  77. Matsubayashi H, Ishiwatari H, Imai K, et al. Steroid therapy and steroid response in autoimmune pancreatitis. Int J Mol Sci 2019; 21(1).

    Google Scholar 

  78. Duconseil P, Turrini O, Ewald J, et al. ‘Peripheric’ pancreatic cysts: performance of CT scan, MRI and endoscopy according to final pathological examination. HPB (Oxford). 2015;17(6):485–9.

    Article  CAS  Google Scholar 

  79. Lisotti A, Frazzoni L, Fuccio L, et al. Repeat EUS-FNA of pancreatic masses after nondiagnostic or inconclusive results: systematic review and meta-analysis. Gastrointest Endosc. 2020;91(6):1234–41.e4.

    Article  PubMed  Google Scholar 

  80. Kersting S, Janot MS, Munding J, et al. Rare solid tumors of the pancreas as differential diagnosis of pancreatic adenocarcinoma. JOP. 2012;13(3):268–77.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Cedars-Sinai Medical Center, Los Angeles, CA, USA

    Daniel Lew

  2. Department of Internal Medicine, Kaiser Permanente, Fontana Medical Center, Fontana, CA, USA

    Shreyas Srinivas

  3. Division of Gastroenterology, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, CA, USA

    Karl Kwok

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  1. Daniel Lew
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  2. Shreyas Srinivas
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  3. Karl Kwok
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Correspondence to Karl Kwok .

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Editors and Affiliations

  1. Medical Director, Capital Health Medical Center Hopewell, Pennington, NJ, USA

    Cataldo Doria

  2. Capital Health Center for Digestive Health, Pennington, NJ, USA

    Jason N. Rogart

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Lew, D., Srinivas, S., Kwok, K. (2021). Approach to the Patient with a Pancreatic Mass. In: Doria, C., Rogart, J.N. (eds) Hepato-Pancreato-Biliary Malignancies. Springer, Cham. https://doi.org/10.1007/978-3-030-37482-2_26-1

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  • DOI: https://doi.org/10.1007/978-3-030-37482-2_26-1

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