Diagnostic accuracy of diffusion restriction in intraductal papillary mucinous neoplasm of the pancreas in comparison with “high-risk stigmata” of the 2012 international consensus guidelines for prediction of the malignancy and invasiveness

Abstract

Background

It is debated whether diagnostic performance of diffusion-weighted imaging (DWI), which is widely used for detection and characterization of various malignant tumors, is comparable with high-risk stigmata of 2012 international consensus guidelines (ICG) for diagnosis of intraductal papillary mucinous neoplasms (IPMNs).

Purpose

To evaluate the diagnostic accuracy of diffusion restriction in IPMNs for prediction of malignancy and invasiveness in comparison with high-risk stigmata of 2012 ICG.

Material and Methods

This retrospective study was institutional review board approved and informed consent was waived. A total of 132 patients with surgically proven IPMNs (49 malignant, 83 benign) who underwent gadoxetic acid-enhanced magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and DWI with a b-value of 0, 100, and 800 s/mm² using a 3.0 T MR system were included. Two radiologists independently evaluated imaging parameters of high-risk stigmata and worrisome features of 2012 ICG and diffusion restriction in IPMNs. Univariate and multivariate logistic regression analyses and McNemar’s test were used for statistical analysis.

Results

The presence of diffusion restriction in IPMNs was the only independent imaging parameter for prediction of malignancy (odds ratio [OR], 11.98; 95% confidence interval [CI], 3.60–39.87; P < 0.001) and invasiveness (OR, 17.92; 95% CI, 3.91–82.03; P < 0.001) on multivariate analysis. The diagnostic accuracy and specificity of diffusion restriction were significantly improved compared to high-risk stigmata of 2012 ICG to prediction of malignant (P = 0.006 and P < 0.001, respectively) or invasive IPMNs (P = 0.009 and P = 0.015, respectively).

Conclusion

The diffusion restriction in IPMNs could be considered as another high-risk stigma of malignancy and predictor for invasiveness.

Keywords

Pancreas intraductal papillary mucinous neoplasms magnetic resonance imaging (MRI)diffusion restriction

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References

Machado

Al Qadhi

Al Wahibi

. Intraductal papillary mucinous neoplasm of pancreas. N Am J Med Sci 2015; 7: 160–175.

Werner

Fritz

Büchler

. Intraductal papillary mucinous neoplasms of the pancreas—a surgical disease. Nat Rev Gastroenterol Hepatol 2012; 9: 253–259.

Falconi

Salvia

Bassi

et al.

Clinicopathological features and treatment of intraductal papillary mucinous tumour of the pancreas. Br J Surg 2001; 88: 376–381.

Tanaka

Fernandez-Del Castillo

Adsay

et al.

International Association of Pancreatology (2012) International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 2012; 12: 183–197.

Aso

Ohtsuka

Matsunaga

et al.

“High-risk stigmata” of the 2012 international consensus guidelines correlate with the malignant grade of branch duct intraductal papillary mucinous neoplasms of the pancreas. Pancreas 2014; 43: 1239–1243.

Roch

Ceppa

Dewitt

et al.

International Consensus Guidelines parameters for the prediction of malignancy in intraductal papillary mucinous neoplasm are not properly weighted and are not cumulative. HPB (Oxford) 2014; 16: 929–935.

Goh

Lin

Tan

et al.

Evaluation of the Fukuoka Consensus Guidelines for intraductal papillary mucinous neoplasms of the pancreas: Results from a systematic review of 1,382 surgically resected patients. Surgery 2015; 158: 1192–1202.

Wang

Miller

Chen

et al.

Diffusion-weighted MR imaging of solid and cystic lesions of the pancreas. Radiographics 2011; 31: E47–E64.

Fattahi

Balci

Perman

et al.

Pancreatic diffusion-weighted imaging (DWI): Comparison between mass-forming focal pancreatitis (FP), pancreatic cancer (PC), and normal pancreas. J Magn Reson Imaging 2009; 29: 350–356.

10.

Inan

Arslan

Akansel

et al.

Diffusion-weighted imaging in the differential diagnosis of cystic lesions of the pancreas. Am J Roentgenol 2008; 191: 1115–1121.

11.

Jang

Kim

Min

et al.

Value of diffusion-weighted MRI for differentiating malignant from benign intraductal papillary mucinous neoplasms of the pancreas. Am J Roentgenol 2014; 203: 992–1000.

12.

Kang

Lee

Shin

et al.

Added value of diffusion-weighted imaging to MR cholangiopancreatography with unenhanced mr imaging for predicting malignancy or invasiveness of intraductal papillary mucinous neoplasm of the pancreas. J Magn Reson Imaging 2013; 38: 555–563.

13.

Sandrasegaran

Akisik

Patel

et al.

Diffusion-weighted imaging in characterization of cystic pancreatic lesions. Clin Radiol 2011; 66: 808–814.

14.

Kang

Lee

Yoon

et al.

Intravoxel incoherent motion diffusion-weighted MR imaging for characterization of focal pancreatic lesions. Radiology 2014; 270: 444–453.

15.

Ogawa

Horaguchi

Fujita

et al.

Diffusion-weighted magnetic resonance imaging for evaluating the histological degree of malignancy in patients with intraductal papillary mucinous neoplasm. J Hepatobiliary Pancreat Sci 2014; 21: 801–808.

16.

Zhang

Rao

S-X

X-F

et al.

Value of apparent diffusion coefficient for predicting malignancy of intraductal papillary mucinous neoplasms of the pancreas. Diagn Interv Radiol 2016; 22: 308–313.

17.

Silbernagl S. Nutrition and digestion. In: Silbernagl S, Despopoulos A (eds) Color atlas of physiology. 6th ed. New York: Thieme, 2009: 229–267.

18.

Banks

Bollen

Dervenis

et al.

Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102–111.

19.

Haradome

Grazioli

Tsunoo

et al.

Can MR fluoroscopic triggering technique and slow rate injection provide appropriate arterial phase images with reducing artifacts on gadoxetic acid-DTPA (Gd-EOB-DTPA)-enhanced hepatic MR imaging?

J Mag Reson Imaging 2010; 32: 334–340.

20.

Vullierme

M-P

Giraud-Cohen

Hammel

et al.

Malignant intraductal papillary mucinous neoplasm of the pancreas: in situ versus invasive carcinoma—surgical resectability 1. Radiology 2007; 245: 483–490.

21.

Kawamoto

Lawler

Horton

et al.

MDCT of intraductal papillary mucinous neoplasm of the pancreas: evaluation of features predictive of invasive carcinoma. Am J Roentgenol 2006; 186: 687–695.

22.

Taouli

Vilgrain

Vullierme

M-P

et al.

Intraductal papillary mucinous tumors of the pancreas: helical CT with histopathologic correlation. Radiology 2000; 217: 757–764.

23.

Sohn

Yeo

Cameron

et al.

Intraductal papillary mucinous neoplasms of the pancreas: an updated experience. Ann Surg 2004; 239: 788–799.

24.

Xiao

S-Y

. Intraductal papillary mucinous neoplasm of the pancreas: an update. Scientifica (Cairo) 2012; 2012: 893632–893632.

25.

Watanabe

Nishihara

Niina

et al.

Validity of the management strategy for intraductal papillary mucinous neoplasm advocated by the international consensus guidelines 2012: a retrospective review. Surg Today 2016; 46: 1045–1052.

26.

Jemal

Siegel

Ward

et al.

Cancer statistics, 2008. CA Cancer J Clin 2008; 58: 71–96.

27.

Ogawa

Itoh

Ikeda

et al.

Intraductal papillary mucinous neoplasm of the pancreas: assessment of the likelihood of invasiveness with multisection CT. Radiology 2008; 248: 876–886.

28.

Kim

Song

Hwang

J-H

et al.

Predictors of malignancy in pure branch duct type intraductal papillary mucinous neoplasm of the pancreas: A nationwide multicenter study. Pancreatology 2015; 15: 405–410.

29.

Kawada

Uehara

Nagata

et al.

Predictors of malignancy in branch duct intraductal papillary mucinous neoplasm of the pancreas. JOP 2014; 15: 459–464.

30.

Zhang

H-M

Yao

Liu

G-F

et al.

The differences in imaging features of malignant and benign branch duct type of intraductal papillary mucinous tumor. Eur J Radiol 2011; 80: 744–748.

31.

Walter

Steffen

Stelter

et al.

Implications of imaging criteria for the management and treatment of intraductal papillary mucinous neoplasms–benign versus malignant findings. Eur Radiol 2015; 25: 1329–1338.

32.

Kawada

Uehara

Nagata

et al.

Imaging morphological changes of intraductal papillary mucinous neoplasm of the pancreas was associated with its malignant transformation but not with development of pancreatic ductal adenocarcinoma. Pancreatology 2015; 15: 654–660.

33.

Morales-Oyarvide

Mino-Kenudson

Ferrone

et al.

Acute pancreatitis in intraductal papillary mucinous neoplasms: A common predictor of malignant intestinal subtype. Surgery 2015; 158: 1219–1225.

34.

Seo

Byun

Kim

et al.

Validation of the 2012 International Consensus Guidelines using computed tomography and magnetic resonance imaging: branch duct and main duct intraductal papillary mucinous neoplasms of the pancreas. Ann Surg 2015; 263: 557–564.

35.

Kim

Park

Pyo

et al.

Imaging features to distinguish malignant and benign branch-duct type intraductal papillary mucinous neoplasms of the pancreas: a meta-analysis. Ann Surg 2014; 259: 72–81.

36.

Yamada

Fujii

Murotani

et al.

Comparison of the international consensus guidelines for predicting malignancy in intraductal papillary mucinous neoplasms. Surgery 2016; 159: 878–884.