Pancreatic colloid carcinoma (CC) is a rare subtype of invasive carcinoma arising from intraductal papillary mucinous neoplasm (IPMN), characterized by abundant extracellular mucin and an intestinal phenotype. Its rarity (1–3

OBJECTIVE:To determine the rate of malignancy in radiologically classified mixed-type intraductal papillary mucinous neoplasms (IPMNs) undergoing surgical resection compared to main-duct (MD) and branch-duct (BD) IPMNs. BACKGROUND:Mixed-IPMNs are widely perceived as high-risk lesions; however, limited and heterogeneous data available on this category raise uncertainty regarding their true risk profile. METHODS:Retrospective analysis of 836 consecutive resected IPMNs (2000-2025) from a prospectively maintained single-institution database. IPMNs were classified and compared based on preoperative imaging. Malignancy was defined as high-grade dysplasia or invasive carcinoma. RESULTS:Of 773 patients who met inclusion criteria, 305 (39.4%) had a radiologically defined mixed-IPMN, 135 (17.5%) MD-IPMN, and 333 (43.1%) BD-IPMN. Malignancy was observed in 46.5% of mixed-IPMNs (142/305), 79.2% MD-IPMNs (107/135), and 33.9% BD-IPMNs (113/333). The rate of invasive carcinoma was 19.0% (58/305) in mixed-IPMNs and 45.9% (62/135) in MD-IPMNs ( P <0.001). In the absence of high-risk stigmata, the malignancy rate of mixed-IPMNs decreased to 24.7% (46/186), and did not differ from that of BD-IPMNs (51/252, 20.2%; P =0.263). Moreover, when main pancreatic duct (MPD) dilatation was the single worrisome feature, the malignancy rate was 6.3%, with risk increasing significantly only in the presence of multiple worrisome features or when MPD dilatation reached 7-8 mm. Furthermore, in one-third of radiologically defined mixed-IPMNs (103/305), final pathology revealed no MPD involvement. CONCLUSIONS:Mixed-IPMNs are highly heterogeneous and have a lower malignancy rate than previously reported in resected cohorts. In the absence of high-risk stigmata, most lesions are benign, highlighting limitations of current risk stratification and selection for surgery.

Objective: To determine the rate of malignancy in radiologically classified mixed-type intraductal papillary mucinous neoplasms (IPMNs) undergoing surgical resection compared to main-duct (MD) and branch-duct (BD) IPMNs. Background: Mixed-IPMNs are widely perceived as high-risk lesions; however, limited and heterogeneous data available on this category raise uncertainty regarding their true risk profile. Methods: Retrospective analysis of 836 consecutive resected IPMNs (2000–2025) from a prospectively maintained single-institution database. IPMNs were classified and compared based on preoperative imaging. Malignancy was defined as high-grade dysplasia or invasive carcinoma. Results: Of 773 patients who met inclusion criteria, 305 (39.4%) had a radiologically defined mixed-IPMN, 135 (17.5%) MD-IPMN, and 333 (43.1%) BD-IPMN. Malignancy was observed in 46.5% of mixed-IPMNs (142/305), 79.2% MD-IPMNs (107/135), and 33.9% BD-IPMNs (113/333). The rate of invasive carcinoma was 19.0% (58/305) in mixed-IPMNs and 45.9% (62/135) in MD-IPMNs ( P <0.001). In the absence of high-risk stigmata, the malignancy rate of mixed-IPMNs decreased to 24.7% (46/186), and did not differ from that of BD-IPMNs (51/252, 20.2%; P =0.263). Moreover, when main pancreatic duct (MPD) dilatation was the single worrisome feature, the malignancy rate was 6.3%, with risk increasing significantly only in the presence of multiple worrisome features or when MPD dilatation reached 7-8 mm. Furthermore, in one-third of radiologically defined mixed-IPMNs (103/305), final pathology revealed no MPD involvement. Conclusions: Mixed-IPMNs are highly heterogeneous and have a lower malignancy rate than previously reported in resected cohorts. In the absence of high-risk stigmata, most lesions are benign, highlighting limitations of current risk stratification and selection for surgery.

BACKGROUND:Exocrine pancreatic insufficiency (EPI), a common complication of pancreatic cancer (PC), reduces quality of life and may shorten survival. While pancreatic enzyme replacement therapy (PERT) improves symptoms and outcomes, real-world patterns of EPI workup and PERT use across PC subtypes remain poorly described in the United States. PATIENTS AND METHODS:We retrospectively analyzed 250 patients with resectable or metastatic PC from a single institution's prospectively maintained registry (2013-2018), collecting data on clinical characteristics, EPI symptoms, fecal elastase testing, and PERT prescriptions. In addition to the retrospective analysis, a quality improvement intervention for EPI management was implemented (1/2021-1/2023), and outcomes were analyzed. RESULTS:Among 250 patients, 97 underwent surgery for resectable disease and 153 received non-surgical management for metastatic PC. Exocrine pancreatic insufficiency symptoms occurred in 58% of metastatic and 68% of surgical patients. Fecal elastase testing was rarely performed (2% vs 9%, respectively). Pancreatic enzyme replacement therapy was prescribed to 46.5% of metastatic and 84% of surgical patients, but average doses were suboptimal (18 500 vs 20 000 USP units per meal; recommended: ≥40 000). Among those on PERT, symptom resolution was reported in 33% of metastatic and 44% of surgical patients. Contrasting with results from the retrospective analysis, the quality improvement intervention led to 90% of 41 participants being prescribed PERT at an average dose of 44 700 USP units per meal. Treated patients (74.1%) experienced complete resolution of EPI symptoms. CONCLUSION:Despite prevalent EPI symptoms in PC patients, fecal elastase testing was infrequently utilized, and PERT was often underdosed. Educational initiatives are needed to improve guideline adherence and optimize outcomes.

BACKGROUND AND AIMS:Progressive Crohn's disease (CD) often requires early initiation of biologic or immunomodulator therapy for disease management. However, some patients may have a milder disease course that may be managed with a less aggressive strategy. Our study aims to determine cross-sectional radiographic features that predict progression of CD. METHODS:This was a multi-institution, retrospective cohort of adult CD patients without prior immunomodulator or biologic use, prior surgery, or CD-related hospitalization, who underwent abdominal cross-sectional imaging prior to 2018. Index cross-sectional imaging was reviewed by 2 radiologists who extracted 37 features pertaining to the intestine, mesentery, or extra-luminal complications. The primary outcome was composite progression of disease defined as initiation of an immunomodulator or biologic agent, surgical intestinal resection, or CD-related hospitalization. RESULTS:Our study included 177 CD patients who underwent cross-sectional imaging (81% CT). 81 patients (45.8%) experienced composite progression of disease. On multivariable regression, small bowel wall thickening >5 mm (aOR 8.59; P < .001), distal colonic inflammation (aOR 3.95; P = .03), and segmental mural hyperenhancement (aOR 2.44; P = .04) were independently associated with progression of disease. Absence of radiologic features identified a subgroup with a low rate (13.7%) of disease progression. CONCLUSIONS:Cross-sectional imaging can be used to identify patients with mild CD who are at higher risk for progression. Absence of these features may identify mild CD requiring less aggressive treatment strategies and define a population eligible for trials of management strategies for mild CD.

Early detection is key to improving survival and mortality from pancreatic cancer. Traditional periodic screening for cancer in an asymptomatic population is infeasible and not recommended for this low-incidence disease. We describe a novel approach we call "heuriskance" (hyou-ris-kance), wherein a systematic search for and 1-time workup of a "heurisk" (hyou-risk) leads to earlier detection of cancer. A heurisk is an early-warning sign with 3 defining characteristics: (1) the individual has a higher-than-threshold probability of having prevalent invasive cancer, (2) it is associated with a meaningful lead time to diagnosis, and (3) it is identifiable by a systematic and scalable process in the population. Heuriskance aims to systematically detect cancer with clinically meaningful lead time to clinical diagnosis, minimize the proportion of patients with advanced disease, and maximize treatment options, leading to increases in lead time-adjusted 1-, 3-, and 5- year survival. A specific example of a heurisk for pancreatic cancer is glycemically defined new-onset diabetes and the Early Detection Initiative for Pancreatic Cancer (ClinicalTrials.gov identifier NCT04662879) an example of glycemically defined new-onset diabetes-based heuriskance. As heuriskance has no precedent, we provide (1) a tiered risk stratification approach (Define-Enrich-Find), (2) metrics for choosing a heurisk, (3) success metrics for strategy, and (4) phases 1-5 for evaluating the strategy in retrospective and prospective studies. Like all current cancer therapies, heuriskance aims to iteratively improve survival from a fatal disease using a pragmatic, evidence-based, systematic approach to its earlier detection. We apply the concept of heuriskance to pancreatic cancer, but it could be extended to other cancer types.

OBJECTIVES:To explore magnetic resonance imaging (MRI) and gallium-68 ( 68 Ga)-DOTATATE positron emission tomography (PET) performance in the assessment of neuroendocrine liver metastases (NELMs) on a per-lesion basis, with particular attention to the contribution of individual MRI sequences and assessment of other factors that might influence their detection. MATERIALS AND METHODS:This observational retrospective study included patients with histologically confirmed neuroendocrine tumors who underwent both contrast-enhanced MRI and 68 Ga-DOTATATE PET within 12 weeks between August 2017 and December 2023. Three readers in consensus assessed individual MRI sequences [diffusion-weighted imaging (DWI), dynamic contrast-enhanced imaging (DCE), and hepatobiliary phase (HBP) imaging when available], entire MRI data set, and PET in random order. The reference standard was histopathology or follow-up imaging. Diagnostic performance metrics were calculated using generalized estimating equations with Bonferroni correction. Correlations were assessed using Pearson correlation coefficients. RESULTS:A total of 1249 lesions, comprising 1050 metastases, were analyzed in 60 patients (mean age: 64.9±11.5 years; 56.7% male). Compared with PET, MRI demonstrated superior sensitivity (93% vs. 59%, P <0.001) and accuracy (93% vs. 63%, P <0.001), with DWI and HBP providing the highest sensitivity (89% and 92%). Size-stratified analysis showed that MRI outperformed PET, particularly for metastases <5 mm (81.6% vs. 19.7%) and 5 to 10 mm (96.1% vs. 61.8%) ( P <0.001). Arterial enhancement and portal venous washout were present in 67.8% and 23.7% of metastases, respectively, with only portal venous washout showing size dependence (11.9% in <5 mm to 55.6% in >20 mm lesions, P <0.01). PET-negative metastases were smaller than PET-positives (5.0 vs. 8.0 mm, P =0.001), with lesion size correlating with maximum standardized uptake values and normalized uptake ratios ( r =0.54 to 0.59, P <0.001). CONCLUSIONS:MRI outperformed 68 Ga-DOTATATE PET in detecting NELMs, with DWI and HBP providing particularly high sensitivity for small metastases.

Individuals with cystic fibrosis (CF) develop pancreatic cysts and cancer more frequently than the general population, particularly among lung transplant recipients due to long-term immunosuppression. CF lung transplant guidelines address many gastrointestinal malignancies including colorectal cancer, but do not provide recommendations for routine surveillance of the pancreas. We aim to highlight the increased risk that CF lung transplant patients face for developing pancreatic cysts and malignancy. This study may inform future multicenter studies and guideline revisions to include monitoring of the pancreas in this population. An observational, retrospective chart review of CF lung transplant recipients (N = 54) was conducted monitoring pancreatic cyst incidence and severity. Statistics and figures were generated in RStudio. Twenty-two patients (40.7

Ovarian cancer is the second-most common gynecologic malignancy and one of the leading causes of cancer-related deaths in women. However, its incidence remains low, accounting for approximately 1% of all types of cancers. Ovarian cancer encompasses a heterogeneous group of tumors classified based on distinctive histopathologic and molecular features. Epithelial ovarian tumors are the most common type, accounting for approximately 90% of ovarian cancers, and can be further divided into type I and type II cancers. Type II epithelial ovarian cancers are the most common and most aggressive, with high-grade serous carcinoma being the most common subtype.

Objective: To understand the natural history of serous cystadenoma (SCA), and the diagnostic accuracy of SCA and identify possible factors that lead to the correct diagnosis. Background:SCA is a benign cystic pancreatic neoplasm of the pancreas, accounting for similar to 15% of resected pancreatic cysts. Current recommendations are to proceed with surgical resection in symptomatic patients or when there is uncertainty regarding diagnosis. The latter continues to be a challenge since intentional resection of an SCA accounts for only a minority of resected cases. Methods: Retrospective single-institution review of patients who on final pathology had a diagnosis of pancreatic SCA and of patients who had this diagnosis and were managed nonoperatively. Demographic data, cyst characteristics, and growth rate were collected for analysis. Results: A total of 250 patients were analyzed. Median age was 62 (range: 22-89), 65% were females, and 34% had symptoms. Tumor size ranged from 0.6 to 20, with a median of 3.4 cm. The morphologic appearance was microcystic in 58%, macrocystic in 16%, mixed-type in 23%, and solid in 3%. Pancreatic duct dilation and pancreatic atrophy were found in 22% and 14%, respectively. The average growth rate was 1.8 mm/year regardless of tumor size. Of the 172 patients who underwent surgery, SCA was the preoperative diagnosis in only 33%. A correct diagnosis was independently associated with large tumors and cyst fluid carcinoembryonic antigen analysis. Pancreatic duct dilation was independently associated with an in-growing cyst and the presence of calcification. Conclusions: SCA is a slow-growing pancreatic cystic neoplasm that is mostly asymptomatic but can lead to pancreatic duct dilation and atrophy in some patients. A surprisingly small number of correct preoperative diagnoses confirms that this entity continues to be a diagnostic challenge. A more thorough preoperative workup that includes endoscopic ultrasonography should improve the rate of misdiagnosis.

BACKGROUND:Obesity is a risk factor for diverticulitis. However, it remains unclear whether visceral fat area, a more precise measurement of abdominal fat, is associated with the risk of diverticulitis. OBJECTIVE:To estimate the risk of incident and recurrent diverticulitis according to visceral fat area. DESIGN:A retrospective cohort study. SETTINGS:The Mass General Brigham Biobank. PATIENTS:A total of 6654 patients who underwent abdominal CT for clinical indications and had no diagnosis of diverticulitis, IBD, or cancer before the scan were included. MAIN OUTCOME MEASURES:Visceral fat area, subcutaneous fat area, and skeletal muscle area were quantified using a deep-learning model applied to abdominal CT. The main exposures were z -scores of body composition metrics normalized by age, sex, and race. Diverticulitis cases were identified using the International Classification of Diseases codes for the primary or admitting diagnosis from the electronic health records. The risks of incident diverticulitis, complicated diverticulitis, and recurrent diverticulitis requiring hospitalization according to quartiles of body composition metrics z -scores were estimated. RESULTS:A higher visceral fat area z -score was associated with an increased risk of incident diverticulitis (multivariable HR comparing the highest vs lowest quartile, 2.09; 95% CI, 1.48-2.95; p for trend <0.0001), complicated diverticulitis (HR, 2.56; 95% CI, 1.10-5.99; p for trend = 0.02), and recurrence requiring hospitalization (HR, 2.76; 95% CI, 1.15-6.62; p for trend = 0.03). The association between visceral fat area and diverticulitis was not materially different among different strata of BMI. Subcutaneous fat area and skeletal muscle area were not significantly associated with diverticulitis. LIMITATIONS:The study population was limited to individuals who underwent CT scans for medical indication. CONCLUSIONS:Higher visceral fat area derived from CT was associated with incident and recurrent diverticulitis. Our findings provide insight into the underlying pathophysiology of diverticulitis and may have implications for preventive strategies. See Video Abstract . GRASA VISCERAL CUANTIFICADA MEDIANTE UN ALGORITMO DE APRENDIZAJE PROFUNDO TOTALMENTE AUTOMATIZADO Y RIESGO DE DIVERTICULITIS RECURRENTE E INCIDENTAL:ANTECEDENTES:La obesidad es un factor de riesgo de la diverticulitis. Sin embargo, sigue sin estar claro si el área de grasa visceral, con medida más precisa de la grasa abdominal esté asociada con el riesgo de diverticulitis.OBJETIVO:Estimar el riesgo de diverticulitis incidente y recurrente de acuerdo con el área de grasa visceral.DISEÑO:Un estudio de cohorte retrospectivo.AJUSTE:El Biobanco Mass General Brigham.PACIENTES:6.654 pacientes sometidos a una TC abdominal por indicaciones clínicas y sin diagnóstico de diverticulitis, enfermedad inflamatoria intestinal o cáncer antes de la exploración.PRINCIPALES MEDIDAS DE RESULTADOS:Se cuantificaron, área de grasa visceral, área de grasa subcutánea y área de músculo esquelético, utilizando un modelo de aprendizaje profundo aplicado a la TC abdominal. Las principales exposiciones fueron puntuaciones z de métricas de composición corporal, normalizadas por edad, sexo y raza. Los casos de diverticulitis se definieron con los códigos ICD para el diagnóstico primario o de admisión de los registros de salud electrónicos. Se estimaron los riesgos de diverticulitis incidente, diverticulitis complicada y diverticulitis recurrente que requiriera hospitalización según los cuartiles de las puntuaciones z de las métricas de composición corporal.RESULTADOS:Una puntuación z más alta del área de grasa visceral se asoció con un mayor riesgo de diverticulitis incidente (HR multivariable que compara el cuartil más alto con el más bajo, 2,09; IC del 95 %, 1,48-2,95; P para la tendencia < 0,0001), diverticulitis complicada (HR, 2,56; IC del 95 %, 1,10-5,99; P para la tendencia = 0,02) y recurrencia que requiriera hospitalización (HR, 2,76; IC del 95 %, 1,15-6,62; P para la tendencia = 0,03). La asociación entre el área de grasa visceral y la diverticulitis no fue materialmente diferente entre los diferentes estratos del índice de masa corporal. El área de grasa subcutánea y el área del músculo esquelético no se asociaron significativamente con la diverticulitis.LIMITACIONES:La población del estudio se limitó a individuos sometidos a tomografías computarizadas por indicación médica.CONCLUSIÓN:Una mayor área de grasa visceral derivada de la tomografía computarizada se asoció con diverticulitis incidente y recurrente. Nuestros hallazgos brindan información sobre la fisiopatología subyacente de la diverticulitis y pueden tener implicaciones para las estrategias preventivas. (Traducción: Dr. Fidel Ruiz Healy ).

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related deaths worldwide, necessitating accurate and early diagnosis to guide therapy, along with assessment of treatment response. Response assessment criteria have evolved from traditional morphologic approaches, such as WHO criteria and Response Evaluation Criteria in Solid Tumors (RECIST), to more recent methods focused on evaluating viable tumor burden, including European Association for Study of Liver (EASL) criteria, modified RECIST (mRECIST) and Liver Imaging Reporting and Data System (LI-RADS) Treatment Response (LI-TR) algorithm. This shift reflects the complex and evolving landscape of HCC treatment in the context of emerging systemic and locoregional therapies. Each of these criteria have their own nuanced strengths and limitations in capturing the detailed characteristics of HCC treatment and response assessment. The emergence of functional imaging techniques, including dual-energy CT, perfusion imaging, and rising use of radiomics, are enhancing the capabilities of response assessment. Growth in the realm of artificial intelligence and machine learning models provides an opportunity to refine the precision of response assessment by facilitating analysis of complex imaging data patterns. This review article provides a comprehensive overview of existing criteria, discusses functional and emerging imaging techniques, and outlines future directions for advancing HCC tumor response assessment.

Objective: To investigate the incidence and management of pancreatic fistula and fluid collections (FC) after distal pancreatectomy (DP). Summary Background Data: Pancreatic fistula and FC are common after DP. The relationship between pancreatic fistula, FC, and surgical drain placement remains unclear. Methods: We retrospectively reviewed patients who underwent DP at a single institution between June 2000 and August 2023. Results: 1,212 patients were reviewed. Amongst them, 300 (24.9%) developed a biochemical leak, and 162 (13.4%) developed a postoperative pancreatic fistula (POPF). Of the 949 patients who had at least one postoperative cross-sectional imaging, 500 (52.7%) had a FC. Most FCs were asymptomatic (68%); however, when associated with POPF, the majority (n=121, 89%) became symptomatic and required treatment. Patients with POPF were significantly more likely to develop FC (OR 9.49), whereas biochemical leakage did not significantly increase this risk. Surgical drains did not significantly decrease the likelihood of FC (52% vs. 66%, P=0.06), but did increase POPF (13.9% vs. 4.7%, P<0.001) and the need for intervention for FC (33.6% vs. 12.9%, P=0.019). Conclusions: FC develop in over half of the patients undergoing DP, with approximately one-fourth of these cases associated with POPF. In most instances, FC remain asymptomatic; however, when linked to POPF, they are nine times more likely to become symptomatic and require therapeutic intervention. Although surgical drain placement may not contribute to FC, it was associated with a higher rate of POPF.

BACKGROUND:Intraductal papillary mucinous neoplasms (IPMNs) are common pancreatic cystic neoplasms. Observation or surgical resection in patients with high-risk IPMNs is recommended because there is a risk of malignant transformation leading to pancreatic adenocarcinoma. Risk factors for the development of IPMNs are not well characterized. The authors hypothesized that common genetic variants are associated with development of IPMNs. METHODS:Individuals were enrolled and genotyped as part of the Mass General Brigham Biobank, and individuals with IPMNs were identified retrospectively using electronic medical records. Single nucleotide variants (SNVs) with a minor allele frequency ≥5% were examined for an association with IPMNs. SNVs that surpassed the significance threshold (p < 5e-08) were further examined in a validation cohort. RESULTS:Of 68,931 individuals, 2525 (3.6%) had IPMNs. After genome-wide association analysis, a genetic locus at chromosome 19 was identified as associated with IPMNs. The lead SNVs were reference SNVs rs681343 (19:49206462; odds ratio, 1.01; p = 1.04e-8) and rs601338 (19:49206674; odds ratio, 1.01; p = 1.06e-8). This result was verified in an independent cohort of 5014 individuals. The rs601338 variant is in a noncoding exon of fucosyltransferase 2 (FUT2) and causes replacement of a normal codon with a stop codon and termination of protein translation. FUT2 codes the FUT2 enzyme, an important enzyme in the Lewis antigen system. CONCLUSIONS:FUT2 variants are associated with the development of pancreatic IPMNs. FUT2 and rs601338 have important functions in mucin synthesis, biliopancreatic duct homeostasis, carcinoembryonic antigen, and cancer antigen 19-9 regulation, which provide a biologically plausible role in IPMN pathogenesis.