Faculty Bibliography

BACKGROUND:Pancreatic surveillance commonly detects pancreatic cysts, most of which are presumed intraductal papillary mucinous neoplasms (IPMN). FUT2, the gene responsible for secretor status, has been implicated in IPMN development, although not with pancreatic cancer risk. METHODS:We evaluated the association between inactivating variants in FUT2, FUT3 and ABO and pancreatic cysts in 1,865 patients in the multicenter Cancer of the Pancreas Screening (CAPS) cohort. Multivariable logistic regression was performed to estimate adjusted odds for presumed IPMN prevalence. A Johns Hopkins surgical cohort of 1582 patients with IPMN, pancreatic ductal adenocarcinoma (PDAC), or carcinoma arising from IPMN was analyzed to examine trend in variant proportion by malignant progression. RESULTS:In the CAPS cohort, older age (OR per year; 1.06 [1.05-1.07]; p < 0.001), FUT2-null (non-secretors) (OR: 1.66 [1.30-2.12]; p<0.001), non-O blood group (OR: 1.31 [1.06-1.62]; p=0.012), having familial-only vs. genetic/familial risk (OR: 1.49 [1.20-1.85] p<0.001), and participating site (OR; 2.20 [1.78-2.73], p<0.001) were associated with having pancreatic cysts. There were no significant FUT2/ABO presumed IPMN prevalence interactions. In the combined cohort, the proportion of FUT2-null patients with IPMN without carcinoma (by imaging or pathology) was 319 (27.4%) of 1162; 57 (24.3% of 234) with IPMN and carcinoma, and 225 (22.5%) of 998 with PDAC alone (p=0.009 for trend). CONCLUSIONS:IPMN is more prevalent in FUT2-null patients under pancreas surveillance, but the increased FUT2-null prevalence is not observed in patients with IPMN with carcinoma. IMPACT/CONCLUSIONS:Pancreatic cancer risk conferred by having IPMN may be lower in FUT2-null compared to FUT2-intact individuals.

PURPOSE/OBJECTIVE:To assess the prevalence of pancreatic cysts on abdominal MRI and identify factors at the examination, patient, and cyst levels associated with prospective reporting. METHODS:In this retrospective single-center study, high-risk individuals (HRIs, per NCCN criteria) and matched average-risk individuals (ARIs) who underwent abdominal MRI from 2018 to 2023 were identified. Pancreatic cysts prospectively documented on original radiology reports were extracted using a validated large language model. MRI examinations without prospectively reported cysts underwent manual image review by three radiology residents to identify additional visible cysts. A composite reference standard combining prospectively reported and retrospectively identified cysts was used to assess overall cyst prevalence. Patient-, cyst-, and examination-level factors associated with prospective reporting were evaluated using univariable and multivariable logistic regression. RESULTS:The final cohort included 942 patients (314 HRIs, 579 female, mean age 61 ± 10.4 years). Using the composite reference standard, cyst prevalence was 47.9% (451/942), compared with 32.4% (305/942) based on original radiology reports alone. Among the cyst-positive patients identified by the composite reference standard, nearly one-third (32.3%, 146/451) had cysts that were not prospectively reported. Cyst reporting was associated with older age, pancreas-related indication, and larger cyst size: 44.3% of cysts < 5 mm, 77.8% of cysts 5-10 mm, and 95.5% of cysts ≥ 10 mm were reported. HRI status was associated with higher prevalence on unadjusted analysis (OR 1.57 [1.20-2.07], p = 0.001) but not after adjustment for diagnostic-quality MRCP availability (aOR 1.10 [0.82-1.49], p = 0.515). CONCLUSION/CONCLUSIONS:Pancreatic cysts are common but frequently unreported, particularly when < 5 mm. Reporting is associated with indication, cyst size, and age.

PURPOSE/OBJECTIVE:To evaluate the prevalence and clinical relevance of incidental findings detected during pancreatic cyst surveillance and explore their implications for pancreas-focused imaging protocols. METHODS:This single-center retrospective study analyzed abdominal MRI and CT reports for pancreatic cyst surveillance (2005-2025) using a large language model (LLM). Incidental findings were findings unrelated to the clinical indication. Only the earliest surveillance examination per patient was included. Patients were stratified into cyst-only surveillance (cyst-only), cyst surveillance with high-risk pancreatic screening (cyst-HRI), or cyst surveillance with additional clinical indications (cyst-other). Electronic health record (EHR) review evaluated suspected extrapancreatic neoplastic incidental findings and incidental intrapancreatic hyperenhancing lesions. LLM performance was validated against two reviewers in 100 sampled reports. Multivariable logistic regression adjusted for age and sex. RESULTS:6174 patients (mean age, 70.6 ± 12.3 years; 65.7% women) were included; 94.8% underwent MRI. LLM-reviewer agreement was high (Cohen κ = 0.857 and 0.882). Incidental findings were identified in 43.0% of examinations and were predominantly nonneoplastic (98.7%), with most not requiring further action (70.2%). EHR targeted review confirmed 19 extrapancreatic neoplasms, most commonly renal neoplasms (n = 14). Extrapancreatic neoplasms were more frequent in cyst-other than cyst-only patients (14/906 [1.55%] vs. 5/4,822 [0.10%]; aOR, 14.20; 95% CI 5.09-39.61; p < 0.001). No extrapancreatic neoplasms were identified in cyst-HRI patients (0/446; 95% CI 0.00-0.82%). Incidentally detected intrapancreatic hyperenhancing lesions were uncommon (31/6,174, 0.50%); final diagnoses included 25 neuroendocrine tumors and four intrapancreatic splenules. CONCLUSION/CONCLUSIONS:Clinically significant extrapancreatic neoplasms were rare during pancreatic cyst surveillance, particularly among cyst-only and cyst-HRI patients. While this study did not directly assess the diagnostic performance of reduced field-of-view or non-contrast MRI, the low burden of extrapancreatic neoplasms suggests these protocol strategies warrant further evaluation in selected populations.

BACKGROUND:Symptomatic postoperative fluid collections (POFCs) can result in significant morbidity and mortality after abdominal surgery requiring timely intervention. EUS-guided drainage is traditionally delayed up to four weeks to allow wall maturation and reduce perforation or peritonitis risk. However, some POFCs may be suitable for earlier intervention. This study compared the efficacy and safety of acute (≤ 15 days), early (16-30 days), and delayed (> 30 days) EUS-guided drainage. METHODS:A retrospective cohort of patients undergoing EUS-guided drainage for symptomatic POFCs between 2013 and 2023 at a single tertiary center was evaluated. Technical success was defined as accessing and draining a POFC by transmural stent placement on initial endoscopy. Clinical success was defined as radiographically or endosonographically confirmed symptomatic POFC improvement without further percutaneous or surgical intervention. RESULTS:Among 85 patients with POFCs, most (61%) had undergone distal pancreatectomy with splenectomy. 59% required drainage ≤ 30 days after surgery, with 28% managed acutely. Most (83%) received lumen-apposing metal stents. Overall technical and clinical success rates were 94% and 79%, respectively, after a median 2 endoscopies (IQR 2-3). Success did not differ by timing (technical: 92% vs. 96% vs. 94%; clinical: 83% vs. 85% vs. 71%; P = 0.86 and P = 0.37). Adverse event rates were similar across groups (P = 0.85). Transgastric access was associated with clinical success (P < 0.001) and fewer adverse events (P = 0.03). Transduodenal access predicted technical (P = .05) and clinical failure (P = 0.02). CONCLUSIONS:In this large single-center experience of symptomatic POFCS, acute and early EUS-guided drainage with lumen-apposing metal stents in carefully selected patients was found to be technically safe and clinically effective, potentially avoiding more morbid interventions such as ERCP, percutaneous drainage, or surgery. Further randomized, prospective studies are needed to define predictors of technical and clinical success as well as adverse events.

Endoscopic ultrasound (EUS) guided ablation is an evolving minimally invasive approach for treating pancreatic lesions. While current guidelines do not yet recommend routine use, EUS ablation offers targeted, organ-sparing therapy that bridges the gap between surveillance and surgical resection. Techniques are evolving but data is available for ethanol ablation, intralesional chemoablation, radiofrequency ablation, among many others. For pancreatic cystic lesions and neuroendocrine tumors, EUS ablation achieves promising complete and partial response rates and favorable safety profile. Early studies in unresectable pancreatic adenocarcinoma show technical feasibility, safety, and potential synergy with systemic therapy. This review summarizes the current literature on EUS-guided ablation, highlighting clinical outcomes, limitations, and techniques, while emphasizing the need for further research to define optimal patient selection and long-term efficacy.

OBJECTIVES/OBJECTIVE:Pancreatic ductal adenocarcinoma (PDAC) screening is recommended for High-Risk Individuals (HRI) with Familial Pancreatic Cancer (FPC) or certain pathogenic germline variants (PGVs). Screening MRI commonly identifies pancreatic cystic lesions (PCLs), but comparative data between HRI and average-risk individuals (ARI) are limited. We aimed to quantify and characterize PCL differences between these groups. METHODS:In this retrospective study, 317 HRI were age-, sex- and race-matched to 634 ARI undergoing MRI/MRCP between 7/2018-9/2024. Demographics, genetic factors, and baseline MRI/MRCP outcomes were analyzed. HRI were classified as FPC or PGV±PDAC family history. Statistical analysis compared: all HRI vs. all ARI; single HRI subgroups vs. matched ARI; single HRI subgroups vs. other HRI. RESULTS:HRIs were more likely to have PCLs than ARIs (50.8% vs. 25.7%, P <0.001). FPC HRI were more likely to have PCLs (54.1% vs. 44.4%, P =0.049) than PGV HRI. However, PCLs in HRI were smaller than in ARI (7.4±5.7 vs. 10.8±12.6 mm; P =0.002). HRI and ARI did not differ regarding worrisome feature prevalence. No solid lesions were observed. CONCLUSIONS:PCLs are significantly more common among HRI than matched ARI, although typically small and low-risk. Future longitudinal studies should determine whether the higher prevalence of PCLs among HRI translates into increased risk of PCL-derived malignancy or reflects heighted detection on MRI.

BACKGROUND/UNASSIGNED:Acute pancreatitis (AP) is a common gastrointestinal disease with a rising global incidence. While most cases are mild, severe AP (SAP) carries high mortality. Early and accurate severity prediction facilitates management optimization. However, existing clinical severity prediction models, such as Bedside Index of Severity in Acute Pancreatitis (BISAP) and Modified CT Severity Index (mCTSI), have modest accuracy and often rely on data unavailable at admission. PURPOSE/UNASSIGNED:This study proposes a deep learning (DL) model to predict AP severity using abdominal contrast-enhanced CT scans acquired within 24 hours of admission. MATERIALS AND METHODS/UNASSIGNED: = 518 patients). RESULTS/UNASSIGNED: = .002). In retrospective triage analysis, the model correctly identified 50%-73% of patients who progressed to SAP and 40%-73% of those with MAP. CONCLUSION/UNASSIGNED:The proposed DL model achieved performance comparable to or better than established prognostic tools and maintained robust external performance. These findings suggest that AI-assisted CT analysis may support early, automated risk stratification of AP.

INTRODUCTION/BACKGROUND:Accurate preoperative evaluation of pancreatic cysts is essential. However, cytology and biochemical analysis are often limited by low cellularity, and risk stratification is critical for management. PancreaSeq Genomic Classifier (GC) analyzes cyst fluid for molecular alterations to aid diagnosis and risk assessment. MATERIALS AND METHODS/METHODS:We retrospectively analyzed 219 pancreatic cysts from 206 patients using PancreaSeq GC, integrating molecular findings with cytology, biochemical, imaging, surgical pathology, and follow-up. RESULTS:PancreaSeq GC successfully analyzed 216/219 cysts (99%) and detected alterations in 182 (83%). Among cases with both cytology and molecular data (n = 201), concordance was high in cytologically mucinous neoplasms (94%) and atypical cases (95%). Notably, among cases reported as negative for malignancy or nondiagnostic on cytology (n = 128), PancreaSeq GC identified mucinous neoplasms in 82 cases (64%), demonstrating added value in limited samples. Surgical pathology correlation (n = 24) showed excellent performance for distinguishing mucinous from nonmucinous cysts (area under the curve [AUC] = 0.94, P < 0.001). Risk stratification for detection of any dysplasia yielded an AUC of 0.78 (P = 0.006), and for high-grade dysplasia an AUC of 0.74 (P = 0.046). PancreaSeq GC reliably predicted neuroendocrine tumors, but the sensitivity for focal high-grade dysplasia in mucinous neoplasms and serous cystadenoma was limited. Compared with carcinoembryonic antigen (CEA), cyst fluid glucose showed higher sensitivity but lower specificity for mucinous cyst detection. CONCLUSIONS:PancreaSeq GC provides significant diagnostic and risk-stratification value that complements cytological evaluation, particularly in indeterminate or nondiagnostic cytology specimens and when biochemical data are unavailable. Integration of molecular findings improves cyst classification and dysplasia risk assessment. Multidisciplinary assessment remains essential, given the assay's limited sensitivity for focal high-grade dysplasia and serous cystadenomas.