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Ohno E, Balduzzi A, Hijioka S, De Pastena M, Marchegiani G, Kato H, Takenaka M, Haba S, Salvia R. Association of high-risk stigmata and worrisome features with advanced neoplasia in intraductal papillary mucinous neoplasms (IPMN): A systematic review. Pancreatology 2024; 24:48-61. [PMID: 38161091 DOI: 10.1016/j.pan.2023.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/24/2023] [Accepted: 12/03/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND This systematic review aimed to assess the diagnostic accuracy of the International Consensus Fukuoka Guidelines (ICG2017) in identifying high-risk lesions of Intraductal Papillary Mucinous Neoplasms (IPMNs). METHODS The ICG2017 revision committee conducted a comprehensive literature review to establish evidence-based statements on IPMNs. The review focused on articles examining the diagnostic value of imaging features (e.g., cyst or main pancreatic duct diameter), clinical symptoms associated with IPMN, and serum biomarkers. Five clinical questions regarding high-risk stigmata (HRS) and worrisome features (WF) in the ICG2017 guidelines were addressed. RESULTS A total of 210 articles were reviewed. The findings revealed a significant association between the presence of mural nodules ≥5 mm in diameter or solid components with contrast enhancement and the diagnosis of high-grade dysplasia or invasive carcinoma. Contrast-enhanced diagnostic tools, such as CT, MRI, or EUS, demonstrated the highest prediction rate and were recommended. Positive cytology was identified as an HRS, while symptoms like acute pancreatitis and cyst diameter growth ≥2.5 mm per year were considered WFs. The use of nomograms and multiple diagnostic factors was recommended for optimal IPMN management. CONCLUSIONS This systematic review provides evidence supporting the improved diagnostic accuracy of ICG2017 in identifying high-risk lesions of IPMN. The multidisciplinary incorporation of HRS and WF based on imaging findings and clinical symptoms is crucial. These findings should inform the revision of ICG2017, enhancing the evaluation and management of IPMN patients. By implementing these recommendations, clinicians can make more informed decisions, leading to better diagnosis and treatment outcomes for high-risk IPMN cases.
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Affiliation(s)
- Eizaburo Ohno
- Fujita Health University, Department of Gastroenterology and Hepatology, Japan; Nagoya University Hospital, Department of Gastroenterology and Hepatology, Japan
| | - Alberto Balduzzi
- The Pancreas Institute Verona, Unit of General and Pancreatic Surgery Department of Surgery, Dentistry, Paediatrics and Gynaecology University of Verona, Italy
| | - Susumu Hijioka
- National Cancer Center Hospital, Department of Hepatobiliary and Pancreatic Oncology, Japan
| | - Matteo De Pastena
- The Pancreas Institute Verona, Unit of General and Pancreatic Surgery Department of Surgery, Dentistry, Paediatrics and Gynaecology University of Verona, Italy
| | - Giovanni Marchegiani
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences (DISCOG), University of Padua, Padua, Italy
| | - Hironari Kato
- Okayama University Hospital, Department of Gastroenterology and Hepatology, Japan
| | - Mamoru Takenaka
- Kindai University, Department of Gastroenterology and Hepatology, Japan
| | - Shin Haba
- Aichi Cancer Center Hospital, Department of Gastroenterology, Japan
| | - Roberto Salvia
- The Pancreas Institute Verona, Unit of General and Pancreatic Surgery Department of Surgery, Dentistry, Paediatrics and Gynaecology University of Verona, Italy.
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Wiggins B, Banno F, Miller J. Acute Pancreatitis Secondary to Newly Diagnosed Intraductal Papillary Mucinous Neoplasm. Cureus 2022; 14:e24526. [PMID: 35651426 PMCID: PMC9138680 DOI: 10.7759/cureus.24526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2022] [Indexed: 11/18/2022] Open
Abstract
Acute pancreatitis (AP) is a common gastrointestinal cause of hospital admissions and is prevalent in the United States. AP etiologies include alcohol use, cholelithiasis, hypertriglyceridemia, hypercalcemia, autoimmune phenomena, medications, or idiopathic. Rarely, intraductal papillary mucinous neoplasms can cause AP, as we present in this case report.
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Grudzińska E, Szmigiel P, Mrowiec S. Fast-growing malignant intraductal papillary mucinous neoplasm and chronic pancreatitis. Asian J Surg 2022; 45:1920-1921. [PMID: 35440393 DOI: 10.1016/j.asjsur.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/07/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Ewa Grudzińska
- Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland.
| | - Paweł Szmigiel
- Department of Gastrointestinal Surgery, University Clinical Center of Medical University of Silesia, Katowice, Poland
| | - Sławomir Mrowiec
- Department of Gastrointestinal Surgery, Medical University of Silesia, Katowice, Poland
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Jee KN. Metachronous occurrence of main-duct intraductal papillary mucinous neoplasm (IPMN) and adenocarcinoma in a chronic pancreatitis patient: A case report. Medicine (Baltimore) 2022; 101:e28770. [PMID: 35147102 PMCID: PMC8830832 DOI: 10.1097/md.0000000000028770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/19/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Chronic pancreatitis (CP) is a risk factor for developing pancreatic ductal adenocarcinoma (PDAC). In addition, a patient with partial pancreatectomy for intraductal papillary mucinous neoplasm (IPMN) can also lead to PDAC. In contrast, IPMN is a distinct disease entity, independent of CP, and there have been few reports that CP is the cause of IPMN. To the best of our knowledge, this is the first clinical case report of the metachronous occurrence of main-duct IPMN and PDAC with a 9 and half-year interval in a patient with chronic alcoholic pancreatitis. PATIENT CONCERNS A 50-year-old man with a long medical history of recurrent alcoholic pancreatitis and hepatitis over a decade was diagnosed with another episode of acute pancreatitis based on laboratory findings and clinical symptoms. The patient underwent pylorus-preserving pancreaticoduodenectomy (PPPD) for a small nodular lesion in the main duct of the pancreatic head and was diagnosed with main-duct IPMN low-grade dysplasia and associated fibrosing CP. Nine and a half years later, a 59-year-old man lost 7 kg over 3 months and was diagnosed with new-onset diabetes mellitus. DIAGNOSIS The patient was diagnosed with metachronous, well-differentiated PDAC with concomitant CP. INTERVENTIONS The patient underwent radical antegrade modular pancreatosplenectomy (RAMPS) for a small nodular mass in the remnant pancreas. OUTCOMES The patient was healthy for 44 months without evidence of tumor recurrence during clinical follow-up examinations including laboratory findings, tumor marker, and imaging studies. LESSONS Early diagnosis of metachronous pancreatic neoplasia in a patient with chronic pancreatitis could be made by correlating newly developed clinical symptoms and signs with careful radiological examinations.
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Miyamoto R, Amikura K, Matsudaira S, Ishida H, Ogura T, Takahashi A, Kihara A, Kanda H, Kawashima Y. Colloid carcinoma derived from intraductal papillary mucinous neoplasm of the pancreatic head with calcification: A case report and literature review. Surg Case Rep 2021; 7:202. [PMID: 34487254 PMCID: PMC8421485 DOI: 10.1186/s40792-021-01286-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/29/2021] [Indexed: 11/21/2022] Open
Abstract
Background Colloid carcinoma derived from intraductal papillary mucinous neoplasm (IPMN) of the pancreatic head with prominent calcification is exceedingly rare. Only a few studies about this entity have been reported in the literature. Therefore, its biological behavior, appropriate treatment modalities, and overall patient prognosis remain largely unclear. In this report, we present a case of a resected colloid carcinoma derived from IPMN with prominent calcification. In addition, we review the relevant literature and discuss the clinical management of colloid carcinoma derived from IPMN with prominent calcification, including the histopathological features. Case presentation A 75-year-old man presented with a pancreatic tumor measuring 58 mm on the head of the pancreas that was incidentally detected by abdominal ultrasonography. Abdominal computed tomography and endosonography revealed a multilobular cystic lesion with a 17 mm mural nodule in the pancreatic head. Furthermore, prominent calcification was observed on part of the cyst wall. Magnetic resonance cholangiopancreatography showed a multilobular cyst in the branch duct lacking communication between the cystic lesion and the main pancreatic duct. Thus, the lesion was diagnosed as intraductal papillary mucinous carcinoma (IPMC) with a preoperative classification of T1N0M0 stage IA according to the 8th Union for International Cancer Control (UICC) guidelines, and the patient underwent conventional pancreatoduodenectomy. The resected specimen was microscopically found to contain colloid carcinoma, probably derived from IPMN. In addition, marked calcification was confirmed in the partition wall of the cystic mass. The postoperative course was uneventful, and no evidence of recurrence or metastasis was observed after 10 months of follow-up. Conclusions We consider that colloid carcinoma derived from IPMN should be differentially diagnosed as a pancreatic multilobular cystic lesion with prominent calcification that shows no sign of systemic chronic pancreatitis.
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Affiliation(s)
- Ryoichi Miyamoto
- Department of Gastroenterological Surgery, Saitama Cancer Center, 780 Komuro, Ina-machi, Kita-Adachi-gun, Saitama, 362-0806, Japan.
| | - Katsumi Amikura
- Department of Gastroenterological Surgery, Saitama Cancer Center, 780 Komuro, Ina-machi, Kita-Adachi-gun, Saitama, 362-0806, Japan
| | - Shinichi Matsudaira
- Department of Gastroenterological Surgery, Saitama Cancer Center, 780 Komuro, Ina-machi, Kita-Adachi-gun, Saitama, 362-0806, Japan
| | - Hiroyuki Ishida
- Department of Gastroenterological Surgery, Saitama Cancer Center, 780 Komuro, Ina-machi, Kita-Adachi-gun, Saitama, 362-0806, Japan
| | - Toshiro Ogura
- Department of Gastroenterological Surgery, Saitama Cancer Center, 780 Komuro, Ina-machi, Kita-Adachi-gun, Saitama, 362-0806, Japan
| | - Amane Takahashi
- Department of Gastroenterological Surgery, Saitama Cancer Center, 780 Komuro, Ina-machi, Kita-Adachi-gun, Saitama, 362-0806, Japan
| | - Atsushi Kihara
- Department of Pathology, Jichi Medical University, Tochigi, Japan
| | - Hiroaki Kanda
- Department of Pathology, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
| | - Yoshiyuki Kawashima
- Department of Gastroenterological Surgery, Saitama Cancer Center, 780 Komuro, Ina-machi, Kita-Adachi-gun, Saitama, 362-0806, Japan
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Main Duct Dilatation Is the Best Predictor of High-grade Dysplasia or Invasion in Intraductal Papillary Mucinous Neoplasms of the Pancreas. Ann Surg 2020; 272:1118-1124. [PMID: 30672797 DOI: 10.1097/sla.0000000000003174] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The purpose of this study is to determine preoperative factors that are predictive of malignancy in patients undergoing pancreatic resection for intraductal papillary mucinous neoplasms (IPMN). SUMMARY BACKGROUND DATA IPMN of the pancreas may be precursor lesions to pancreatic cancer (PC) and represent a target for early diagnosis or prevention. While there has been much effort to define preoperative risk factors for malignant pathology, guidelines are ever-changing and controversy remains surrounding which patients would benefit most from resection. METHODS We performed a retrospective analysis of 901 consecutive patients obtained from two tertiary referral centers who underwent pancreatic resection for histologically proven IPMN between 2004 and 2017. Collected data included patient demographic characteristics, preoperative symptoms, radiological findings, and laboratory data. RESULTS Main pancreatic duct (MPD) dilatation was the only variable that was significantly associated with increased probability of malignancy (defined high-dysplasia or invasion) on both univariate and multivariate analysis. Even middle-range MPD dilatation from 5 mm to 9.9 mm (n = 286) was associated with increased odds of HG-IPMN (OR = 2.74; 95% CI = 1.80-4.16) and invasion (OR = 4.42; 95% CI = 2.55-7.66). MPD dilatation >10 mm (n = 150) had even greater odds of HG-IPMN (OR = 6.57; 95% CI = 3.94-10.98) and invasion (OR = 15.07; 95% CI = 8.21-27.65). A cutoff of 5 to 7 mm MPD diameter was determined to be the best predictor to discriminate between malignant and benign lesions. CONCLUSIONS In agreement with current IPMN management guidelines, we found MPD dilatation, even low levels from 5 mm to 9.9 mm, to be the single best predictor of HG-IPMN or invasion, highlighting the critical role that MPD plays in the selection of surgical candidates.
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Matsuda R, Miyasaka Y, Yamada Y, Kawata J, Sakihama K, Yamamoto T, Saeki K, Yamamoto H, Ohishi Y, Koga Y, Nakamura M, Oda Y. Chronic inflammatory changes and oxidative stress in the background of "pancreatic ductal adenocarcinoma concomitant with intraductal papillary mucinous neoplasm". Virchows Arch 2020; 477:799-806. [PMID: 32468246 DOI: 10.1007/s00428-020-02844-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 05/02/2020] [Accepted: 05/07/2020] [Indexed: 12/27/2022]
Abstract
Cases of "pancreatic ductal adenocarcinoma (PDAC) concomitant with intraductal papillary mucinous neoplasm" (IPMN) have multiple PDAC lesions more frequently than cases of "PDAC without IPMN". However, the mechanism of carcinogenesis in this former disease category remains unknown. The main objective of this work was thus to investigate the effects of chronic inflammation on carcinogenesis in PDAC cases. We selected 31 "PDAC concomitant with IPMN" patients and 58 "PDAC without IPMN" patients and pathologically evaluated their background pancreatic parenchyma. Fibrosis and inflammation scores of background pancreas were higher in "PDAC concomitant with IPMN" than in "PDAC without IPMN" (P < 0.0001 and P < 0.0001, respectively), whereas the fatty infiltration score of background pancreas was high in "PDAC without IPMN" (P = 0.0024). Immunohistochemically, the expression of 8-hydroxy-2'-deoxyguanosine (8-OHDG), an oxidative stress marker, in the background pancreas was high in "PDAC concomitant with IPMN" compared with that in "PDAC without IPMN" (P < 0.0001). Chronic inflammation activates oxidative stress in tissue throughout the pancreas and probably confers susceptibility to tumorigenesis in "PDAC concomitant with IPMN".
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Affiliation(s)
- Ryota Matsuda
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Miyasaka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Surgery, Fukuoka University Chikushi Hospital, Chikushino, Japan
| | - Yuichi Yamada
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jun Kawata
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kukiko Sakihama
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takeo Yamamoto
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kiyoshi Saeki
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hidetaka Yamamoto
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Ohishi
- Department of Diagnostic Pathology, Iizuka Hospital, Iizuka, Japan
| | - Yutaka Koga
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Amodio A, De Marchi G, de Pretis N, Crinò SF, D'Onofrio M, Gabbrielli A, Ciccocioppo R, Frulloni L. Painless chronic pancreatitis. Dig Liver Dis 2020; 52:1333-1337. [PMID: 32921601 DOI: 10.1016/j.dld.2020.08.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 08/23/2020] [Accepted: 08/25/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Painless chronic pancreatitis (CP) is a rare form of the disease. AIM To evaluate the prevalence and the characteristics of this overlooked form of pancreatitis. METHODS Patients with a diagnosis of CP and absence of pain were selected, excluding patients suffering from autoimmune pancreatitis. Clinical data, imaging features, and exocrine and endocrine function were therefore analyzed. RESULTS Among 781 patients observed between 2010 and 2016, 74 patients with painless CP (9.5%) were selected. Mean age at diagnosis was 60.8 (SD 10.8) years. 38(51%) individuals did not report any symptom, 36(49%) were affected by symptoms other than pain. Pancreatic calcifications were diagnosed in 70 patients (95%), main pancreatic duct dilation in 55(74%), and pancreatic atrophy in 39(53%).Thirty-six patients (55%) had severe exocrine pancreatic insufficiency(EPI). Diabetes was observed in 34 out of 72 patients (47%). During a mean follow-up of 2.9 (SD 2.8) years, only a mild pancreatitis was diagnosed in a 71-year old female. No patient underwent endoscopic treatment or surgery, developed pancreatic cancer or died. CONCLUSIONS In a tertiary center painless CP is observed in 10% of cases, and it is frequently associated with EPI. The probability of onset of pain is very low in a short-term follow-up.
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Affiliation(s)
- Antonio Amodio
- Gastroenterology B Unit, Department of Medicine, The Pancreas Institute, University and Hospital Trust of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134 Verona, Italy
| | - Giulia De Marchi
- Gastroenterology B Unit, Department of Medicine, The Pancreas Institute, University and Hospital Trust of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134 Verona, Italy.
| | - Nicolò de Pretis
- Gastroenterology B Unit, Department of Medicine, The Pancreas Institute, University and Hospital Trust of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134 Verona, Italy
| | - Stefano Francesco Crinò
- Gastroenterology B Unit, Department of Medicine, The Pancreas Institute, University and Hospital Trust of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134 Verona, Italy
| | - Mirko D'Onofrio
- Department of Radiology, The Pancreas Institute, University and Hospital Trust of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134 Verona, Italy
| | - Armando Gabbrielli
- Gastroenterology B Unit, Department of Medicine, The Pancreas Institute, University and Hospital Trust of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134 Verona, Italy
| | - Rachele Ciccocioppo
- Gastroenterology B Unit, Department of Medicine, The Pancreas Institute, University and Hospital Trust of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134 Verona, Italy
| | - Luca Frulloni
- Gastroenterology B Unit, Department of Medicine, The Pancreas Institute, University and Hospital Trust of Verona, Policlinico GB Rossi, Piazzale L.A. Scuro, 10, 37134 Verona, Italy
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In vivo magnetic resonance imaging of orthotopic prostate cancer. Biotechniques 2020; 69:395-403. [PMID: 32363906 DOI: 10.2144/btn-2020-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Methods for imaging orthotopic prostate tumors within the prostate or small tumors with extension outside the prostate are needed to more closely model human prostate tumors, which are most commonly located within the gland or may extend just through the gland. By comparing MR sequences, we found that the T2-based Dixon 'water only' sequence best visualized tumors within the prostate of mouse models in both young and old mice and that tumor weight derived from this sequence correlated highly with ex vivo tumor weight (r2 = 0.98, p < 0.001, n = 12). This should aid tumor detection, margin delineation and evaluation of tumor burden to enable studies including, but not limited to, evaluating the natural history of the disease, the mechanisms of action and the efficacy of therapeutic interventions.
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Stuart CM, Lundgren MP, Lavu H, Yeo CJ. Pylorus-Preserving Total Pancreatectomy for Intraductal Papillary Mucinous Neoplasm in the Setting of Previous Roux-en-Y Cystjejunostomy for Pancreatic Pseudocyst. J Pancreat Cancer 2020; 6:1-4. [PMID: 32043065 PMCID: PMC6964803 DOI: 10.1089/pancan.2019.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Intraductal papillary mucinous neoplasms (IPMNs) are cystic lesions of the pancreas with malignant potential. The Sendai and Fukuoka criteria offer guidelines for surgical management of an IPMN. Presentation: A 69-year-old patient with a history of recurrent pancreatitis presented with steatorrhea and unintentional weight loss. Upon workup, he was found to have an IPMN, for which he met Sendai and Fukuoka criteria for surgical management. At the time of surgery, the patient's reported operative history was remarkable only for cholecystectomy; however, during the procedure, he was found to have a Roux-en-Y limb of jejunum attached to the head of the pancreas. Postoperative discussion with the patient and family revealed that this was likely the result of a past cystjejunostomy procedure used to drain what may have been a pancreatic pseudocyst that had developed after a bout of severe acute pancreatitis. Ultimately, the previously created Roux-en-Y limb was used in the reconstruction after specimen excision by total pancreatectomy. Conclusions: Main duct IPMNs have a high incidence of carcinoma. Those that meet Sendai and Fukuoka criteria should be surgically managed. In this study we present a case of IPMN management by total pancreatectomy with unique reconstruction using a previously created Roux-en-Y limb.
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Affiliation(s)
- Christina M Stuart
- Sidney Kimmel Medical College at Thomas Jefferson University, Class of 2020, Philadelphia, Pennsylvania
| | - Megan P Lundgren
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Harish Lavu
- Section of Hepatopancreatobiliary Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.,Pancreas, Biliary and Related Cancer Center, Jefferson Health, Philadelphia, Pennsylvania
| | - Charles J Yeo
- Section of Hepatopancreatobiliary Surgery, Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.,Pancreas, Biliary and Related Cancer Center, Jefferson Health, Philadelphia, Pennsylvania
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Characteristics and Clinical Outcomes of Individuals at High Risk for Pancreatic Cancer: A Descriptive Analysis from a Comprehensive Cancer Center. GASTROINTESTINAL DISORDERS 2019; 1:106-119. [PMID: 32601617 PMCID: PMC7324042 DOI: 10.3390/gidisord1010008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Pancreatic cancer (PC), a leading cause of cancer-related deaths in the United States, is typically diagnosed at an advanced stage. To improve survival, there is an unmet need to detect pre-malignant lesions and early invasive disease. Prime populations to study for early detection efforts include cohorts of high risk individuals (HRI): those with increased risk to develop pre-malignant pancreatic cysts and PC because of a familial or hereditary predisposition to the disease and those in the general population of sporadic cases who are incidentally found to harbor a pre-malignant pancreatic cyst. The objective of this study was to describe the characteristics and clinical outcomes of cohorts of HRI identified at Moffitt Cancer Center. We set out to determine the uptake of screening, the prevalence and characteristics of solid and cystic pancreatic lesions detected via screening or as incidental findings, and the age at which lesions were detected. Of a total of 329 HRI, roughly one-third were found to have pancreatic lesions, most of which constituted pre-malignant cysts known as intraductal papillary mucinous neoplasms. Individuals with the highest genetic risk for PC were found to have smaller cysts at a much earlier age than sporadic cases with incidental findings; however, many individuals at high genetic risk did not have abdominal imaging reports on file. We also identified a subset of HRI at moderate genetic risk for PC that were found to have cystic and solid pancreatic lesions as part of a diagnostic work-up rather than a screening protocol. These findings suggest the pancreatic research community should consider expanding criteria for who should be offered screening. We also emphasize the importance of continuity of care between cancer genetics and gastrointestinal oncology clinics so that HRI are made aware of the opportunities related to genetic counseling, genetic testing, and screening.
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Abstract
OBJECTIVE The aim of this study was to identify the distinct pathological changes on the endocrine and exocrine pancreas of slowly progressive insulin-dependent diabetes mellitus (SPIDDM) or latent autoimmune diabetes in adults. METHODS The pancreases from 12 islet autoantibody-positive SPIDDM patients and 19 age-matched subjects with no diabetes were examined histologically for islet inflammation/insulitis, expressions of cytokines, and enterovirus VP1 protein, exocrine pancreatic inflammation, pancreatic ductal changes, major histocompatibility complex class I hyperexpression, and amylin-positive amyloid in the islets. RESULTS Insulitis dominant for CD8 T-cells and CD68 macrophages was observed in all SPIDDM cases irrespective of duration of diabetes and weight of residual beta cells. Major histocompatibility complex class I hyperexpression on residual beta cells was observed in SPIDDM. All SPIDDM exocrine pancreases showed extensive inflammation, dilated pancreatic ducts, and periductal fibrosis. As many as 75% (9/12) of pancreases had pancreatic intraepithelial neoplasia, which is assumed to be associated with ductal obstruction/narrowing and exocrine pancreatic inflammation, in SPIDDM. Amylin-positive amyloid deposition was not detected in SPIDDM. CONCLUSIONS Persistent insulitis with preserved beta cells and major histocompatibility complex class I hyperexpression and exocrine pancreatic inflammation with pancreatic intraepithelial neoplasia are distinct histological features of SPIDDM pancreas.
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13
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Comparison of Clinical Data and Scores of Quality of Life, Anxiety, and Depression in Patients With Different Types of Intraductal Papillary Mucinous Neoplasms: A Prospective Study. Pancreas 2017; 46:1029-1034. [PMID: 28787332 DOI: 10.1097/mpa.0000000000000890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES This study aims to evaluate the well-being of patients with main duct intraductal papillary mucinous neoplasms (MD-IPMNs) or mixed type IPMNs (mixed-IPMNs) of the pancreas. METHODS Twenty-two patients with MD/mixed-IPMNs of the pancreas were studied, and an equal number of patients having branch duct IPMNs (BD-IPMNs) were used as controls. The short form (SF) -12 Health Survey, State Trait Anxiety Inventory Y-1 and Y-2, General Health Questionnaire, and Beck Depression Inventory II were used to evaluate the quality of life once a year for 2 consecutive years. RESULTS At basal evaluation, the SF-12 Health Survey questionnaire administered to the 44 patients showed that the values of the physical component and mental component scores were similar between the 2 groups of patients studied. The State Trait Anxiety Inventory Y-1 and Y-2, General Health Questionnaire, and Beck Depression Inventory II scores were also similar in the 2 groups at basal evaluation. No differences were found between MD/mixed-IPMNs and BD-IPMNs at the 1-year and the 2-year evaluations. CONCLUSIONS The well-being of patients with MD/mixed-IPMNs did not differ as compared with patients with BD-IPMNs.
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Crippa S, Pergolini I, Rubini C, Castelli P, Partelli S, Zardini C, Marchesini G, Zamboni G, Falconi M. Risk of misdiagnosis and overtreatment in patients with main pancreatic duct dilatation and suspected combined/main-duct intraductal papillary mucinous neoplasms. Surgery 2016; 159:1041-9. [DOI: 10.1016/j.surg.2015.11.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 10/09/2015] [Accepted: 11/04/2015] [Indexed: 01/27/2023]
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15
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Fernandes SR, Correia LA, Antunes T, Cortez-Pinto H. Intraductal papillary mucinous neoplasm presenting with recurrent pancreatitis: a report of a painful 3-decade-long history. BMJ Case Rep 2016; 2016:bcr-2016-214640. [PMID: 27001600 DOI: 10.1136/bcr-2016-214640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Intraductal papillary mucinous neoplasm represents the most common pancreatic cystic neoplasm and harbours significant malignant potential. Duct obliteration can lead to recurrent episodes of pancreatic inflammation mimicking acute and chronic pancreatitis. We report a case of a patient with multiple episodes of idiopathic pancreatitis occurring over a period of three decades. Following admission with severe upper gastrointestinal bleeding, the patient was diagnosed as having invasive pancreatic adenocarcinoma. Examination of the surgical specimen confirmed an intraductal papillary mucinous neoplasm with multiple foci of invasive adenocarcinoma. This case is of significant interest, highlighting the long delay until diagnosis seen in this situation. Intraductal papillary mucinous neoplasm should be considered in the presence of recurrent acute or chronic pancreatitis of unknown aetiology.
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Affiliation(s)
| | - Luís Araújo Correia
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Lisbon, Portugal
| | - Teresa Antunes
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Lisbon, Portugal
| | - Helena Cortez-Pinto
- Serviço de Gastrenterologia e Hepatologia, Hospital de Santa Maria, Lisbon, Portugal
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16
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Ozmen Z, Aktas F, Okan İ, Özsoy Z, Arıcı A. Sub-branch and mixed-type intraductal papillary mucinous neoplasms of the pancreas: 2 case reports. Radiol Case Rep 2016; 11:4-10. [PMID: 26973726 PMCID: PMC4769611 DOI: 10.1016/j.radcr.2015.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 11/09/2015] [Indexed: 11/28/2022] Open
Abstract
Intraductal papillary mucinous neoplasia (IPMN) is one of the cystic neoplasias of the pancreas. The imaging findings provide that these tumors are differentiated from the other cystic lesions of the pancreas, especially from the chronic pancreatitis, where the treatment protocol is completely different. Therefore, the correct diagnosis and classification of the IPMN ensures that the patient receives the correct approach and the appropriate surgery, if necessary. The purpose of this study is to emphasize the imaging findings of the different types of the IPMN and the changes in the management protocol of the patients according to these radiological findings.
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Affiliation(s)
- Zafer Ozmen
- Department of Radiology, Gaziosmanpaşa University, School of Medicine, Gaziosmanpaşa St, Tokat, Turkey
| | - Fatma Aktas
- Department of Radiology, Gaziosmanpaşa University, School of Medicine, Gaziosmanpaşa St, Tokat, Turkey
| | - İsmail Okan
- Department of General Surgery, Gaziosmanpaşa University, School of Medicine, Gaziosmanpaşa St, Tokat, Turkey
| | - Zeki Özsoy
- Department of General Surgery, Gaziosmanpaşa University, School of Medicine, Gaziosmanpaşa St, Tokat, Turkey
| | - Akgül Arıcı
- Department of Pathology, Gaziosmanpaşa University, School of Medicine, Gaziosmanpaşa St, Tokat, Turkey
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Lévy P, Rebours V. Differential Diagnosis of Cystic Pancreatic Lesions Including the Usefulness of Biomarkers. VISZERALMEDIZIN 2015; 31:7-13. [PMID: 26285674 PMCID: PMC4433139 DOI: 10.1159/000371786] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Cystic pancreatic lesions are more and more often found. Malignant risk ranges from nil to more than 60%. A precise diagnosis is required to adapt surveillance or therapeutic strategy. Methods We tried to identify the most difficult differential diagnoses encountered in a tertiary center of pancreatology and to guide the reader as how to reach the correct strategy and diagnosis in these situations. Results We identified eight clinically difficult situations: i) chronic pancreatitis versus intraductal papillary mucinous neoplasms, ii) serous versus mucinous cystic neoplasms, iii) serous cystic neoplasms versus branch-duct intraductal papillary mucinous neoplasms, iv) intraductal papillary mucinous neoplasms versus acinar cell cystadenoma, v) (pseudo-) solid serous cystic neoplasm versus neuroendocrine tumor, vi) pancreatic neuroendocrine tumors versus solid pseudopapillary tumors, vii) cystic forms of a solid tumor, and viii) rare pancreatic or peripancreatic cystic lesions. The work-up should rely on computed tomography scan, pancreatic magnetic resonance imaging, and, only if necessary, endoscopic ultrasound with or without fine needle aspiration. Conclusion An expert analysis of imaging data allows a precise diagnosis in most of the cases. Pancreatic resection should no longer be performed in case of diagnostic doubt.
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Affiliation(s)
- Philippe Lévy
- AP-HP, DHU Unity, Department of Gastroenterology and Pancreatology, Beaujon Hospital, Clichy, France ; DHU Unity, Faculté Denis Diderot, Paris-Diderot University, Paris, France
| | - Vinciane Rebours
- AP-HP, DHU Unity, Department of Gastroenterology and Pancreatology, Beaujon Hospital, Clichy, France ; DHU Unity, Faculté Denis Diderot, Paris-Diderot University, Paris, France
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18
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Nishi T, Kawabata Y, Ishikawa N, Araki A, Yano S, Maruyama R, Tajima Y. Intraductal papillary mucinous carcinoma of the pancreas associated with pancreas divisum: a case report and review of the literature. BMC Gastroenterol 2015; 15:78. [PMID: 26152300 PMCID: PMC4495851 DOI: 10.1186/s12876-015-0313-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 06/30/2015] [Indexed: 01/15/2023] Open
Abstract
Background Pancreas divisum, the most common congenital anomaly of the pancreas, is caused by failure of the fusion of the ventral and dorsal pancreatic duct systems during embryological development. Although various pancreatic tumors can occur in patients with pancreas divisum, intraductal papillary mucinous neoplasm is rare. Case presentation A 77-year-old woman was referred to our hospital because she was incidentally found to have a cystic tumor in her pancreas at a regular health checkup. Contrast-enhanced abdominal computed tomography images demonstrated a cystic tumor in the head of the pancreas measuring 40 mm in diameter with slightly enhancing mural nodules within the cyst. Endoscopic retrograde pancreatography via the major duodenal papilla revealed a cystic tumor and a slightly dilated main pancreatic duct with an abrupt interruption at the head of the pancreas. The orifice of the major duodenal papilla was remarkably dilated and filled with an abundant extrusion of mucin, and the diagnosis based on pancreatic juice cytology was “highly suspicious for adenocarcinoma”. Magnetic resonance cholangiopancreatography depicted a normal, non-dilated dorsal pancreatic duct throughout the pancreas. The patient underwent a pylorus-preserving pancreaticoduodenectomy under the diagnosis of intraductal papillary mucinous neoplasm with suspicion of malignancy arising in the ventral part of the pancreas divisum. A pancreatography via the major and minor duodenal papillae on the surgical specimen revealed that the ventral and dorsal pancreatic ducts were not connected, and the tumor originated in the ventral duct, i.e., the Wirsung’s duct. Microscopically, the tumor was diagnosed as intraductal papillary mucinous carcinoma with microinvasion. In addition, marked fibrosis with acinar cell depletion was evident in the ventral pancreas, whereas no fibrotic change was noted in the dorsal pancreas. Conclusion Invasive ductal carcinomas of the pancreas associated with pancreas divisum usually arise from the dorsal pancreas, in which the occurrence of pancreatic cancer may link to underlying longstanding chronic pancreatitis in the dorsal pancreas; however, the histopathogenesis of intraductal papillary mucinous neoplasm in this anomaly is a critical issue that warrants further investigation in future.
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Affiliation(s)
- Takeshi Nishi
- Deparment of Surgery, Matsue Red Cross Hospital, 200 Horo-machi, Matsue, Shimane, 690-8506, Japan. .,Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Yasunari Kawabata
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Noriyoshi Ishikawa
- Department of Organ Pathology, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Asuka Araki
- Department of Organ Pathology, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Seiji Yano
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Riruke Maruyama
- Department of Organ Pathology, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
| | - Yoshitsugu Tajima
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan.
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Wang W, Gong B, Jiang WS, Liu L, Bielike K, Xv B, Wu YL. Endoscopic treatment for pancreatic diseases: Needle-knife-guided cannulation via the minor papilla. World J Gastroenterol 2015; 21:5950-5960. [PMID: 26019460 PMCID: PMC4438030 DOI: 10.3748/wjg.v21.i19.5950] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 12/30/2014] [Accepted: 02/05/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine the efficacy and safety of meticulous cannulation by needle-knife.
METHODS: Three needle-knife procedures were used to facilitate cannulation in cases when standard cannulation techniques failed. A total of 104 cannulations via the minor papilla attempted in 74 patients at our center between January 2008 and June 2014 were retrospectively reviewed.
RESULTS: Standard methods were successful in 79 cannulations. Of the 25 cannulations that could not be performed by standard methods, 19 were performed by needle-knife, while 17 (89.5%) were successful. Needle-knife use improved the success rate of cannulation [76.0%, 79/104 vs 92.3%, (79 + 17)/104; P = 0.001]. When the 6 cases not appropriate for needle-knife cannulation were excluded, the success rate was improved further (80.6%, 79/98 vs 98.0%, 96/98; P = 0.000). There were no significant differences in the rates of post-endoscopic retrograde cholangiopancreatography adverse events between the group using standard methods alone and the group using needle-knife after failure of standard methods (4.7% vs 10.5%, P = 0.301).
CONCLUSION: The needle-knife procedure may be an alternative method for improving the success rate of cannulation via the minor papilla, particularly when standard cannulation has failed.
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Abstract
OBJECTIVES The majority of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are branch duct (BD) IPMNs, and these neoplasms are being diagnosed with increasing frequency; no data are also available on the well-being (quality of life [QoL]) of these patients. We aimed to evaluate the 2-year follow-up results in consecutive patients with BD-IPMNs to assess symptoms at presentation and their morphological progression; the physical and psychological statuses of these patients were also evaluated. METHODS One hundred one patients with BD-IPMN of the pancreas were enrolled in the study (37.6% men and 62.4% women; mean [SD] age, 66.3 [10.4] years). Magnetic resonance imaging was used to evaluate the modification of the cystic lesions at baseline as well as in the follow-up. The SF-12 Health Survey, the State-Trait Anxiety Inventory Y-1 and Y-2, the 12-Item General Health Questionnaire, as well as the Beck Depression Inventory-II were used to evaluate the QoL once a year. RESULTS The mean (SD) basal size of the major lesion was 15.5 (8.9) mm, and in the follow-up period, the size remained stable. The QoL did not change during the follow-up period. CONCLUSIONS Branch duct IPMNs are very slow-growing neoplasms, and they do not affect the QoL of affected patients.
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21
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Kantarci M, Bayraktutan U, Yılmaz O, Karatas D. MRCP Imaging of Intraductal Papillary-Mucinous Neoplasm of the Pancreas. Eurasian J Med 2015; 44:61-2. [PMID: 25610210 DOI: 10.5152/eajm.2012.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Accepted: 10/26/2011] [Indexed: 11/22/2022] Open
Affiliation(s)
- Mecit Kantarci
- Department of Radiology, Medical Faculty, Ataturk University, Erzurum, Turkey
| | | | - Omer Yılmaz
- Department of Gastroenterology, Medical Faculty, Ataturk University, Erzurum, Turkey
| | - Dilek Karatas
- Department of Radiology, Medical Faculty, Ataturk University, Erzurum, Turkey
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22
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Yamada S, Fujii T, Shimoyama Y, Kanda M, Nakayama G, Sugimoto H, Koike M, Nomoto S, Fujiwara M, Nakao A, Kodera Y. Clinical implication of morphological subtypes in management of intraductal papillary mucinous neoplasm. Ann Surg Oncol 2014; 21:2444-52. [PMID: 24562937 DOI: 10.1245/s10434-014-3565-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Indexed: 12/12/2022]
Abstract
PURPOSE Morphological subtypes of intraductal papillary mucinous neoplasm (IPMN) have been established. Invasive IPMNs include colloid carcinoma and tubular carcinoma. Few studies have explored the association between the morphological and invasive subtypes in a large population. Clinical relevance of the morphological subtypes remains unclear. METHODS One hundred sixty-nine consecutive patients who underwent curative resection of IPMN were enrolled. The intraductal components were classified into four distinct epithelial subtypes: gastric, intestinal, pancreatobiliary, and oncocytic. The invasive components were classified as colloid or tubular. RESULTS The numbers of patients with gastric, intestinal, pancreatobiliary, and oncocytic subtypes were 123, 42, 3, and 1, respectively. Fifty-six patients had invasive cancer (tubular type, 42; colloid type, 14). The proportions of gastric type IPMN within each histological grade were 88 % among adenomas, 43 % among noninvasive carcinomas, 41 % among minimally invasive carcinomas, and 74 % among invasive carcinomas. Gastric subtype was more commonly associated with branch duct type and intestinal subtype with main duct type, and these tendencies were statistically significant (P = 0.0131). Furthermore, there was a strong correlation between gastric and tubular types and between intestinal and colloid types (P < 0.0001). The 5-year survival rate among the 56 invasive cancers was 52.7 % for gastric type and 89.7 % for intestinal type, which was statistically significant (P = 0.030). CONCLUSIONS Gastric type IPMN is mostly derived from branch duct IPMN and often demonstrates benign behavior, as seen with adenomas. However, once gastric type IPMN develops into invasive carcinoma, the survival rate is significantly lower than other types.
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Affiliation(s)
- Suguru Yamada
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan,
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23
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Dumonceau JM, Macias-Gomez C. Endoscopic management of complications of chronic pancreatitis. World J Gastroenterol 2013; 19:7308-7315. [PMID: 24259962 PMCID: PMC3831213 DOI: 10.3748/wjg.v19.i42.7308] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 07/15/2013] [Accepted: 07/19/2013] [Indexed: 02/06/2023] Open
Abstract
Pseudocysts and biliary obstructions will affect approximately one third of patients with chronic pancreatitis (CP). For CP-related, uncomplicated, pancreatic pseudocysts (PPC), endoscopy is the first-choice therapeutic option. Recent advances have focused on endosonography-guided PPC transmural drainage, which tends to replace the conventional, duodenoscope-based coma immediately approach. Ancillary material is being tested to facilitate the endosonography-guided procedure. In this review, the most adequate techniques depending on PPC characteristics are presented along with supporting evidence. For CP-related biliary obstructions, endoscopy and surgery are valid therapeutic options. Patient co-morbidities (e.g., portal cavernoma) and expected patient compliance to repeat endoscopic procedures are important factors when selecting the most adapted option. Malignancy should be reasonably ruled out before embarking on the endoscopic treatment of presumed CP-related biliary strictures. In endoscopy, the gold standard technique consists of placing simultaneous, multiple, side-by-side, plastic stents for a one-year period. Fully covered self-expandable metal stents are challenging this method and have provided 50% mid-term success.
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24
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Abstract
Endoscopic therapy is recommended as the first-line therapy for painful chronic pancreatitis with an obstacle on the main pancreatic duct (MPD). The clinical response should be evaluated at 6 to 8 weeks. Calcified stones that obstruct the MPD are first treated by extracorporeal shockwave lithotripsy; dominant MPD strictures are optimally treated with a single, large, plastic stent that should be exchanged within 1 year even in asymptomatic patients. Pancreatic pseudocysts for which therapy is indicated and are within endoscopic reach should be treated by endoscopy.
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Affiliation(s)
- Jean-Marc Dumonceau
- Division of Gastroenterology and Hepatology, Geneva University Hospitals, Rue Gabrielle Perret Gentil 4, Geneva 1211, Switzerland.
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25
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Pathohistological subtype predicts survival in patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas. Ann Surg 2013; 258:324-30. [PMID: 23532107 DOI: 10.1097/sla.0b013e318287ab73] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate different subtypes of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas and their prognostic value. BACKGROUND IPMNs of the pancreas are estimated to have a better prognosis than pancreatic ductal adenocarcinomas (PDACs). In addition to the different growth types (ie, main duct vs. branch duct types), the histological subtypes of IPMNs (ie, intestinal, pancreatobiliary, gastric, and oncocytic type) are prognostically relevant. These subtypes can be characterized by different mucin (MUC) expression patterns. In this study, we analyzed the IPMNs from 2 pancreatic cancer referral centers by correlating the MUC expression, histological subtype, and clinical outcome. METHODS We re-evaluated all resections due to a pancreatic tumor over a period of 15 years. Cases with IPMNs were identified, and the subtypes were distinguished using histopathological analysis, including the immunohistochemical analysis of MUC (ie, MUC1, MUC2, and MUC5AC) expression. Furthermore, we determined clinical characteristics and patient outcome. RESULTS A total of 103 IPMNs were identified. On the basis of the MUC profile, histopathological subtypes were classified into the following categories: intestinal type [n = 45 (44%)], pancreatobiliary type [n = 41 (40%)], gastric type [n = 13 (12%)], and oncocytic type [n = 4 (4%)]. The following types of resections were performed: pancreatic head resections [n = 77 (75%)], tail resections [n = 16 (15%)], total pancreatectomies [n = 5 (5%)], and segment resections [n = 5 (5%)]. The 5-year survival of patients with intestinal IPMNs was significantly better than pancreatobiliary IPMNs (86.6% vs. 35.6%; P < 0.001). The pancreatobiliary subtype was strongly associated with malignancy [odds ratio (OR): 6.76], recurrence (P < 0.001), and long-term survival comparable with that of PDAC patients. CONCLUSIONS Evaluation of IPMN subtypes supports postoperative patient prognosis prediction. Therefore, subtype differentiation could lead to improvements in clinical management. Potentially identifying subgroups with the need for adjuvant therapy may be possible.
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26
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Emuron D, Senadhi V, Teagarden S, Parasher VK. Pancreatic cysts: a systematic approach and second look. J Gastrointest Cancer 2013; 43:526-31. [PMID: 22735974 DOI: 10.1007/s12029-012-9390-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pancreatic cysts are relatively rare, but constitute an important disease entity that poses a challenge with clinical, radiological, and pathological differential diagnosis. METHODS New attention has been drawn to pancreatic cysts given their potential cure rates with resection. However, preoperative distinction between neoplastic and benign lesions needs further study for effective strategies in identification and management. The role and safety of cystic fluid analysis remains to be clarified in this context. RESULTS The presence of mural nodules is a significant indicator for malignancy; however, size as a reliable predictor remains controversial. Specific criteria are required with particular focus on the histologic subtype of pancreatic lesions. CONCLUSION We review recent developments in the understanding and management of cystic lesions of the pancreas.
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Affiliation(s)
- Dennis Emuron
- Johns Hopkins University/Sinai Hospital, Baltimore, MD, USA
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Sorio C, Mafficini A, Furlan F, Barbi S, Bonora A, Brocco G, Blasi F, Talamini G, Bassi C, Scarpa A. Elevated urinary levels of urokinase-type plasminogen activator receptor (uPAR) in pancreatic ductal adenocarcinoma identify a clinically high-risk group. BMC Cancer 2011; 11:448. [PMID: 21999221 PMCID: PMC3213238 DOI: 10.1186/1471-2407-11-448] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 10/14/2011] [Indexed: 12/17/2022] Open
Abstract
Background The urokinase plasminogen activator receptor is highly expressed and its gene is amplified in about 50% of pancreatic ductal adenocarcinomas; this last feature is associated with worse prognosis. It is unknown whether the level of its soluble form (suPAR) in urine may be a diagnostic-prognostic marker in these patients. Methods The urinary level of suPAR was measured in 146 patients, 94 pancreatic ductal adenocarcinoma and 52 chronic pancreatitis. Urine from 104 healthy subjects with similar age and gender distribution served as controls. suPAR levels were normalized with creatinine levels (suPAR/creatinine, ng/mg) to remove urine dilution effect. Results Urinary suPAR/creatinine values of pancreatic ductal adenocarcinoma patients were significantly higher (median 9.8; 25th-75th percentiles 5.3-20.7) than those of either healthy donors (median 0; 0-0.5) or chronic pancreatitis patients (median 2.7; 0.9-4.7). The distribution of values among cancer patients was widespread and asymmetric, 53% subjects having values beyond the 95th percentile of healthy donors. The values of suPAR/creatinine did not correlate with tumour stage, Ca19-9 or CEA levels. Higher values correlated with poor prognosis among non-resected patients at univariate analysis; multivariate Cox regression identified high urinary suPAR/creatinine as an independent predictor of poor survival among all cancer patients (odds ratio 2.10, p = 0.0023), together with tumour stage (stage III odds ratio 2.65, p = 0.0017; stage IV odds ratio 4.61, p < 0.0001) and female gender (odds ratio 1.85, p = 0.01). Conclusions A high urinary suPAR/creatinine ratio represents a useful marker for the identification of a subset of patients with poorer outcome.
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Affiliation(s)
- Claudio Sorio
- Department of Pathology and Diagnostics, University of Verona, Italy
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Kim JH, Hong SS, Kim YJ, Kim JK, Eun HW. Intraductal papillary mucinous neoplasm of the pancreas: differentiate from chronic pancreatits by MR imaging. Eur J Radiol 2011; 81:671-6. [PMID: 21324627 DOI: 10.1016/j.ejrad.2011.01.066] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2010] [Revised: 01/13/2011] [Accepted: 01/17/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate the differentiating factors for intraductal papillary mucinous neoplasm of the pancreas and chronic pancreatitis as determined by MR imaging. MATERIALS AND METHODS During a three-year period, we performed MR imaging on 33, consecutive patients with IPMN and on 41 patients with chronic pancreatitis. All IPMNs were confirmed by surgery. Two radiologists retrospectively analyzed the ductal change, the cyst shape, CBD dilatation, lymphadenopathy, and parenchymal change. The sensitivity and specificity were calculated for each MRI findings using the Chi square test. Statistically significant MR findings were further analyzed using multivariate logistic regression analysis. The diagnostic performance was evaluated according to the area under the receiver operating characteristic curve (A(z)) using specific MRI findings. Simple κ statistics were used to evaluate the inter-observer reliability. RESULTS Statistically specific findings for IPMN compared with those for chronic pancreatitis, were duct dilatation without stricture (specificity=95.1%, sensitivity=75.8%, p<0.0001), bulging ampulla (specificity=97.6%, sensitivity=30.3%, p<0.0001), nodule in a duct (specificity=100%, sensitivity=15.2%, p<0.0004), grape-like cyst shape (specificity=97.6%, sensitivity=78.8%, p<0.0001), and nodule in a cyst (specificity=100%, sensitivity=24.2%, p<0.0001). Statistically specific findings for chronic pancreatitis compared with those for IPMN, were duct dilatation with strictures (specificity=93.9%, sensitivity=95.1%, p<0.0001), the presence of a stone (specificity=97.0%, sensitivity=56.1%, p<0.0001), and a unilocular cyst shape (specificity=93.9%, sensitivity=34.1%, p<0.0004). Duct dilatation without stricture and a grape-like cyst shape were independently associated with the IPMN. Duct dilatation with strictures was independently associated with the chronic pancreatitis. Interobserver agreement was good to excellent for each finding (κ=0.762-1.000). CONCLUSION Highly specific findings for IPMN include duct dilatation without stricture, bulging ampulla, nodule in a duct, grape-like cyst shape, and nodule in a cyst. MRI is very useful for differentiating IPMN from chronic pancreatitis using these specific findings.
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Affiliation(s)
- Jung Hoon Kim
- Department of Radiology and Institute of Radiation Medicine, Seoul National University College of Medicine, 101 Daehang-no, Chongno-gu, Seoul 110-744, Republic of Korea.
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Grützmann R, Niedergethmann M, Pilarsky C, Klöppel G, Saeger HD. Intraductal papillary mucinous tumors of the pancreas: biology, diagnosis, and treatment. Oncologist 2010; 15:1294-309. [PMID: 21147870 DOI: 10.1634/theoncologist.2010-0151] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Pancreatic intraductal papillary mucinous neoplasms (IPMNs) rank among the most common cystic tumors of the pancreas. For a long time they were misdiagnosed as mucinous cystadenocarcinoma, ductal adenocarcinoma in situ, or chronic pancreatitis. Only in recent years have IPMNs been fully recognized as clinical and pathological entities, although their origin and molecular pathogenesis remain poorly understood. IPMNs are precursors of invasive carcinomas. When resected in a preinvasive state patient prognosis is excellent, and even when they are already invasive, patient prognosis is more favorable than with ductal adenocarcinomas. Subdivision into macroscopic and microscopic subtypes facilitates further patient risk stratification and directly impacts treatment. There are main duct and branch duct IPMNs, with the main duct type including the intestinal, pancreatobiliary, and oncocytic types and the branch duct type solely harboring the gastric type. Whereas main duct IPMNs have a high risk for malignant progression, demanding their resection, branch duct IPMNs have a much lower risk for harboring malignancy. Patients with small branch duct/gastric-type IPMNs (<2 cm) without symptoms or mural nodules can be managed by periodic surveillance.
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Affiliation(s)
- Robert Grützmann
- University Hospital Carl Gustav Carus, Department of General, Vascular, and Thoracic Surgery, Dresden, Germany.
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Khan S, Sclabas G, Reid-Lombardo KM. Population-based epidemiology, risk factors and screening of intraductal papillary mucinous neoplasm patients. World J Gastrointest Surg 2010; 2:314-8. [PMID: 21160836 PMCID: PMC2999209 DOI: 10.4240/wjgs.v2.i10.314] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 09/16/2010] [Accepted: 09/23/2010] [Indexed: 02/06/2023] Open
Abstract
Intraductal papillary mucinous neoplasm (IPMN) was first recognized in the 1980s with increasing publications over the last decade as the incidence increased sharply, especially at tertiary-care referral centers. Population-based studies have estimated the age and sex-adjusted cumulative incidence of IPMN to be 2.04 per 100 000 person-years (95% confidence interval: 1.28-2.80). It is now understood that IPMN can be classified anywhere along the spectrum of the adenoma to carcinoma sequence and often harbors mutations in genes such as KRAS early in the disease process. Many patients are diagnosed incidentally after imaging of the abdomen for other diagnostic purposes. Patients that present with a history of symptoms such as pancreatitis and abdominal pain are at high risk of harboring a malignancy. Clinicopathologic features such as involvement of the main pancreatic duct, presence of mural nodules, and side branch disease > 3.0 cm in size may indicate that there is an underlying invasive component to the IPMN. In addition, the incidence of extra-pancreatic neoplasms is higher in patients with IPMN, with reported rates of 25% to 50%. There are no current screening recommendations to detect and diagnose IPMN but once the diagnosis is made, screening for extrapancreatic neoplasms such as colon polyps and colorectal cancer should be considered. Surgical resection is the recommend treatment for patients with high-risk features while close observation can be offered to patients without worrisome signs and symptoms of carcinoma.
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Affiliation(s)
- Saboor Khan
- Saboor Khan, Guido Sclabas, Kaye M Reid-Lombardo, Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN 55905, United States
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Kalaitzakis E, Braden B, Trivedi P, Sharifi Y, Chapman R. Intraductal papillary mucinous neoplasm in chronic calcifying pancreatitis: Egg or hen? World J Gastroenterol 2009; 15:1273-5. [PMID: 19291831 PMCID: PMC2658849 DOI: 10.3748/wjg.15.1273] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Intraductal papillary mucinous neoplasm (IPMN) is an increasingly reported entity. Extensive pancreatic calcification is generally thought to be a sign of chronic pancreatitis, but it may occur simultaneously with IPMN leading to diagnostic difficulties. We report a case of a patient initially diagnosed with chronic calcifying pancreatitis who was later shown to have a malignant IPMN. This case illustrates potential pitfalls in the diagnosis of IPMN in the case of extensive pancreatic calcification as well as clues that may lead the clinician to suspecting the diagnosis. The possible mechanisms of the relation between pancreatic calcification and IPMN are also reviewed.
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Liszka Ł, Zielińska-Pajak E, Pajak J, Gołka D. Colloid carcinoma of the pancreas: review of selected pathological and clinical aspects. Pathology 2008; 40:655-63. [DOI: 10.1080/00313020802436444] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Ishida M, Egawa S, Kawaguchi K, Aoki T, Sakata N, Mikami Y, Motoi F, Abe T, Fukuyama S, Katayose Y, Sunamura M, Unno M, Moriya T, Horii A, Furukawa T. Synchronous and metachronous extrapancreatic malignant neoplasms in patients with intraductal papillary-mucinous neoplasm of the pancreas. Pancreatology 2008; 8:577-82. [PMID: 18824881 DOI: 10.1159/000159844] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2007] [Accepted: 11/27/2007] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS Patients with intraductal papillary-mucinous neoplasm (IPMN) of the pancreas are likely to have a better prognosis than those with conventional pancreatic ductal adenocarcinoma. Recently there have been some reports on extrapancreatic malignant neoplasms (EPM) occurring in patients with IPMN. The purpose of this study was to discover the characteristic features of IPMN with EPM compared with IPMN without EPM. METHODS 61 patients with IPMN who underwent surgery at Tohoku University Hospital between 1988 and 2006 were retrospectively analyzed. RESULTS The 61 patients with IPMN in this study comprised 25 with intraductal papillary-mucinous adenomas (IPMA) and 36 with intraductal papillary-mucinous carcinomas (IPMC) including 6 with invasive carcinomas. Synchronous and metachronous EPM were observed in 15 out of the 61 patients (24.6%). Three of these patients, including 2 with IPMA and 1 with invasive carcinoma associated with IPMC, died of the EPM. None of the features, including sex, age, smoking, family history, macroscopic types (main duct type or branch duct type), histological types (gastric, intestinal, pancreatobiliary or oncocytic), and aberrant expression of molecules including CDKN2A, TP53, SMAD4 and DUSP6, except for the histological diagnoses were associated with the occurrence of EPM, i.e., the EPM occurred more often in patients with IPMA (10 out of 25) than in those with IPMC (5 out of 36) in our series (p = 0.0199 by the chi(2) test, p = 0.0330 by Fisher's exact probability test, p = 0.0422 by Yates' correction). CONCLUSION Patients with IPMA were more likely to have EPM than those with IPMC. Patients with IPMA are usually expected to have a fair prognosis but EPM could be fatal in some of them, so it must be noted during follow-up.
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Affiliation(s)
- Masaharu Ishida
- Department of Gastroenterological Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Japan
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Chen X, Han G, Zhai H, Zhang F, Wang J, Li X, Huang S, Wang X, Fan D. Expression and clinical significance of CacyBP/SIP in pancreatic cancer. Pancreatology 2008; 8:470-7. [PMID: 18765951 DOI: 10.1159/000151774] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2007] [Accepted: 11/06/2007] [Indexed: 12/11/2022]
Abstract
AIMS Calcyclin-binding protein or Siah-1-interacting protein (CacyBP/SIP), a component of the ubiquitin-mediated proteolysis, could bind SKP1-CUL1-F box protein complex and participate in beta-catenin degradation, which was found to be related to the malignant phenotypes of gastric cancer and renal cancer. However, the role of CacyBP/SIP in pancreatic cancer progression still remains unclear. Therefore, the aim of the present study was to investigate the expression and clinical significance of CacyBP/SIP in pancreatic cancer. METHODS Immunohistochemistry was carried out on paraffin-embedded sections of pancreatic cancer and normal pancreatic tissues. In addition, Western blot and semiquantitative RT-PCR were carried out to analyze mRNA and protein expression of CacyBP/SIP in 8 pairs of freshly resected pancreatic cancer and their adjacent nontumorous tissue. RESULTS CacyBP/SIP expression was significantly increased in pancreatic cancer tissue (28/68 or 41.2%) and correlated with differentiation degree, higher TNM (tumor, node, metastasis) stage and distance metastasis. Also, mRNA and protein expression of CacyBP/SIP were found to be at higher levels in almost all cancer tissues compared to adjacent tissues. CONCLUSIONS CacyBP/SIP protein might play an important role in the process of pancreatic carcinogenesis and high-level CacyBP/SIP expression might be related to the malignant potential of pancreatic cancer.
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Affiliation(s)
- Xiong Chen
- State Key Laboratory of Cancer Biology, Institute of Digestive Disease, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a largely diagnostic to a largely therapeutic modality. Cross-sectional imaging, such as computed tomography (CT) and magnetic resonance imaging (MRI), and less invasive endoscopy, especially endoscopic ultrasound (EUS), have largely taken over from ERCP for diagnosis. However, ERCP remains the “first line” therapeutic tool in the management of mechanical causes of acute recurrent pancreatitis, including bile duct stones (choledocholithiasis), ampullary masses (benign and malignant), congenital variants of biliary and pancreatic anatomy (e.g. pancreas divisum, choledochoceles), sphincter of Oddi dysfunction (SOD), pancreatic stones and strictures, and parasitic disorders involving the biliary tree and/or pancreatic duct (e.g Ascariasis, Clonorchiasis).
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Seijo Ríos S, Lariño Noia J, Iglesias García J, Lozano León A, Domínguez Muñoz JE. [Intraductal papillary mucinous tumor: diagnostic and therapeutic approach]. GASTROENTEROLOGIA Y HEPATOLOGIA 2008; 31:92-7. [PMID: 18279647 DOI: 10.1157/13116092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Primary cystic pancreatic neoplasms are rare tumors, with an approximate prevalence of 10% of cystic pancreatic lesions. Most of these lesions correspond to mucinous cystic neoplasm, serous cystoadenoma and intraductal papillary mucinous tumor (IPMT). IPMT is characterized by diffuse dilatation of the main pancreatic duct and/or side branches with inner defects related to mucin or tumor, or mucin extrusion from a patent ampulla. IPMT has a low potential for malignancy, with a low growth rate, a low rate of metastatic spread and postsurgical recurrence. Over the last few years, major advances have been made in the diagnostic and therapeutic management of this tumor.
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Affiliation(s)
- Susana Seijo Ríos
- Servicio de Aparato Digestivo. Hospital Clínico Universitario de Santiago. Fundación para la Investigación en Enfermedades de Aparato Digestivo (FIENAD). Santiago de Compostela. A Coruña. España.
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