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Karam C, Haque IU, Das A, Merrett N, Apostolou C. Mucin-containing pancreatic lymphoepithelial cyst: a potential surgical pitfall. ANZ J Surg 2020; 90:2376-2378. [PMID: 32065709 DOI: 10.1111/ans.15772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/04/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Charbel Karam
- Department of Upper Gastrointestinal Surgery, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Izhar-Ul Haque
- Department of Upper Gastrointestinal Surgery, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
| | - Amitabha Das
- Department of Upper Gastrointestinal Surgery, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Neil Merrett
- Department of Upper Gastrointestinal Surgery, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Christos Apostolou
- Department of Upper Gastrointestinal Surgery, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,School of Medicine, University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, University of Sydney, Sydney, New South Wales, Australia
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Müssle B, Distler M, Wolk S, Shrikhande SV, Aust DE, Arlt A, Weitz J, Hackert T, Welsch T. Management of patients with pancreatic cystic lesions: A case-based survey. Pancreatology 2017; 17:431-437. [PMID: 28456590 DOI: 10.1016/j.pan.2017.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/19/2017] [Accepted: 04/07/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic cystic lesions (PCL), including intraductal papillary mucinous neoplasia (IPMN), harbor different malignant potential and the optimal management is often challenging. The present study aims to depict the compliance of experts with current consensus guidelines and the accuracy of treatment recommendations stratified by the medical specialty and hospital volume. METHODS An international survey was conducted using a set of 10 selected cases of PCL that were presented to a cohort of international experts on pancreatology. All presented cases were surgically resected between 2004 and 2015 and histopathological examination was available. Accuracy of the treatment recommendations was based on the European and international consensus guideline algorithms, and the histopathological result. RESULTS The response rate of the survey was 26% (46 of 177 contacted experts), consisting of 70% surgeons and 30% gastroenterologists/oncologists (GI/Onc). In the case of main-duct IPMN (MD-IPMN), surgeons preferred more often the surgical approach in comparison with the GI/Onc (55 versus 44%). The mean accuracy rate based on the European and international consensus guidelines, and the histopathological result, were 71/76/38% (surgeons), and 70/73/34% (GI/Onc), respectively. High-volume centers achieved insignificantly higher accuracy scores with regard to the histopathology. Small branch-duct IPMN with cysts <2 cm and malignant potential were not identified by the guideline algorithms. CONCLUSION The survey underlines the complexity of treatment decisions for patients with PCL; less than 40% of the recommendations were in line with the final histopathology in this selected case panel. Experts and consensus guidelines may fail to predict malignant potential in small PCL.
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Affiliation(s)
- B Müssle
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - M Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - S Wolk
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - S V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Ernest Borges Marg, Parel, Mumbai, 400012, India
| | - D E Aust
- Institute for Pathology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - A Arlt
- Department of Internal Medicine I, Christian-Albrechts-University & UKSH Campus Kiel, Kiel, Germany
| | - J Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - T Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany.
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Two Large Benign Branch-Duct Gastric-Type Ιntraductal Papillary Mucinous Neoplasms of the Pancreas With Positive GNAS Mutations A Question of When or Using Which Technique to Operate? Pancreas 2016; 45:e16-7. [PMID: 27077715 DOI: 10.1097/mpa.0000000000000600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Elkak AE. Cystic Tumours of the Pancreas: A Challenging Pathology, Diagnosis and Management. JOURNAL OF CANCER THERAPY 2016; 07:712-728. [DOI: 10.4236/jct.2016.710073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Abstract
Cystic neoplasms of the pancreas are being identified at an increasing frequency largely due to the increased use of abdominal cross-sectional imaging. These neoplasms represent a heterogeneous group of tumors with various genetic alterations, molecular features, and risks of malignancy. Despite the use of high-resolution radiographic studies, endoscopic evaluation, cyst fluid analysis, and novel molecular diagnostics, many of these lesions remain difficult to classify without operative resection. These diagnostic challenges are coupled with an improving but limited understanding of the natural history of these neoplasms. Treatment of pancreatic cystic neoplasms therefore remains controversial but consists largely of a selective tumor-specific approach to surgical resection. Future research remains necessary to better discriminate the biological behavior of these tumors in order to more appropriately select patients for operative intervention.
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Affiliation(s)
- Rohit Chandwani
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065; ,
| | - Peter J Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065; ,
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Kim JR, Jang JY, Kang MJ, Park T, Lee SY, Jung W, Chang J, Shin Y, Han Y, Kim SW. Clinical implication of serum carcinoembryonic antigen and carbohydrate antigen 19-9 for the prediction of malignancy in intraductal papillary mucinous neoplasm of pancreas. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:699-707. [PMID: 26178866 DOI: 10.1002/jhbp.275] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 06/08/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND Little is known about the prognostic significance of serum carbohydrate antigen (CA) 19-9 and carcinoembryonic antigen (CEA) concentrations for predicting malignancy in patients with intraductal papillary mucinous neoplasm (IPMN) of pancreas. METHOD The study cohort consisted of 367 patients with surgical biopsy proven IPMN at Seoul National University Hospital. Preoperative serum tumor markers were evaluated and compared with other clinical variables. RESULTS Malignant pathology (high grade dysplasia [HGD] and invasive IPMN) was identified in 117 (31.9%) patients. Elevated serum CA19-9 was more frequent in patients with malignant (34.2%, P < 0.001; invasive IPMN vs. HGD 47.9% vs. 11.4%, P < 0.001) and main duct type (40.0%, P = 0.003) IPMN. Multivariate analysis showed main pancreatic duct (MPD) >5 mm (P < 0.001), mural nodules (P < 0.001), and elevated serum CA19-9 (P < 0.001) were independent predictors of malignancy. The sensitivity, specificity and accuracy were 34.2%, 92.4%, and 73.8%, respectively, for elevated serum CA19-9; 63.3%, 78.0%, and 73.3%, for MPD >5 mm; and 59.0%, 86.4%, and 77.7%, for mural nodules. CONCLUSION Serum CA19-9 is significantly higher in patients with malignant IPMN, especially in patients with invasive and main duct type IPMN. The diagnostic power of serum CA19-9 in predicting malignancy is comparable to that of MPD >5 mm and mural nodules.
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Affiliation(s)
- Jae Ri Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Mee Joo Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Taesung Park
- Department of Statistics, Seoul National University College of Natural Sciences, Seoul, Korea
| | - Seung Yeoun Lee
- Department of Mathematics and Statistics, Sejong University College of Natural Sciences, Seoul, Korea
| | - Woohyun Jung
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Jihoon Chang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Youngchan Shin
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Sun-Whe Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
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Pancreatic main-duct involvement in branch-duct IPMNs: an underestimated risk. Ann Surg 2015; 260:848-55; discussion 855-6. [PMID: 25379856 DOI: 10.1097/sla.0000000000000980] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES This study aimed to analyze a large single-center population of resected intraductal papillary mucinous neoplasms (IPMN) of the pancreas with respect to risk factors of malignant transformation. BACKGROUND There is international consensus that main-duct (MD) as well as mixed-type IPMNs should be treated surgically due to a high risk of malignancy. In contrast, there is an ongoing controversy about surgery of branch-duct type IPMN (BD-IPMN). METHODS All consecutive patients who underwent surgery for IPMN between January 2004 and December 2012 were included. Clinical characteristics and preoperative imaging were correlated with histopathological features. RESULTS A total of 512 patients underwent pancreatic surgery and had a histological proof of IPMN. According to preoperative imaging, 74 patients had MD-IPMN (14%), 205 mixed-type (40%), and 233 suspected BD-IPMN (46%). On histopathology, 162 of 512 patients revealed low-grade, 105 moderate, and 52 high-grade dysplasia. One hundred ninety-three IPMN patients (38%) suffered from invasive carcinoma. Among invasive IPMNs, the majority (58%) were mixed-type lesions according to preoperative imaging. Of 141 Sendai negative BD-IPMNs, a malignancy rate of 18% (high-grade dysplasia and invasive carcinoma) was found. Most interesting, 29% of suspected BD-IPMNs (67/233) revealed histological involvement of the main pancreatic duct not evident in preoperative imaging. CONCLUSIONS All subtypes of IPMNs display a relevant risk for malignant transformation. By abdominal imaging, many IPMNs are misclassified as BD-IPMNs but reveal mixed-type lesions in histopathology. Because currently available preoperative diagnostics are not sufficient to reliably diagnose BD-IPMNs, surgical resection for suspected small branch-duct IPMN should be considered in patients fit for surgery.
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Noninvasive intraductal papillary mucinous neoplasms and mucinous cystic neoplasms: recurrence rates and postoperative imaging follow-up. Surgery 2015; 157:473-83. [PMID: 25596773 DOI: 10.1016/j.surg.2014.09.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 08/14/2014] [Accepted: 09/19/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although surveillance guidelines for resected invasive mucinous neoplastic cysts are well-established, those for noninvasive cysts are not defined. We used our experience with resected noninvasive mucinous neoplastic cysts to define recurrence rates and the optimal frequency of postoperative imaging follow-up. METHODS We reviewed the medical records of 134 patients with resected, pathologically confirmed noninvasive mucinous neoplasms between 2002 and 2012. Demographics, comorbidities, cyst characteristics, and recurrence were evaluated. Survival analysis was used to estimate the distribution of time to recurrence and regression models were used to investigate factors associated with recurrence. RESULTS Eighty-seven patients with intraductal papillary mucinous neoplasms (IPMNs) were compared with 47 patients with mucinous cystic neoplasms (MCNs). Those with MCNs were more often females (P = .001), significantly younger (P = .001), more symptomatic (P = .009), and had cysts more often located in the tail (P < .001). Median follow-up was 42 months. Recurrence rates for IPMNs were 0%, 5%, and 10% versus 0% for MCNs respectively at postoperative years 1, 2, and 3 (P = .014). On multivariable analysis, size >3 cm (P = .027), higher grade dysplasia (P = .043), and positive resection margins (P < .001) were significantly associated with recurrence. CONCLUSION Resected noninvasive IPMNs with moderate- or high-grade dysplasia and negative resection margins require imaging follow-up every 2 years, given the 16% overall recurrence rate. Although the follow-up interval for noninvasive, low-grade, dysplastic IPMNs with negative margins could be lengthened, all noninvasive IPMNs having positive margins require yearly follow-up at the minimum. Resected noninvasive MCNs--irrespective of grade and margin status--do not require surveillance, although the development of branch duct-IPMNs in the remnant pancreas can be investigated in the long term at the discretion of the provider.
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Mucinous cystic neoplasms and serous cystadenomas arising in the body-tail of the pancreas: MR imaging characterization. Eur Radiol 2014; 25:940-9. [PMID: 25417125 DOI: 10.1007/s00330-014-3493-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 10/10/2014] [Accepted: 11/10/2014] [Indexed: 12/13/2022]
Abstract
PURPOSE To identify magnetic resonance (MR)/MR cholangiopancreatography (MRCP) imaging signs helpful in the differential diagnosis between serous cystadenomas (SCAs) and mucinous cystic neoplasms (MCNs), arising from the body/tail of the pancreas. MATERIAL AND METHODS This retrospective study had institutional review board approval and informed consent was waived. Fifty-three patients with non-communicating cystic pancreatic neoplasm of the body/tail, undergoing MR/MRCP, were included. Qualitative image analysis assessed the macroscopic pattern, number of cysts, presence of central scar, contrast enhancement of peripheral wall, and mural nodules. Quantitative analysis assessed the maximum diameter of the neoplasm, thickness of the peripheral wall, and calibre of the upstream main pancreatic duct. RESULTS Histopathology results revealed that 27/53 (51 %) were SCAs, 26/53 (49 %) were MCNs. Microcystic pattern was observed in 88.2 % of SCAs and 11.8 % of MCNs; macrocystic pattern was observed in 90.5 % of MCNs and 9.5 % of SCAs (p < 0.0001). Central scar was detected in 29.6 % of SCAs and no MCNs (p = 0.003). Contrast enhancement of the peripheral wall was evident in 99.5 % of MCNs and 11.5 % of SCAs (p < 0.0001); mural nodules were depicted in 94.1 % of MCNs and 5.9 % of SCAs (p < 0.0001). Median maximum diameter was 54 mm for MCNs, 32 mm for SCAs (p = 0.001); median wall thickness was 4 mm for MCNs, 2 mm for SCAs (p < 0.0001). CONCLUSIONS Macrocystic pattern, enhancement of a peripheral wall and mural nodules are suggestive of MCNs; whereas microcystic pattern, lack of peripheral wall and central scar are suggestive of SCAs. KEY POINTS • MCNs have macrocystic patterns, contrast enhancement of the peripheral wall and mural nodules • Microcystic pattern and central scar are suggestive of SCA • Mural nodules detected in MCNs correlate with epithelial dysplasia • Chronic obstructive pancreatitis is equally depicted in patients with MCNs and SCAs.
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Wu W, Hong X, Tian R, You L, Dai M, Liao Q, Zhang T, Zhao Y. An increased total resected lymph node count benefits survival following pancreas invasive intraductal papillary mucinous neoplasms resection: an analysis using the surveillance, epidemiology, and end result registry database. PLoS One 2014; 9:e107962. [PMID: 25264746 PMCID: PMC4179272 DOI: 10.1371/journal.pone.0107962] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 08/16/2014] [Indexed: 12/30/2022] Open
Abstract
Background The therapeutic effect of lymph node dissection for pancreas invasive intraductal papillary mucinous neoplasms (IPMN) remains unclear. The study investigated whether cancer-specific survival (CSS) and overall survival (OS) rates among invasive IPMN patients improve when more lymph nodes are harvested during surgery. Study Design The study cohort was retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. The lymph node count was categorized into quartiles. The relationship between lymph node count and survival was analyzed using Kaplan–Meier curves and a Cox proportional-hazards model. The stage migration was assessed by Chi-square tests. Propensity score matching (PSM) was used to minimize confounding variables between groups. Results In total, 1,080 patients with resected invasive IPMNs from 1992 to 2011 were included. Univariate and multivariate Cox models indicated that an increased lymph node count independently improves survival. The Kaplan-Meier and log-rank tests identified 16 nodes as an optimal cut-off value that yielded a significant survival benefit for all invasive IPMN patients. The stage migration effect existed in this cohort. After PSM, the 5-year CSS increased from 36% to 47%, and the median survival rate increased from 30 months to 40 months by increasing the lymph node count to over 16, alone. The 5-year OS rate also provided additional support for this result. Conclusion Increased lymph node counts were associated with improved survival in invasive IPMN patients. One cut-off value of lymph node count was 16 for this improvement.
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Affiliation(s)
- Wenming Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
| | - Xiafei Hong
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
| | - Rui Tian
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
| | - Lei You
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
| | - Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
| | - Quan Liao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China; and Peking Union Medical College, Beijing, China
- * E-mail:
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Kuroki H, Hayashi H, Okabe H, Hashimoto D, Takamori H, Nakahara O, Nakagawa S, Fukushima Y, Chikamoto A, Beppu T, Hirota M, Iyama KI, Baba H. EZH2 is associated with malignant behavior in pancreatic IPMN via p27Kip1 downregulation. PLoS One 2014; 9:e100904. [PMID: 25084021 DOI: 10.1371/journal.pone.0100904] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 05/28/2014] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The epigenetic mechanism of tumorigenesis in pancreatic intraductal papillary mucinous neoplasm (IPMN) remains largely unknown. The aim of this study is to examine the role of enhancer of zeste homologue 2 (EZH2) alteration in pancreatic IPMN progression. METHODS Fifty-four surgically resected pancreatic IPMN specimens, including a total of 181 lesions (normal duct in 48, adenoma in 50, borderline atypia in 53, carcinoma in situ (CIS) in 19, and invasive carcinoma in 11) were analyzed by immunohistochemical staining (EZH2, Ki-67, p27Kip1). Using paraffin embedded sections, total RNA was successfully extracted from 20 IPMN lesions (borderline IPMN in 9, CIS in 6, invasive carcinoma in 5) and 7 pancreatic normal ducts, and then levels of EZH2 and p27Kip1 mRNA were analyzed by real time PCR. RESULTS In immunohistochemical analysis, cell proliferative activity revealed by Ki-67 positive nuclei was increased during IPMN progression (normal duct<adenoma<borderline atypia<CIS ≈ invasive carcinoma). EZH2 expression displayed a similar pattern (normal duct<adenoma<borderline atypia<CIS ≈ invasive carcinoma) with cell proliferative activity. EZH2 expression in malignant (CIS and invasive carcinoma) IPMNs was significantly higher than that in adenoma and borderline-atypia IPMNs. EZH2 expression level in IPMN lesions was positively correlated with the Ki-67 positive nuclear ratio (p<0.0001). EZH2-positive cells in malignant IPMN did not express p27Kip1. EZH2 mRNA expressions in malignant lesions were significantly higher than those in benign lesions (p<0.0001). In contrast, p27Kip1 mRNA in malignant lesions was significantly decreased compared to those in benign lesion (p<0.05), and there was an inverse correlation between EZH2 and p27Kip1 mRNA levels (p = 0.0109). CONCLUSION EZH2 is associated with the accelerated cell proliferation and malignant step in pancreatic IPMN via the downregulation of p27Kip1.
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Affiliation(s)
- Hideyuki Kuroki
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiromitsu Hayashi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hirohisa Okabe
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Daisuke Hashimoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroshi Takamori
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Osamu Nakahara
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shigeki Nakagawa
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yukiko Fukushima
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Akira Chikamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Toru Beppu
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masahiko Hirota
- Department of Surgery, Kumamoto Regional Medical Center, Kumamoto, Japan
| | - Ken-ichi Iyama
- Department of Surgical Pathology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Zaheer A, Pokharel SS, Wolfgang C, Fishman EK, Horton KM. Incidentally detected cystic lesions of the pancreas on CT: review of literature and management suggestions. ACTA ACUST UNITED AC 2013; 38:331-41. [PMID: 22534872 DOI: 10.1007/s00261-012-9898-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To facilitate a better understanding of incidentally noted cystic pancreatic lesions, since these lesions often pose a challenge regarding appropriate management. METHODS This article reviews pathophysiology, prevalence, significance, and recommendations for management of the various pancreatic cystic lesions. Illustrative cases are demonstrated. RESULTS Diagnostic benign lesions can be left alone. Cross-sectional imaging can be used to follow-up benign appearing lesions and to stage more aggressive ones. Endoscopic ultrasound with fine needle aspiration and cyst fluid analysis can be performed on certain indeterminate lesions. Lesions with high malignant potential should undergo resection. CONCLUSIONS A better understanding of the variety of incidentally detected pancreatic cystic lesions can help direct appropriate management.
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Affiliation(s)
- Atif Zaheer
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, 601 N. Caroline Street, JHOC 3235 A, Baltimore, MD 21231, USA.
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Abstract
OBJECTIVE The purpose of this review is to outline the management guidelines for the care of patients with cystic pancreatic lesions. CONCLUSION The guidelines are as follows: Annual imaging surveillance is generally sufficient for benign serous cystadenomas smaller than 4 cm and for asymptomatic lesions. Asymptomatic thin-walled unilocular cystic lesions smaller than 3 cm or side-branch intraductal papillary mucinous neoplasms should be followed up with CT or MRI at 6 and 12 months interval after detection. Cystic lesions with more complex features or with growth rates greater than 1 cm/year should be followed more closely or recommended for resection if the patient's condition allows surgery. Symptomatic cystic lesions, neoplasms with high malignant potential, and lesions larger than 3 cm should be referred for surgical evaluation. Endoscopic ultrasound with fine-needle aspiration (FNA) biopsy can be used preoperatively to assess the risk of malignancy.
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Farah JFDM, Lupinacci RM, Apodaca-Torres FR. Laparoscopic resection of pancreatic cystadenomas. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2013; 25:165-8. [PMID: 23411805 DOI: 10.1590/s0102-67202012000300006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 05/26/2012] [Indexed: 01/04/2023]
Abstract
BACKGROUND Laparoscopic pancreatic resections have become increasingly frequent with good results reported by several centers. However, few studies have focused on laparoscopic treatment of pancreatic cystic lesions. AIM To analyze the results of minimally invasive treatment of pancreatic cystic lesions. METHODS Were included all laparoscopic pancreatic resections performed at three centers. Surgical procedures included resection of the pancreas and left enucleations (with or without splenectomy). The post-operative complications were classified according to the classification proposed by Clavien and Dindo6. The diagnosis of pancreatic fistula was confirmed if the amylase dosage of the drainage liquid in the third postoperative day was more than three times the amount of serum amylase. RESULTS Were performed 44 laparoscopic pancreatic resections. Fifteen patients underwent surgery for suspected pancreatic cystadenoma and 13 had this diagnosis confirmed. There were 12 women (92%), and the average age of patients was 50 years. Six patients had minor postoperative complications. There were five (38%) pancreatic fistulas, neither considered as severe (C), and only one patient required hospital readmission and radiological drainage. In this series, there were no conversions, reoperations, or mortality. CONCLUSIONS The laparoscopic approach is a safe and effective option for the treatment of pancreatic cystic lesions. The incidence of pancreatic fistula has good evolution and not diminishes the benefits of minimally invasive surgery.
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Abstract
OBJECTIVE The aim of this study was to evaluate existing management guidelines for branch-duct intraductal papillary mucinous neoplasms (IPMNs). BACKGROUND According to current treatment guidelines (Sendai criteria), patients with asymptomatic branch-duct type IPMNs of the pancreas less than 3 cm in diameter without suspicious features in preoperative imaging should undergo conservative treatment with yearly follow-up examinations. Nevertheless, the risk of harboring malignancy or invasive cancer remains a significant matter of consequence. METHODS All patients who were surgically resected for branch-duct IPMNs between January 2004 and July 2010 at the University Clinic of Heidelberg were analyzed. Clinical characteristics of the patients and preoperative imaging were examined with regard to the size of the lesions, presence of mural nodules, thickening of the wall, dilation of the main pancreatic duct, and tumor markers. Results were correlated with histopathological features and were discussed with regard to the literature. RESULTS Among a total of 287 consecutively resected IPMNs, 123 branch-duct IPMNs were identified analyzing preoperative imaging. Some 69 branch-duct IPMNs were less than 3 cm in size, without mural nodules, thickening of the wall, or other features characteristic for malignancy ("Sendai negative"). Of all the Sendai negative branch-duct IPMNs, 24.6% (17/69) showed malignant features (invasive carcinoma or carcinoma in situ) upon histological examination of the surgical specimen. CONCLUSIONS Although many branch-duct IPMNs are small and asymptomatic, they harbor a significant risk of malignancy. We believe that both main-duct and branch-duct IPMNs represent premalignant lesions. This should be taken into account for adequate therapeutic management. With regard to these results, the current Sendai criteria for branch-duct IPMNs need to be adjusted.
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Fritz S, Schirren M, Klauss M, Bergmann F, Hackert T, Hartwig W, Strobel O, Grenacher L, Büchler MW, Werner J. Clinicopathologic characteristics of patients with resected multifocal intraductal papillary mucinous neoplasm of the pancreas. Surgery 2012; 152:S74-80. [PMID: 22770954 DOI: 10.1016/j.surg.2012.05.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 05/11/2012] [Indexed: 01/03/2023]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms of the pancreas are defined as mucin-producing neoplasms arising in the main pancreatic duct (main duct type), its major branches (branch duct type), or in both (mixed type). Intraductal papillary mucinous neoplasms of the pancreas can occur as a single collection of cysts or as multifocal lesions. While subtypes of intraductal papillary mucinous neoplasms of the pancreas are well described in literature, little is known about the importance of multifocal intraductal papillary mucinous neoplasms of the pancreas. This study evaluated the clinicopathologic characteristics of patients with surgically resected, multifocal intraductal papillary mucinous neoplasm of the pancreas. METHODS Clinicopathologic features and preoperative imaging of patients resected for multifocal intraductal papillary mucinous neoplasm of the pancreas defined as intraductal papillary mucinous neoplasm of the pancreas occurring in more than just 1 area, from January 2004 to July 2010 at the Department of Surgery, University of Heidelberg were analyzed. Preoperative parameters, including number of cysts, cyst size, presence of nodules, and epidemiologic data, were assessed and compared to patients with unifocal intraductal papillary mucinous neoplasms of the pancreas. RESULTS Among 287 patients with resected intraductal papillary mucinous neoplasms of the pancreas, 51 patients (17.8%) with multifocal cystic pancreatic lesions were identified by preoperative imaging. The median age of patients with multifocal intraductal papillary mucinous neoplasms of the pancreas was ≥ 68 years (P = .002) compared to patients with unifocal intraductal papillary mucinous neoplasm of the pancreas (median age, 64 years). Thirty-one multifocal intraductal papillary mucinous neoplasms of the pancreas were of mixed type (60.8%), 15 of branch duct type (29.4%), and 5 of main duct type (9.8%). Histologically, 10 multifocal intraductal papillary mucinous neoplasms of the pancreas had low-grade dysplasia (19.6%), 11 had moderate dysplasia (21.6%), 6 had high-grade dysplasia (11.8%), and 24 had invasive carcinoma (47.1%). CONCLUSION Most multifocal intraductal papillary mucinous neoplasms of the pancreas involve the main pancreatic duct and synchronously its major side branches (mixed type). Patients with multifocal intraductal papillary mucinous neoplasm of the pancreas present at an older age compared to patients with single cystic pancreatic neoplasm. The risk of harboring malignancy-nearly 60% in the present study-seems to be increased in patients with multifocal intraductal papillary mucinous neoplasms of the pancreas compared to single lesions.
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Affiliation(s)
- Stefan Fritz
- Department of General and Visceral Surgery, University of Heidelberg, Germany
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Werner J, Fritz S, Büchler MW. Intraductal papillary mucinous neoplasms of the pancreas--a surgical disease. Nat Rev Gastroenterol Hepatol 2012; 9:253-9. [PMID: 22392299 DOI: 10.1038/nrgastro.2012.31] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cystic pancreatic neoplasms are increasingly recognized, with intraductal papillary mucinous neoplasms of the pancreas (IPMNs) being the most frequently observed type. IPMNs are characterized by mucin production and epithelial growth within the pancreatic ducts, and are generally differentiated according to location: main pancreatic duct, its major side branches, or both (mixed type). IPMNs vary from benign to malignant and are considered precursor lesions of pancreatic adenocarcinoma. However, the exact time to neoplastic transformation and whether all IPMNs progress to malignant tumors is unclear. Surgical resection is warranted for all main-duct and mixed-type IPMNs (they harbor a high risk of malignancy of ~70%). By contrast, branch-duct IPMNs progress to cancer in only ~30% of cases. Thus, according to current guidelines (Sendai criteria), asymptomatic side-branch IPMNs <3 cm in size without suspicious radiological features (such as size progression) can be treated conservatively. Lately, even this approach has become controversial, owing to a number of Sendai-negative IPMNs showing malignant transformation. Although most IPMNs should be resected by standard oncological procedures (including lymphadenectomy), small Sendai-negative IPMNs can be treated with limited resections. This Review summarizes current knowledge of the treatment of IPMNs, with a particular focus on surgical approaches to this disease.
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Affiliation(s)
- Jens Werner
- Department of General and Visceral Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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Pezzilli R, Fabbri D, Corsi MM, Imbrogno A, Barassi A, Morselli-Labate AM, Dogliotti G, Casadei R, Corinaldesi R, Melzi d'Eril G. Plasma concentrations of angiogenetic factors and angiogenetic inhibitors in patients with ductal pancreatic neoplasms. A pilot study. Clin Chem Lab Med 2011; 49:1047-51. [PMID: 21410412 DOI: 10.1515/cclm.2011.159] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The aim of the study was to evaluate the circulating concentrations of vascular endothelial growth factor (VEGF), vascular endothelial growth factor receptor-2 (VEGFR-2), vascular endothelial growth factor-D (VEGF-D) and endostatin in patients with intraductal papillary mucinous neoplasm (IPMN), and in those with ductal adenocarcinomas. METHODS Sixty patients (32 males, 28 females, mean age 69.3±11.3 years) were enrolled: 31 (51.7%) had IPMNs and 29 (48.3%) had histologically confirmed pancreatic adenocarcinomas. Thirty blood donors were also studied as controls. In all study subjects, the concentrations of VEGF, VEGF-D, VEGFR-2, and endostatin were determined using enzyme-linked immunosorbent assays. RESULTS Serum concentrations of VEGF, VEGF-D, and VEGFR-2 were significantly higher in patients with pancreatic ductal adenocarcinoma and those with IPMNs compared with healthy subjects, while endostatin was significantly higher only in patients with pancreatic ductal adenocarcinoma compared with healthy subjects. Within the group of patients, VEGFR-2 was significantly higher in patients with ductal adenocarcinoma compared to those with IPMNs. The sensitivity and the specificity of VEGFR-2 in differentiating patients with ductal adenocarcinomas from those with IPMN at a cut-off range of 4003-4034 pg/mL was 86.2% and 54.8%, respectively. CONCLUSIONS IPMNs have serum VEGFR-2 concentrations different from those in patients with ductal adenocarcinomas. However, serum VEGFR-2 cannot be routinely utilized to differentiate IPMNs from pancreatic ductal adenocarcinomas.
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Affiliation(s)
- Raffaele Pezzilli
- Department of Digestive Diseases and Internal Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
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Abstract
Cysts of the pancreas most often develop after chronic or acute inflammation of the pancreas. Cystic neoplasia of the pancreas have been increasingly recognized in clinical practice and 90% are represented by four types: serous microcystic (SCN), mucinous cystic (MCN), intraductal papillary-mucinous (IPMN) and solid pseudopapillary (SPN) neoplasia. IPMN is the most common form nowadays and main duct and branch duct types can be differentiated by morphology. This classification is of prognostic and therapeutic relevance. While main duct IPMNs have a high risk of malignant progression and resection is therefore recommended, branch duct IPMNs have a much lower risk of harboring malignancy. Small branch duct IPMNs (<2 cm) without symptoms or mural nodules can be managed by periodic surveillance. Recently, it has become clear that IPMN constitutes a heterogeneous group with at least four subtypes. Their stratification reveals that the various subtypes of IPMN have different biological properties with different prognostic implications, but the subclassification is usually not known prior to surgery. Moreover, even differentiation between inflammatory and neoplastic cysts can be challenging. Clear indications for resection are local complications (jaundice or gastric outlet obstruction), large and increasing tumors, symptoms or secretion of mucinous fluid from the papilla of Vater.
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Fritz S, Hackert T, Hinz U, Hartwig W, Büchler MW, Werner J. Role of serum carbohydrate antigen 19-9 and carcinoembryonic antigen in distinguishing between benign and invasive intraductal papillary mucinous neoplasm of the pancreas. Br J Surg 2010; 98:104-10. [PMID: 20949535 DOI: 10.1002/bjs.7280] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2010] [Indexed: 01/01/2023]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasm (IPMN) of the pancreas has malignant potential. Although serum levels of carbohydrate antigen (CA) 19-9 and carcinoembryonic antigen (CEA) are known to be raised in pancreatic ductal adenocarcinoma, little has been reported about their significance in IPMN. METHODS Preoperative CA19-9 and CEA levels were measured in consecutive patients undergoing surgical resection for IPMN. Results were correlated with histopathological and clinical features. RESULTS In 142 patients, raised CEA and CA19-9 serum levels were significantly associated with invasiveness in both branch-duct and main-duct/mixed-type IPMN. Some 74 per cent of patients with an invasive IPMN had raised levels of CA19-9, compared with only 14 per cent who had non-invasive tumours. With a cut-off level of 37 units/ml, CA19-9 had a specificity of 85·9 per cent, a negative predictive value of 85·9 per cent, a positive predictive value of 74·0 per cent and accuracy of 81·7 per cent. Overall, 80 per cent of patients with an invasive IPMN had raised serum levels of CA19-9 and/or CEA compared with only 18 per cent of those with a non-invasive tumour (P < 0·001). CONCLUSION Serum CA19-9 is a useful non-invasive preoperative tool for differentiating between invasive and benign IPMN, and should be taken into account in the decision to offer surgery. Patients with an IPMN and positive tumour markers have a high risk of malignant disease.
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Affiliation(s)
- S Fritz
- Department of General and Visceral Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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Kargozaran H, Vu V, Ray P, Bagaria S, Steen S, Ye X, Gagandeep S. Invasive IPMN and MCN: Same Organ, Sifferent Outcomes? Ann Surg Oncol 2010; 18:345-51. [DOI: 10.1245/s10434-010-1309-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Indexed: 01/13/2023]
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Abstract
Cystic neoplasms of the pancreas are a heterogeneous group of pancreatic tumors that vary in pathophysiology, malignant potential, clinical course, and outcomes. Their management is heavily predicated on establishing an accurate diagnosis. This can be particularly challenging, but can often be achieved by a thorough history and physical examination combined with high-quality, thin-slice computed tomography, although additional diagnostic tools may be required. Once the diagnosis is established, treatment can range from simple observation to total pancreatectomy. This decision rests on a clear and complete understanding of each disease process in the context of the patient's age and comorbidities. This article reviews the most common cystic neoplasms of the pancreas, focusing on their diagnosis and management.
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Abstract
Cystic neoplasms of the pancreas have been recognized for almost 2 centuries, but the principles of management continue to evolve. Clinicians have a better understanding now of the diverse pathologies and behaviors of cystic neoplasms, and can characterize them more precisely into benign, malignant, and of uncertain potential in their manifestations. Treatment is dependent on accurate diagnosis and tailored to the potential aggressiveness of the lesion, the surgical fitness of the patient, and the probability of effecting long-term palliation or survival of the patient. In this article the authors review the classification based on the World Health Organization classification and the latest evidence-based literature of cystic neoplasms, and present their considerations for surgical management of the various lesions. A better understanding of the biologic potential of cystic neoplasms such as intraductal papillary mucinous neoplasms allows for a more patient-specific evidence-based management plan.
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Pezzilli R, Barassi A, Corsi MM, Morselli-Labate AM, Campana D, Casadei R, Santini D, Corinaldesi R, D'Eril GM. Serum leptin, but not adiponectin and receptor for advanced glycation end products, is able to distinguish autoimmune pancreatitis from both chronic pancreatitis and pancreatic neoplasms. Scand J Gastroenterol 2010; 45:93-9. [PMID: 19883273 DOI: 10.3109/00365520903358907] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Serum leptin and adiponectin determinations have been proposed as markers for distinguishing pancreatic cancer and chronic pancreatitis from autoimmune pancreatitis; however, no studies exist in patients with autoimmune pancreatitis and in those with intraductal papillary mucinous tumors of the pancreas. The aim of this paper was to evaluate the circulating concentrations of receptor for advanced glycation end products (RAGE), leptin and adiponectin in patients with chronic pancreatic diseases. MATERIAL AND METHODS Seventy-five consecutive patients with chronic pancreatic diseases (47 males, 28 females; mean age 67.0 +/- 13.2 years; range 37-97 years) were studied: six (8.0%) had autoimmune pancreatitis, 23 (30.7%) had chronic pancreatitis, 34 (45.3%) had pancreatic cancer and the remaining 12 (16.0%) had intraductal papillary mutinous tumors of the pancreas. Leptin, adiponectin and RAGE were determined in serum using commercially available kits. The leptin concentrations were normalized to the lower and upper reference limits because of the different gender reference ranges. RESULTS Normalized leptin concentrations were significantly lower in chronic pancreatitis patients (0.53 +/- 1.28; p = 0.008) and in those with pancreatic cancer (0.12 +/- 0.33; p < 0.001) compared to the overall population (0.58 +/- 1.23), whereas autoimmune pancreatitis patients had significantly higher concentrations of this protein (2.18 +/- 2.56; p = 0.004) compared to the overall population. RAGE and adiponectin concentrations were similar among the four groups of patients studied. Among the clinical variables considered, only pain was significantly related to leptin concentrations (patients with pain 0.18 +/- 0.54, patients without pain 1.07 +/- 1.64; p = 0.001). CONCLUSION Serum leptin seems to be a good serum marker for differentiating autoimmune pancreatitis patients from those with chronic pancreatitis and pancreatic cancer.
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Affiliation(s)
- Raffaele Pezzilli
- Department of Digestive Diseases and Internal Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
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Sharma RR, London MJ, Magenta LL, Posner MC, Roggin KK. Preemptive surgery for premalignant foregut lesions. J Gastrointest Surg 2009; 13:1874-87. [PMID: 19513795 DOI: 10.1007/s11605-009-0935-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Accepted: 05/20/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Preemptive surgery is the prophylactic removal of an organ at high risk for malignant transformation or the resection of a precancerous or "early" malignant neoplasm in an individual with a hereditary predisposition to cancer. Recent advances in molecular diagnostic techniques have improved our understanding of the biologic behavior of these conditions. Predictive testing is an emerging field that attempts to assess the potential risk of cancer development in predisposed individuals. Despite substantial improvement in these forms of testing, all results are imperfect. This information often becomes an important tool that is used by healthcare providers to evaluate the risk-benefit ratio of various risk modifying strategies (i.e., intensive surveillance or preemptive surgery). METHODS A systematic literature review was performed using Medline and the bibliographies of all referenced publications to identify articles relating to preemptive surgery for premalignant foregut lesions. RESULTS AND DISCUSSION In this review, we outline the controversies surrounding predictive risk assessment, surveillance strategies, and preemptive surgery in the management of high-grade dysplasia (HGD) in Barrett's esophagus (BE), hereditary diffuse gastric cancer (HDGC), bile duct cysts, primary sclerosing cholangitis (PSC), and pancreatic cystic neoplasms. Resection of BE is supported by the progressive nature of the disease, the risk of occult carcinoma, and the lethality of esophageal cancer. Prophylactic total gastrectomy for HDGC appears reasonable in the absence of accurate screening tests but must be balanced by the impact of surgical complications and altered quality of life. Surgical resection of biliary cysts theoretically eliminates the exposed epithelium to decrease the lifetime risk of cholangiocarcinoma. Liver transplantation for PSC remains controversial given the scarcity of donor organs and inability to accurately identify high-risk individuals. Given the uncertain natural history of pancreatic cystic neoplasms, the merits of selective versus obligatory resection will continue to be debated. CONCLUSIONS Preemptive operations require optimal judgment and surgical precision to maximize function and enhance survival. Ultimately, balancing the risk of surgical intervention with less invasive interventions or observation must be individualized on a case-by-case basis.
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Affiliation(s)
- Rohit R Sharma
- Department of Surgery, Section of General Surgery, University of Chicago Medical Center, Chicago, IL, USA
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