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Wood LD, Adsay NV, Basturk O, Brosens LAA, Fukushima N, Hong SM, Kim SJ, Lee JW, Luchini C, Noë M, Pitman MB, Scarpa A, Singhi AD, Tanaka M, Furukawa T. Systematic review of challenging issues in pathology of intraductal papillary mucinous neoplasms. Pancreatology 2023; 23:878-891. [PMID: 37604731 DOI: 10.1016/j.pan.2023.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasms (IPMNs) are a cystic precursor to pancreatic cancer. IPMNs deemed clinically to be at high-risk for malignant progression are frequently treated with surgical resection, and pathological examination of the pancreatectomy specimen is a key component of the clinical care of IPMN patients. METHODS Systematic literature reviews were conducted around eight topics of clinical relevance in the examination of pathological specimens in patients undergoing resection of IPMN. RESULTS This review provides updated perspectives on morphological subtyping of IPMNs, classification of intraductal oncocytic papillary neoplasms, nomenclature for high-grade dysplasia, assessment of T stage, distinction of carcinoma associated or concomitant with IPMN, role of molecular assessment of IPMN tissue, role of intraoperative assessment by frozen section, and preoperative evaluation of cyst fluid cytology. CONCLUSIONS This analysis provides the foundation for data-driven approaches to several challenging issues in the pathology of IPMNs.
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Affiliation(s)
- Laura D Wood
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - N Volkan Adsay
- Department of Pathology, Koç University Hospital and Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey
| | - Olca Basturk
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Noriyoshi Fukushima
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Joo Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae W Lee
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134, Verona, Italy; ARC-Net Research Center, University of Verona, 37134, Verona, Italy
| | - Michaël Noë
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134, Verona, Italy; ARC-Net Research Center, University of Verona, 37134, Verona, Italy
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mariko Tanaka
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toru Furukawa
- Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
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Geramizadeh B, Marzban M, Shojazadeh A, Kadivar A, Maleki Z. Intraductal papillary mucinous neoplasm of the pancreas: Cytomorphology, imaging, molecular profile, and prognosis. Cytopathology 2021; 32:397-406. [PMID: 33792980 DOI: 10.1111/cyt.12973] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 02/15/2021] [Accepted: 02/24/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intraductal papillary mucinous neoplasm (IPMN) constitutes up to 20% of all pancreatic resections, and has been increasing in recent years. Histomorphological findings of IPMN are well established; however, there are not many published papers regarding the cytological findings of IPMN on fine needle aspiration (FNA) specimens. We review the cytomorphological features, molecular profile, imaging findings, and prognosis of IPMN. METHODS The English literature was thoroughly searched with key phrases containing IPMN. OBSERVATIONS IPMN is a rare entity, affecting men and women equally and is usually diagnosed at the age of 60-70 years. The characteristic imaging features include a cystic lesion with associated dilatation of the main or branch pancreatic duct, and atrophy of surrounding pancreatic parenchyma. Cytomorphological features of IPMN include papillary fragments of mucinous epithelium in a background of abundant thick extracellular mucin, a hallmark feature. IPMNs should be evaluated for high-grade dysplasia, which manifests with nuclear atypia, nuclear moulding, prominent nucleoli, nuclear irregularity, and cellular crowding. Molecular profiling of IPMN along with carcinoembryonic antigen and amylase levels is useful in predicting malignancy or high-grade dysplasia arising in IPMN. Overall, the prognosis of IPMN is excellent except in those cases with high-grade dysplasia and malignant transformation. Postoperative surveillance is required for resected IPMNs. CONCLUSION IPMN requires a multidisciplinary approach for management. Cytomorphological findings of IPMN on FNA, in conjunction with tumour markers in pancreatic fluid cytology and imaging findings, are of paramount importance in clinical decision-making for IPMN.
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Affiliation(s)
- Bita Geramizadeh
- Department of Pathology, Medical School of Shiraz University, Shiraz University of Medical Sciences, Shiraz, Iran.,Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahsa Marzban
- University of British Columbia, Vancouver, BC, Canada
| | - Alireza Shojazadeh
- Department of Pathology, Medical School of Shiraz University, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ana Kadivar
- University of Maryland, College Park, MD, USA
| | - Zahra Maleki
- Division of Cytopathology, Department of Pathology, The Johns-Hopkins Hospital, Baltimore, MD, USA
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Carmicheal J, Patel A, Dalal V, Atri P, Dhaliwal AS, Wittel UA, Malafa MP, Talmon G, Swanson BJ, Singh S, Jain M, Kaur S, Batra SK. Elevating pancreatic cystic lesion stratification: Current and future pancreatic cancer biomarker(s). Biochim Biophys Acta Rev Cancer 2019; 1873:188318. [PMID: 31676330 DOI: 10.1016/j.bbcan.2019.188318] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/25/2019] [Accepted: 10/25/2019] [Indexed: 02/06/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an incredibly deadly disease with a 5-year survival rate of 9%. The presence of pancreatic cystic lesions (PCLs) confers an increased likelihood of future pancreatic cancer in patients placing them in a high-risk category. Discerning concurrent malignancy and risk of future PCL progression to cancer must be carefully and accurately determined to improve survival outcomes and avoid unnecessary morbidity of pancreatic resection. Unfortunately, current image-based guidelines are inadequate to distinguish benign from malignant lesions. There continues to be a need for accurate molecular and imaging biomarker(s) capable of identifying malignant PCLs and predicting the malignant potential of PCLs to enable risk stratification and effective intervention management. This review provides an update on the current status of biomarkers from pancreatic cystic fluid, pancreatic juice, and seromic molecular analyses and discusses the potential of radiomics for differentiating PCLs harboring cancer from those that do not.
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Affiliation(s)
- Joseph Carmicheal
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Asish Patel
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Vipin Dalal
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Pranita Atri
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Amaninder S Dhaliwal
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Uwe A Wittel
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Mokenge P Malafa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Geoffrey Talmon
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Benjamin J Swanson
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Shailender Singh
- Department of Internal Medicine, Division of Gastroenterology-Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Maneesh Jain
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sukhwinder Kaur
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Surinder K Batra
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA; Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, USA; Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA; Eppley Institute for Research in Cancer and Allied Diseases, University of Nebraska Medical Center, Omaha, NE, USA.
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Tanaka M, Fernández-Del Castillo C, Kamisawa T, Jang JY, Levy P, Ohtsuka T, Salvia R, Shimizu Y, Tada M, Wolfgang CL. Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology 2017; 17:738-753. [PMID: 28735806 DOI: 10.1016/j.pan.2017.07.007] [Citation(s) in RCA: 991] [Impact Index Per Article: 141.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 07/12/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023]
Abstract
The management of intraductal papillary mucinous neoplasm (IPMN) continues to evolve. In particular, the indications for resection of branch duct IPMN have changed from early resection to more deliberate observation as proposed by the international consensus guidelines of 2006 and 2012. Another guideline proposed by the American Gastroenterological Association in 2015 restricted indications for surgery more stringently and recommended physicians to stop surveillance if no significant change had occurred in a pancreatic cyst after five years of surveillance, or if a patient underwent resection and a non-malignant IPMN was found. Whether or not it is safe to do so, as well as the method and interval of surveillance, has generated substantial debate. Based on a consensus symposium held during the meeting of the International Association of Pancreatology in Sendai, Japan, in 2016, the working group has revised the guidelines regarding prediction of invasive carcinoma and high-grade dysplasia, surveillance, and postoperative follow-up of IPMN. As the working group did not recognize the need for major revisions of the guidelines, we made only minor revisions and added most recent articles where appropriate. The present guidelines include updated information and recommendations based on our current understanding, and highlight issues that remain controversial or where further research is required.
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Affiliation(s)
- Masao Tanaka
- Department of Surgery, Shimonoseki City Hospital, Shimonoseki, Japan.
| | | | - Terumi Kamisawa
- Department of Gastroenterology, Komagome Metropolitan Hospital, Tokyo, Japan
| | - Jin Young Jang
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Philippe Levy
- Pôle des Maladies de l'Appareil Digestif, Service de Gastroentérologie-Pancréatologie, Hopital Beaujon, Clichy Cedex, France
| | - Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Yasuhiro Shimizu
- Dept. of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Christopher L Wolfgang
- Cameron Division of Surgical Oncology and The Sol Goldman Pancreatic Cancer Research Center, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
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Schaberg KB, DiMaio MA, Longacre TA. Intraductal Papillary Mucinous Neoplasms Often Contain Epithelium From Multiple Subtypes and/or Are Unclassifiable. Am J Surg Pathol. 2016;40:44-50. [PMID: 26469398 DOI: 10.1097/pas.0000000000000528] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pancreatic intraductal papillary mucinous neoplasms (IPMNs) are subclassified into gastric, intestinal, pancreatobiliary, and oncocytic subtypes based on histologic features. The WHO classification scheme suggests use of immunohistochemical stains to help subtype IPMNs with ambiguous histology. Seventy-two pancreatic IPMN resections between 2008 and 2014 were retrospectively evaluated. Immunohistochemistry for CDX2, MUC2, and MUC5AC was performed on cases where the histologic subtype could not be determined on routine hematoxylin and eosin (H&E) sections. There were 41 gastric (57%), 8 intestinal (11%), 4 pancreatobiliary (6%), and 1 oncocytic (1%) IPMNs. Eighteen (25%) IPMNs were either unclassifiable due ambiguous morphology or contained distinct epithelium from >1 subtype (i.e., "mixed"). Two IPMNs initially unclassifiable strictly by H&E morphology were definitively classified as intestinal after positive immunohistochemical staining with CDX2, MUC2, and MUC5AC. Immunohistochemistry for another 7 IPMNs unclassifiable by H&E did not indicate a clear subtype and often contained discordant results (e.g., discordant CDX2 and MUC2 staining). In our experience, a considerable number of IPMNs are either unclassifiable or contain epithelium from >1 subtype. Furthermore, among those IPMNs initially unclassifiable by H&E morphology, application of immunohistochemical stains to aid in subtyping allow for definite classification in only a small subset of cases. These data, when taken in context with the significant ranges in the reported prevalence of specific histologic subtypes, suggest that accurate IPMN subtyping is poorly reproducible in up to 25% of cases, and in these problematic cases, immunohistochemistry adds little value.
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Qi X, Zhao X, Su J, Xu M, Zhang W, Sheng H, Li Z, Wang J. Malignant transformation and overall survival of morphological subtypes of intraductal papillary mucinous neoplasms of the pancreas: A network meta-analysis. Eur J Intern Med 2015; 26:652-7. [PMID: 26275457 DOI: 10.1016/j.ejim.2015.07.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 07/15/2015] [Accepted: 07/19/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Emerging evidence suggests the predictive role of morphological subtypes (gastric, intestinal, pancreatobiliary, and oncocytic) of intraductal papillary mucinous neoplasms (IPMNs) in malignant transformation and overall survival. But results of these studies are currently discordant. METHODS A comprehensive literature search in MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) was conducted for eligible studies. Network meta-analysis using the random-effect model was carried out to detect differences in incidences of invasive IPMNs and hazard ratios from survival curves among four morphological subtypes. RESULTS 19 studies were included in the network comparison. The outcomes showed that pancreatobiliary-type (OR for odds ratio=25.87, 95% CI: 12.11-52.10, compared with gastric-type) and oncocytic-type (OR=18.59, 95% CI: 7.18-42.74) IPMNs had the highest risks of progressing to invasive IPMNs, followed by intestinal-type (OR=5.71, 95% CI: 2.85-10.61) and gastric-type IPMNs. With the gastric type as the baseline, pancreatobiliary-type IPMNs were found to have the worst prognosis (HR for hazard ratio=5.05, 95% CrI: 1.33-13.47) while no significant differences were found for the intestinal type (HR=1.90, 95% CrI: 0.59-4.58) and the oncocytic type (HR=3.29, 95% CrI: 0.75-9.71). CONCLUSION It is suggested that pancreatobiliary-type IPMNs are the most likely to become invasive and are associated with poor prognosis. In contrast, the other three subtypes have similar overall survivals even though the oncocytic- and intestinal-type IPMNs are predisposed to be more invasive than gastric-type IPMNs.
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Affiliation(s)
- Xiaolong Qi
- Department of General Surgery, 302 Hospital of PLA, Beijing 100039, China; Division of Surgical Oncology, Brigham and Women's Hospital, Boston, MA, USA
| | - Xin Zhao
- Department of General Surgery, 302 Hospital of PLA, Beijing 100039, China
| | - Junlei Su
- Department of Endocrinology, Shanghai Tenth People's Hospital, Tongji University, Shanghai 200072, China
| | - Mingxin Xu
- Department of Endocrinology, Shanghai Tenth People's Hospital, Tongji University, Shanghai 200072, China
| | - Weifeng Zhang
- Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029 China
| | - Hui Sheng
- Department of Endocrinology, Shanghai Tenth People's Hospital, Tongji University, Shanghai 200072, China
| | - Zhiwei Li
- Department of General Surgery, 302 Hospital of PLA, Beijing 100039, China.
| | - Jiping Wang
- Division of Surgical Oncology, Brigham and Women's Hospital, Boston, MA, USA.
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Abstract
PURPOSE OF REVIEW Our understanding of intraductal papillary mucinous neoplasm (IPMN) of the pancreas has remarkably grown within the last decade; nonetheless there is still an ongoing controversy if the majority of these potentially malignant neoplasms need to be resected or if observation in a subset is well tolerated. RECENT FINDINGS Novel cyst fluid biomarkers, like Gnas mutations or mab DAS-1, could play a pivotal role in the distinction of IPMN vs. other cystic lesions, in the sub-classification of IPMN and in the detection of IPMN with high-grade dysplasia or invasive cancer. Other recent studies focused on natural history of minimal- and extensive-mixed IPMN and the safety of the 2012 AIP guidelines. Small series also described that observation can be an option in selected frail patients with MD-IPMN. Further, data from a large European multicenter study analysis indicated that patients with IPMN do not have an increased frequency of extrapancreatic malignancies. SUMMARY Increasing knowledge about the nature of IPMN and their subtypes has resulted in an individualized approach in diagnosis and treatment. Owing to the availability of accurate diagnostic instruments, timing and indication for pancreatic resection have become more selective, sparing patients with harmless IPMN from major surgery.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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