Branch Duct Lesions Research Articles

Current considerations on intraductal papillary neoplasms of the bile duct and pancreatic duct

Pancreatobiliary intraductal papillary neoplasms (IPNs) represent precursors of pancreatic cancer or bile duct cholangiocarcinoma that can be detected and treated. Despite advances in diagnostic methods, identifying these premalignant lesions is still challenging for treatment providers. Modern imaging, biomarkers and molecular tests for genomic alterations can be used for diagnosis and follow-up. Surgical intervention in combination with new chemotherapeutic agents is considered the optimal treatment for malignant cases. The balance between the risk of malignancy and any risk of resection guides management policy; therefore, treatment should be individualized based on a meticulous preoperative assessment of high-risk stigmata. IPN of the bile duct is more aggressive; thus, early diagnosis and surgery are crucial. The conservative management of low-risk pancreatic branch-duct lesions is safe and effective.

Outcomes in Intra-ductal Papillary Mucinous Neoplasms in the New York Harbor Veteran Population

Introduction: Intra-ductal papillary mucinous neoplasms (IPMN) have become more frequently and incidentally diagnosed in recent years due to increases in imaging procedures. With recommendations based on weak evidence, the only consistent recommendation is for surgical intervention in patients with main duct lesions, branch duct lesions greater than 3 cm, or a solid component of the cyst. The intent of our study is to evaluate the natural history of incidental pancreatic cysts and to determine if these lesions have an effect on morbidity and mortality. Methods: Retrospective chart review was performed on patients with diagnosis of pancreatic cyst, pancreatic lesion, and intra-ductal pancreatic mucinous neoplasm from the New York Harbor Veterans Affairs Hospital from 2000 to 2015. Of 767 patients, 116 were randomly selected for further analysis. Charts were reviewed for outcomes which included progression of IPMN into disease or death of patient from pancreatic or other causes. Results: Of the 116 patients with pancreatic cysts, 47 patients were diagnosed with IPMN. Baseline characteristics are outlined in Table 1. In summary, all patients were male, more than half of patients were over age 70 at diagnosis and more than half had BMI greater than 25. There were few Hispanic (7%) or Asian (0%) patients, with most patients self-identifying as white (42.6%) or black (40.4%). In terms of patient outcomes (Table 2), only 8 of 47 patients had passed away at time of publication, with 3 passing from a pancreatic etiology, 2 being pancreatic cancer. Only 17 (36.2%) patients underwent EUS to further evaluate the cysts and 4 of these 17 had FNA sampling of the cyst. Out of 47 patients, 4 underwent surgical removal of pancreatic lesions and all 4 pathology samples showed IPMN without malignancy.Table: Table. Baseline CharacteristicsTable: Table. IPMN characteristics and outcomesConclusion: Currently, management of IPMNs is based on consensus rather than strong evidence. This study preliminarily supports the evolution of management to conservatively observing these lesions. However, as with many published studies on IPMNs, this study has limitations such as advanced age, all male sample and multiple comorbidities preventing further invasive interventions. Because of this, our findings cannot be applied to the general population. Therefore we recommend further larger multicenter trials to establish the risk of IMPN's developing into pancreatic cancer, specifically in the aging population.

Successful endoscopic ultrasound-guided ethanol with paclitaxel ablation for the pancreas cystic lesion

Successful endoscopic ultrasound-guided ethanol with paclitaxel ablation for the pancreas cystic lesion

Should all branch-duct intraductal papillary mucinous neoplasms be resected?

BackgroundThe relationship between branch-duct intraductal papillary mucinous neoplasms (IPMNs) and malignancy remains controversial and difficult to assess. MethodsBetween January 1, 1999 and January 1, 2013, we identified 84 patients with IPMN who underwent resection. ResultsPreoperatively, 55 patients underwent endoscopic ultrasounds and 58 underwent biopsy. Only 7 lesions were specified preoperatively as branch-duct, which inconsistently correlated with the surgical specimen. Of the 82 patients where the duct was specified, there were 33 malignant lesions. There was no correlation between branch-duct origin and invasive carcinoma. Malignant tumor size did not significantly differ by the duct of origin. Of the 28 patients with invasive carcinoma, branch-duct lesions were significantly associated with the presence of positive lymph nodes, perineural invasion, and lymphovascular invasion. ConclusionsOur study supports the resection criteria for branch-duct IPMN based on size and symptoms. However, it also questions the reliability of our preoperative testing to rule out malignant branch-duct IPMN lesions.

Tu1632 High Visceral Fat Area Is Association With Postoperative Complications in Patients With Crohn's Disease Following Primary Surgery

nectomy, and the remainder had either distal pancreatectomy (36%) or central pancreatectomy (2%). Pathologic evaluation identified 28 branch-duct lesions and 54 main-duct lesions, of which 38 had concurrent branch-duct lesions; duct of origin data was unavailable for 2 specimens. Of the 82 patients where the duct was specified, 33 had associated invasive (n= 28) or in-situ (n=5) carcinoma. There was no correlation between branch-duct origin and invasive carcinoma (main-duct 19 of 54, branch-duct 9 of 28, p=0.78). Multivariate analysis including tumor size did not influence this outcome (OR 1.14, CI 0.4-3.3). Malignant tumor size did not significantly differ by duct of origin (main-duct 3.3cm, branch-duct 3cm, p= 0.2). Furthermore, 2 of 9 malignant branch duct lesions were <2cm in size on pre-operative imaging. Of the 6 patients with branch duct lesions ≥3cm on pre-operative imaging, only 50% harbored invasive malignancy. The presence of symptoms preoperatively was significantly associated with malignancy (51% vs. 22%, p=0.01). Weight loss or jaundice on initial presentation was associated with a subsequent diagnosis of malignancy among patients with branch-duct lesions (both p<0.05). Of the 28 patients with invasive carcinoma, branch-duct lesions were significantly associated with the presence of positive lymph nodes, perineural invasion, and lymphovascular invasion (all p<0.05). Conclusions: Our data suggests that branch-duct lesions are as equally likely to be associated with invasive malignancy as main duct lesions, and may demonstrate more aggressive characteristics when invasion occurs. Themalignant potential of IPMN remains clinically elusive based on current clinical strategies, particularly in regards to invasive characteristics of side-branch IPMN. Therefore, surgical resection is recommended for all IPMN lesions in order to reliably assess for concurrent malignancy.

Uncinate Duct Dilation in Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Radiographic Finding with Potentially Increased Malignant Potential

BackgroundRisk of high-grade dysplasia and invasive carcinoma in intraductal papillary mucinous neoplasms (IPMN) of the pancreas is increased in main duct compared to branch duct lesions. We hypothesized that isolated uncinate duct dilation may also be a radiographic indicator of high-risk disease, as the primary drainage of this portion of the gland originates from a distinct embryologic precursor. MethodsAll patients with available preoperative imaging who underwent resection for IPMN between 1994 and 2010 were included (n = 184). Imaging studies were reviewed by an experienced radiologist who was blinded to the pathologic results, and studies were categorized as main duct, branch duct, or combined-duct. The presence of uncinate duct dilation was assessed as a risk factor for tumors which proved to have high-grade dysplasia (HGD) or invasive carcinoma (IC) on pathologic assessment. ResultsIPMN with HGD or IC were identified in 82 of 184 cases (45 %). Without considering uncinate duct dilation, IPMN with HGD or IC were present in 84 % of patients with main duct IPMN (n = 31/37), 58 % with combined-duct IPMN (n = 23/40), and 26 % with branch \\duct IPMN (n = 28/107). Dilation of the uncinate duct was observed in 47 patients, with or without main duct dilation, and 30 of these (64 %) contained HGD or IC on pathology. Isolated uncinate duct dilation without main duct dilation was observed in 17 patients, and 11 (65 %) had HGD. On multivariate analysis of IPMN without associated main duct dilation, uncinate duct dilation was independently associated with IPMN with HGD or IC (p = 0.002). ConclusionUncinate duct dilation on preoperative radiologic imaging appears to be an additional risk factor for IPMN-associated high-grade dysplasia or adenocarcinoma.

Intraductal Papillary Mucinous Neoplasms of the Pancreas with Concurrent Pancreatic and Periampullary Neoplasms

Context Intraductal papillary mucinous neoplasms (IPMN) have been reported to be associated with concurrent pancreatic ductal adenocarcinoma (PDAC) in about 8% of resected branch duct lesions. In addition other pancreatic and periampullary tumors are occasionally diagnosed with IPMN. Objective To describe the incidence, clinico­pathological characteristics and prognosis of concurrent pancreatic/periampullary neoplasms from two tertiary referral centers. Methods All pancreatic resections performed at the Massachusetts General Hospital, USA, and the Negrar Hospital, Italy, were analyzed to identify patients with IPMN and concurrent pancreatic/ periampullary neoplasms. Results Two-thousands and 762 patients underwent pancreatic surgery from January 2000 to December 2012. Sixteen percent (n=441) had pathologically confirmed IPMN and 11% of them (n=50) had synchronous other pancreatic neoplasm. Sixty-two percent of them were PDAC, followed by neuroendocrine neoplasms (10%), ampullary carcinoma (10%), mucinous and serous cystic neoplasms. In 82%, both lesions were found in the same pancreatic region, mainly in the pancreatic head. Among all patients with synchronous neoplasms, 66% harbored branch duct IPMN, 28% combined IPMN and 6% main duct IPMN, 11% IPMN with high-grade dysplasia, and 4% invasive carcinoma. The median age of patients with concurrent pancreatic neoplasms was 71 years. Abdominal pain and/or jaundice were the leading symptoms in half of patients. Thirty-four percent of patients had a positive history for other extra-pancreatic neoplasms. The median survival time was 15 months (95% CI: 11-19 months) in patients with concurrent PDAC vs . 23 months (95% CI: 0-46 months) in patients with other synchronous malignant neoplasms. Conclusion IPMN, mainly BD-IPMN, are associated with PDAC in about 7% of patients and account for 62% of all concurrent pancreatic/periampullary neoplasms. Other synchronous neoplasms may be found sporadically with IPMN.

Incidentally Diagnosed IPMNs in Liver Cirrhosis: Prevalence and Clinical Relevance

Context Intraductal papillary mucinous neoplasms of the pancreas (IPMN) have become diagnosed with increased frequency mainly due to the improvement and wide spread use of imaging studies, such as computed tomography (CT) and magnetic resonance (MR). The incidental diagnosis of IPMN in patients with other chronic disorders may affect their management. Incidental pancreatic cysts (PCs) are frequent in liver-transplanted patients, but there are no data on their prevalence in patients with liver cirrhosis (LC). Objective The primary aim of this study is to evaluate the prevalence of newly diagnosed PCs and IPMNs in a series of LC patients undergoing CT and/or MR during their follow-up. The secondary aim is to investigate whether LC patients with IPMNs have different features from LC without, and if the diagnosis of IPMN affects their clinical management. Methods Retrospective analysis of a prospective cohort of LC patients seen at our Unit between January 2002 and November 2011, who underwent at least one CT or MR. Clinical and demographic features of all patients, and their follow-up were recorded in a database. LC patients with (group A) or without IPMN (group B) were compared by means of Fisher test or t-test. Results Fourteen of 223 LC patients (6.2%) had an incidental diagnosis of a PC. Of these, 9 patients (4%) had a confirmed diagnosis of IPMN; all of them were branch duct (BD) lesions, with a diameter <3 cm. Patients with IPMN (group A, n=9) were slightly older at diagnosis of LC (mean 67.1 years) as compared to those without any PC (group B, n=209; mean age 62.9 years, P=0.08). There were no differences in terms of sex (male 67% in group A vs . 70% in group B; P=1), viral etiology (56% in group A vs . 40% in group B, P=0.5), alcoholic etiology (22% in group A vs . 39% in group B, P=0.5), HCV positivity (56% in group A vs . 30.5%, P=0.1), and rate of HCC (22% in group A vs . 38% in group B; P=0.5). A similar distribution for clinical liver function was observed (Child A 33%, B 45%, C 22% in group A; Child A 46%, B 40%, C 14% in group B; P NS). IPMNs did not significantly affect the clinical management of LC patients, and none of the patients died due to IPMN during a 17 months mean follow-up. Conclusion In this series of patient with LC, we observed an occasional 4% rate of BD-IPMN, apparently unrelated to the underlying hepatic disease, nor to clinical features. Diagnosed IPMN were small BD lesions, and their finding did not affect the management or the prognosis of LC patients. Future studies should compare the rate of PCs and IPMNs in LC and controls to confirm that the association is merely occasional.

Clinicopathological Characteristics and Molecular Analyses of Multifocal Intraductal Papillary Mucinous Neoplasms of the Pancreas

To examine the clinicopathologic features and clonal relationship of multifocal intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. Intraductal papillary mucinous neoplasms are increasingly diagnosed cystic precursor lesions of pancreatic cancer. Intraductal papillary mucinous neoplasms can be multifocal and a potential cause of recurrence after partial pancreatectomy. Thirty four patients with histologically documented multifocal IPMNs were collected and their clinicopathologic features catalogued. In addition, thirty multifocal IPMNs arising in 13 patients from 3 hospitals were subjected to laser microdissection followed by KRAS pyrosequencing and loss of heterozygosity (LOH) analysis on chromosomes 6q and 17p. Finally, we sought to assess the clonal relationships among multifocal IPMNs. We identified 34 patients with histologically documented multifocal IPMNs. Synchronous IPMNs were present in 29 patients (85%), whereas 5 (15%) developed clinically significant metachronous IPMNs. Six patients (18%) had a history of familial pancreatic cancer. A majority of multifocal IPMNs (86% synchronous, 100% metachronous) were composed of branch duct lesions, and typically demonstrated a gastric-foveolar subtype epithelium with low or intermediate grades of dysplasia. Three synchronous IPMNs (10%) had an associated invasive cancer. Molecular analysis of multiple IPMNs from 13 patients demonstrated nonoverlapping KRAS gene mutations in 8 patients (62%) and discordant LOH profiles in 7 patients (54%); independent genetic alterations were established in 9 of the 13 patients (69%). The majority of multifocal IPMNs arise independently and exhibit a gastric-foveolar subtype, with low to intermediate dysplasia. These findings underscore the importance of life-long follow-up after resection for an IPMN.

Imaging considerations in intraductal papillary mucinous neoplasms of the pancreas

With the widespread use of cross-sectional imaging, particularly computed tomography (CT) and magnetic resonance imaging (MRI), and the continuous improvement in the image quality of these techniques, the diagnosis of incidental pancreatic cysts has increased dramatically in the last decades. While the vast majority of these cysts are not clinically relevant, a small percentage of them will evolve into an invasive malignant tumor making their management challenging. Mucinous cystic neoplasms and intraductal papillary mucinous neoplasms (IPMN) are the most common pancreatic cystic lesions with malignant potential. Imaging findings on CT and MRI correlate tightly with the presence of malignant degeneration in these neoplasms. IPMN can be classified based on their distribution as main duct, branch duct or mixed type lesions. MRI is superior to CT in demonstrating the communication of a branch duct IPMN with the main pancreatic duct (MPD). Most branch duct lesions are benign whereas tumors involving the MPD are frequently associated with malignancy. The presence of solid nodules, thick enhancing walls and/or septae, a wide (> 1 cm) connection of a side-branch lesion with the MPD and the size of the tumor > 3 cm are indicative of malignancy in a branch and mixed type IPMN. A main pancreatic duct > 6 mm, a mural nodule > 3 mm and an abnormal attenuating area in the adjacent pancreatic parenchyma on CT correlates with malignant disease in main duct and mixed type IPMN. An accurate characterization of these neoplasms by imaging is thus crucial for selecting the best management options. In this article, we review the imaging findings of IPMN including imaging predictors of malignancy and surgical resectability. We also discuss follow-up strategies for patients with surgically resected IPMN and patients with incidental pancreatic cysts.

Intraductal papillary-mucinous tumors of the pancreas: predictive criteria of malignancy according to pathological examination of 53 cases.

One of the main problems in the management and treatment of intraductal papillary-mucinous tumors is the lack of a reliable predictive factor for malignancy. Surgical treatment could be adapted to macroscopic criteria (presence of mural nodules and diameter of the pancreatic duct and of the lesion) or to tumor location (main duct, branch duct, or combined lesions) associated with benign or malignant forms. Retrospective study. Two university and tertiary referral centers. Fifty-three consecutive patients who underwent pancreatic resection for intraductal papillary-mucinous tumors between January 1, 1985, and December 31, 2000. Macroscopic analyses of tumors showed 6 main duct lesions, 12 branch duct lesions, and 35 combined lesions. A carcinoma was present in 33 cases (62%): 22 (41%) were invasive and 11 (21%) were noninvasive; 9 (17%) were borderline tumors and 11 (21%) were benign. Carcinoma and invasive carcinoma forms were less frequent in branch duct lesions (P<.001 and P =.009, respectively). Mural nodules were more frequent in carcinomas (P =.006) and invasive carcinomas (P<.001), with a positive predictive value of malignancy of 81%. The diameter of lesions (branch duct lesion > or =30 mm) or main duct (main pancreatic duct > or =15 mm in combined or main pancreatic duct lesions) did not correlate with malignancy. No carcinoma occurred in branch duct types smaller than 30 mm without mural nodules. Limited resection may be appropriate only in this type of tumor.

The incidence of intraductal papillary mucinous tumors of the pancreas

Purpose To review a population-controlled single institution experience with intraductal papillary mucinous tumors (IPMTs) of the pancreas treated in the United States and generate an incidence of this recently described disease process. Background First decribed in 1982, mucin-secreting pancreatic cancer constituted a newly recognized category of pancreatic exocrine tumors distinct from mucinous cystic neoplasms. Since that time, several small series of IPMTs of the pancreas have been reported. Most studies come from Asia and Europe, with limited data from American institutions and no description of the incidence. Methods The authors retrospectively reviewed all patients who underwent pancreatic resections at Madigan Army Medical Center from October 1992 through November 1999. Cases suggestive of IPMTs underwent re-examination by a staff pathologist. Clinical presentation, imaging studies, treatment, histopathology, and outcomes were reviewed for those with IPMTs. The data base of all patients eligible for care was evaluated to obtain a population denominator and determine an incidence for this neoplasm. Results Over 7 years, 78 patients underwent pancreatic resections. Forty-two had pancreatic neoplasms and, of those, 8 (19%) had IPMTs. The mean age was 67 years, with equal numbers of males and females. All patients were symptomatic (abdominal pain, 75%; jaundice, 25%; weight loss, 25%). Abnormal computed tomography scans were noted in 7/8 (88%) cases. Mucin was visualized during endoscopic retrograde cholangiopancreatography in 5/7 (71%) patients. Preoperative diagnosis of IPMT was made in 5 (62%) cases. The locations of the tumors were head (63%), tail (12%), head and body (12%), and body and tail (12%). All lesions were resectable, and procedures included 5 pancreatoduodenectomies, 2 distal pancreatectomies, and 1 total pancreatectomy. Main duct tumors were noted in 63%, whereas the remainder had both main and branch duct lesions. Tumor invasion was discovered in 2 (25%) cases. Mean follow-up was 29 months. Those without invasion were all alive (follow-up, 6 to 86 months). One patient with tumor invasion died 4 months after surgery and the other was living 20 months later. The incidence of IPMTs was 1 case/281,000 patients/year. Conclusions The incidence of IPMTs of the pancreas may be higher than previously recognized. Aggressive resection is warranted based on the favorable prognosis of patients without tumor invasion.