Branch Duct Research Articles

Minimally Invasive Treatment of Chyle Leak After Thyroidectomy and Cervical Lymph Node Dissection in Patients with Thyroid Carcinoma: Results of a Study Involving 36 Patients.

Chyle leak (CL) after head and neck surgery is a rare but well-known complication. In patients with high-output leakage, the treatment can be complicated. This study aims to report on a recent innovation in lymphatic intervention for treating such patients. A retrospective review of 36 patients with chyle leak after neck surgery for thyroid cancer was conducted to assess the efficacy of percutaneous lymphatic embolization and thoracic duct (TD) disruption. Antegrade catheterization of the thoracic duct was achieved in 31 of 36 patients (86.1%). Therefore, embolization of the thoracic duct and thoracic duct branches was performed in 26 and 5 patients, respectively. In 5 cases of unsuccessful antegrade catheterization into the thoracic duct, transcervical access embolization was performed in 2 patients, and TD disruption (TDD) was performed in 3 patients. The pooled overall technical success rate of lymphatic embolization was 33/36 patients (91.7%). One patient who underwent thoracic duct embolization (TDE) with technical success (1/33 patients) but clinical failure had additional treatment directly sclerosing the TD under computed tomography scan. Cervical fluid collection sclerotherapy was done in 7 patients as an additional treatment. Resolution of the chyle leak after procedures was observed in all patients (100%). The mean time to resolution was 3 days (1-7 days). There was no complication intra and after procedures. TDE, selective TD branches embolization and TDD are safe and effective minimally invasive treatments for CL post-surgery for thyroid carcinoma. Sclerosing cervical fluid collection contributes to clinical success.

Spatial transcriptomics identifies candidate stromal drivers of benign prostatic hyperplasia.

Benign prostatic hyperplasia (BPH) is the nodular proliferation of the prostate transition zone in older men, leading to urinary storage and voiding problems that can be recalcitrant to therapy. Decades ago, John McNeal proposed that BPH originates with the "reawakening" of embryonic inductive activity by adult prostate stroma, which spurs new ductal proliferation and branching morphogenesis. Here, by laser microdissection and transcriptional profiling of the BPH stroma adjacent to hyperplastic branching ducts, we identified secreted factors likely mediating stromal induction of prostate glandular epithelium and coinciding processes. The top stromal factors were insulin-like growth factor 1 (IGF1) and CXC chemokine ligand 13 (CXCL13), which we verified by RNA in situ hybridization to be coexpressed in BPH fibroblasts, along with their cognate receptors (IGF1R and CXCR5) on adjacent epithelium. In contrast, IGF1 but not CXCL13 was expressed in human embryonic prostate stroma. Finally, we demonstrated that IGF1 is necessary for the generation of BPH-1 cell spheroids and patient-derived BPH cell organoids in 3D culture. Our findings partially support historic speculations on the etiology of BPH and provide what we believe to be new molecular targets for rational therapies directed against the underlying processes driving BPH.

Optimal Surveillance Interval of Branch Duct Intraductal Papillary Mucinous Neoplasm of the Pancreas

Despite the increasing prevalence of intraductal papillary mucinous neoplasm (IPMN), data on the growth and malignant conversion rates based on long-term surveillance cohorts are limited. Many international guidelines recommend surveillance for benign lesions, but the optimal interval and duration are unclear. To determine the optimal surveillance protocol for IPMN and propose which patients may be exempted from surveillance. This large-scale, international cohort study examined data of 3825 patients with IPMN treated at 5 tertiary pancreatic centers. Included were patients with branch duct (BD) IPMN who underwent surveillance or surgery between January 1, 1988, and December 31, 2020. After a thorough review, 3656 patients were included in the analytic sample. Changes in cyst size, worrisome features or high-risk stigmata, and malignant conversion rates were assessed. Patients who underwent surveillance over 5 years were compared to suggest discontinuation of surveillance protocol. Clinical data collection began in January 1, 2021, and the mean (SD) follow-up duration was 84 (47.7) months. The data analysis was performed from May 2, 2022, through September 14, 2022. The patients with BD-IPMN were followed up based on International Association of Pancreatology guidelines. Patients with suspicious malignant neoplasms during surveillance underwent surgical resection. The main outcome of this study was the optimal follow-up interval and duration of BD-IPMN surveillance. The association among cyst size, growth rate, and progression was examined using descriptive statistics. Of the 3656 patients with BD-IPMN in the analytic sample (1973 [54.0%] female; mean [SD] age, 63.7 [10.2] years), 172 (4.7%) were confirmed to have malignant lesions through surgery. Considering cyst growth, the time to develop worrisome features, and malignant conversion, a 1.5-, 1-, and 0.5-year surveillance interval could be optimal for cysts smaller than 20 mm, 20 to 30 mm, and 30 mm, respectively, after initial short-term (6-month) follow-up. Patients with cysts smaller than 20 mm, no worrisome features, and no growth during 5-year surveillance did not show malignant conversion after 5 years of follow-up and had time to progression of greater than 10 years. These findings suggest that BD-IPMN surveillance may depend on the size of the cyst and morphologic changes at the initial 6-month follow-up. For patients with small cysts (ie, <20 mm) with no morphologic changes during the initial 5-year surveillance period, surveillance may be discontinued for those unfit for surgery or who have a limited life expectancy of 10 years or less.

Abstract A011: Proteomic expression using exosomes in intraductal papillary mucinous neoplasms (IPMN) patients to inform risk stratification

Abstract Introduction Intraductal papillary mucinous neoplasm (IPMN), the most common type of pancreatic mucinous cysts, harbor risks of malignant progression of approximately 50% and 5% when found in the main duct (MD) and branch duct (BD), respectively. Surgical resection is standard of care in patients with high-risk stigmata and in some “indeterminate” cases, while surveillance modalities, which may include invasive imaging, are recommended for cases of cysts with “worrisome features”. Given the poor prognosis of late-stage pancreatic cancer, it is critical to accurately risk-stratify patients with IPMNs. We conducted a pilot study to evaluate the association of IPMN features with protein markers using extracellular vesicles (EVs), including exosomes, isolated from the blood of patients with resected IPMNs. Experimental procedure We evaluated 19 patients with IPMNs who underwent surgical resection (Whipple or distal pancreatectomy). Blood was collected before surgery and the EVs were isolated from plasma using an alternating current electrokinetics (ACE) platform. The concentration of 52 EV proteins was measured using a multiplex immunoassay. Surgical explant pathology reports were available and reviewed on all 19 patients. Data are presented as average concentration and 95% CI, and p-values represent the two-tailed t-test. Results Average age was 69 years (range: 47-83) and, of the 19 patients, 12 (63%) were male. Seventeen patients never smoked or were former smokers (quit &amp;gt; 20 years) before sample collection. A total of 14 patients had acute or chronic pancreatitis (7 historical; 7 found in surgical explant) while 4 patients had previously undiagnosed pancreatic intraepithelial neoplasia (PanIN) at the time of surgery. In our EV analysis, we found multiple EV protein biomarkers to be elevated in patients with various IPMN characteristics. Marker A was significantly elevated in patients with high-grade dysplasia (n=10) compared to low-grade dysplasia (n=9) (10.8 [8.4-13.2] vs. 7.5 [5.8 - 9.2] pg/mL, respectively, p = 0.0241), as defined by surgical explant pathology. When examining 13 patients with main-duct or mixed-type IPMNs, markers B, C, and D were elevated compared to the 6 patients with branch-duct or unspecified IPMNs (marker B: 1.9 [1.4-2.3] vs. 1.1 [0.9-1.4] ng/mL, p=0.0099; marker C: 524.3 [400.2-648.4] vs. 318.8 [209.9-427.7] pg/mL, p=0.0102; marker D: 65.8 [43.8-87.7] vs. 39.9 [31.7-48.1] pg/mL, p=0.0281). Conclusions In this pilot study that evaluated 19 patients with IPMNs, we identified multiple EV proteins that are differentially expressed in subgroups of patients. Our findings suggest that these differentially expressed proteomic markers can lead to the development of an algorithm for IPMN risk-stratification and possibly help discern histopathologic grade. Future studies will expand on these preliminary results with the aim of identifying a panel of biomarkers that can risk-stratify IPMNs to guide medical decision-making. Citation Format: Harmeet Dhani, Roberta V. Alexander, Juan Pablo Hinestrosa, Jesus Izaguirre-Carbonell, Dove Keith, Paul R. Billings, Gregory Cote', Rosalie Sears. Proteomic expression using exosomes in intraductal papillary mucinous neoplasms (IPMN) patients to inform risk stratification [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Pancreatic Cancer; 2023 Sep 27-30; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(2 Suppl):Abstract nr A011.

Intracystic injection of large surface area microparticle paclitaxel for chemoablation of intraductal papillary mucinous neoplasms: Insights from an expanded access protocol

AimsA novel large surface area microparticle paclitaxel (LSAM-PTX) has unique properties of long retention in cystic spaces while maintaining high drug concentration. We prospectively evaluated the safety and response of EUS-guided fine needle injection (EUS-FNI) of LSAM-PTX to chemoablate branch duct (BD)-IPMNs. MethodsSubjects diagnosed with BD-IPMNs exhibiting at least one worrisome criteria and considered non-surgical were enrolled in a multicenter clinical trial (NCT03188991) and subsequently included in an Expanded Access Protocol (EAP) where they received EUS-FNI of LSAM-PTX (15 mg/mL). ResultsSix BD-IPMNs measuring (mean ± SD) 3.18 ± 0.76 cm in diameter among 5 subjects (mean age: 66 years) were treated by EUS-FNI of LSAM-PTX. A mean of 4 doses of LSAM-PTX (mean dose/cyst: 73 ± 31 mg) were administered, and subjects were followed for up to 32 months. The mean volume reduction/cyst ranged from 42 to 89% (9.58 ± 5.1 ml to 2.2 ± 1.1 ml (p = 0.016)). The mean surface area reduction ranged from 31 to 83% (21.9 ± 8.7 cm2 to 5.7 ± 2.5 cm2 (p = 0.009)). Higher dosing-frequency of EUS-FNI of LSAM-PTX significantly correlated with a reduction in cyst volume (R2 = 0.87, p = 0.03) and surface area (R2 = 0.83, p = 0.04). Comparing pre- and post-ablation samples, molecular analysis of the cyst fluid revealed a loss of IPMN-associated mutations in 5 cases (83.3%), while reemergence was observed in 1 case and persistence in 1 case. Intracystic changes (fibrosis/calcification) were observed in 83.3% (n = 5). One subject developed mild acute pancreatitis (1 of 22 EUS-FNIs of LSAM-PTX). ConclusionIn this EAP, EUS-FNI of LSAM-PTX into BD-IPMNs was safe and resulted in volume and surface area reduction, morphological changes, and loss of pathogenic mutations.

A rare case of intraductal tumor of the pancreas in which an intraductal tubulopapillary neoplasm was mixed with a widely spreading gastric-type intraductal papillary-mucinous neoplasm

A 70-year-old man receiving treatment for diabetes mellitus presented with a cystic mass in the border area of the pancreatic body and tail on plain computed tomography (CT) due to impaired glucose intolerance. Contrast-enhanced CT showed a faint hyperattenuated nodular mass extending from the dilated main pancreatic duct (MPD) to the branch duct. Endoscopic retrograde cholangiopancreatography revealed a mildly dilated orifice of the papilla of Vater and MPD stenosis with entire upstream and immediate downstream dilatations. The patient underwent distal pancreatectomy due to the suspicion of mixed-type intraductal papillary-mucinous carcinoma. A pathological examination showed an intraductal solid-nodular mass measuring 25mm in length, consisting of two types of neoplasms. One showed tubulopapillary growth with entirely high-grade (HG) atypical cuboidal epithelium, in which immunohistochemical examinations were positive for MUC6 but negative for human gastric mucin (HGM), MUC1, MUC2, and MUC5AC, fitting the concept of intraductal tubulopapillary neoplasm (ITPN). The other showed the same growth of low-grade (LG) atypical columnar cells positive for HGM and MUC5AC and negative for MUC1 and MUC2, which corresponded to gastric-type intraductal papillary-mucinous neoplasm (IPMN) -LG. The tumor had not invaded the duct walls, and no metastatic lymph nodes were observed. The ITPN was adjacent to the IPMN mainly composed of tubular glands mimicking pyloric glands with LG dysplasia that corresponded to the so-called IPMN-pyloric gland variant. Moreover, the proliferation of low-papillary gastric-type IPMN spread around the intraductal tumors. Consequently, the patient was diagnosed with an intraductal tubular neoplasm comprising a noninvasive ITPN and gastric-type IPMN-LG. ITPN is a recently identified intraductal neoplasm of the pancreas proposed by Yamaguchi et al. and is distinguished by intraductal tubulopapillary growth with HG cellular atypia without overt mucin production, in contrast to IPMN. To date, no cases of intraductal nodular tumors comprising ITPN and IPMN have been reported. We report this original case with imaging and pathological observations and discuss potential processes via which ITPN and IPMN may arise adjacent to each other in the same pancreatic duct.

In the presence of a stable branch duct IPMN for five years, do we have the right to stop monitoring?

In the presence of a stable branch duct IPMN for five years, do we have the right to stop monitoring?

Is preoperative pancreatic juice cytology useful for determining therapeutic strategies for patients with intraductal papillary mucinous neoplasm of the pancreas?

We compared the results of preoperative pancreatic juice cytology (PJC) and final pathological diagnosis after resection in patients who underwent resection of intraductal papillary mucinous neoplasm (IPMN) of the pancreas to determine whether preoperative PJC can help determine therapeutic strategies. Of 1130 patients who underwent surgical resection IPMN at 11 Japanese tertiary institutions, the study included 852 patients who underwent preoperative PJC guided by endoscopic retrograde cholangiopancreatography (ERCP). The accuracy of preoperative PJC for differentiation between cancerous and noncancerous lesions were 55% for IPMN overall; 59% for the branch duct type; 49% for the main pancreatic duct type; 53% for the mixed type, respectively. On classifying IPMN according to the diameters of the mural nodule (MN) and main pancreatic duct (MPD), the corresponding values for diagnostic performance were 40% for type 1 (MN ≥5 mm and MPD ≥ 10 mm); 46% for type 2 (MN ≥5 mm and MPD < 10 mm); 61% for type 3 (MN < 5 mm and MPD ≥ 10 mm); 72% for type 4 (MN < 5 mm and MPD < 10 mm), respectively. PJC in IPMN is not a recommended examination because of its low overall sensitivity and no significant difference in diagnostic performance by type, location, or subclassification. Although the sensitivity is low, the positive predictive value is high, so we suggest that pancreatic juice cytology be performed only in cases where the patient is not sure about surgery.

Treatment efficacy and early complications of Percutaneous Transhepatic Holmium Laser Lithotripsy for biliary stones under Digital Subtraction Angiography guidance

Background: Intrahepatic stones and common bile duct stones are common diseases in Vietnam. Surgical treatments have a high rate of remaining intrahepatic bile duct stones and are ineffective with intrahepatic stones and cases with biliary strictures, while endoscopic retrograde cholangiopancreatography stone removal (ERCP) is usually indicated for small common bile duct stones and has disadvantages such as having to performe sphincterectomie of Oddi, 5% causing acute pancreatitis. Nowadays, minimally invasive treatment techniques are more and more developed. Percutaneous transhepatic lithotripsy under fluoroscopy guidance (TSQD) is an improved method using Holmium laser with small sized trocart (16F) help avoid open surgery and increase the rate of stone clearance, especially with stones located in the intrahepatic duct branches. For that reason, we conducted research to evaluate the treatment effectiveness and early complications of this method. Materials and method: This study was conducted on a group of 38 patients with main biliary tract stones, diagnosed and treated using PTHLL under fluoroscopy guidance at Hanoi Medical University Hospital from July 2018 to December 2019. Results: The PTHLL procedures was performed on patients with main extrahepatic biliary stones (28.9%) and those with intrahepatic stones, either isolated or combined (71.1%). One-step lithotripsy was applied in 26.3% of cases without cholangitis, simple stones. In another hand, Two-steps procedure were indicated in 73.7% of cases with cholangitis, multiple stones, and poor patient health. Stand-alone laser lithotripsy (23.7%) was suitable for simpler cases, while combination with baskets and balloons (76.3%) was used for complex situations. The overall complete stone clearance rate was 84.2%. Complications included septicemie (7.8%) and biloma (2.6%). No major complications like bleeding or deaths were encountered in this study. Conclusion: PTHLL under fluoroscopy guidance is a minimally invasive method that achieves a high rate of complete stone clearance in both intra- and extrahepatic biliary stones, with a low early complication rate. Key words: intervention, biliary stone, percutaneous transhepatic holmium laser lithotripsy.

Impact of preoperative endoscopic procedures on adverse event rates after surgical resection for main-duct and mixed-type intraductal papillary mucinous neoplasms (IPMNs)

BackgroundMain-duct (MD-) and mixed-type (MT-) IPMNs harbor an increased risk of pancreatic cancer and warrant surgical resection. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) are important in the diagnosis of IPMNs. The aim of this study was to investigate whether endoscopic procedures manipulating the MD impact postoperative adverse events in patients with MD- and MT-IPMNs. MethodsWe performed a retrospective study of 369 patients who underwent resections for MD- or MT-IPMN at two tertiary centers (2000–2019). Multivariable logistic regression analyses were performed for postoperative adverse events to compare the risks between intervention (ERCP, EUS-FNA with branch duct (BD) aspirated, EUS-FNA with MD aspirated from the duct directly or cyst/mass arising from MD) versus no-intervention group. Results33.1 % of patients had a preoperative ERCP and 69.4 % had EUS-FNA. Postoperative adverse events included: 30-day readmission (12.7 %), delayed gastric emptying (13.8 %), pancreatic fistula (10.3 %), abdominal abscess (5.7 %), cardiopulmonary adverse events (11.4 %), and mortality (1.4 %). The model was adjusted for potential confounders. There were no significant differences between the ERCP and no-ERCP groups for specific adverse events. Compared to no-EUS-FNA groups, groups of EUS-FNA with BD aspiration and EUS-FNA with MD aspiration from the main pancreatic duct directly or cyst/mass arising from MD did not show a significant increase in specific adverse events. ConclusionsPostoperative adverse events were not significantly increased among patients who had ERCP or EUS-FNA before surgical resection for MD- or MT-IPMNs. Endoscopic procedures directly sampling the MD can be safely pursued for diagnostic purposes in selected cases.

Proposal of a modified classification for hilar cholangiocarcinoma

Abstract Hilar cholangiocarcinoma is a malignant tumor that originates from the left and right hepatic ducts and their confluence. It is highly malignant and associated with a poor prognosis. Surgical resection is the only available curative treatment option. A scientific classification system can aid in the preoperative assessment of resectability and guide the development of appropriate surgical strategies. Several classification systems are available, with the Bismuth-Corlette (BC) classification being the earliest and most widely used. Similar to many other classifications, the BC classification relies on the secondary branching of the bile ducts as an important anatomical landmark, making it unsuitable for cases with variations in the bile duct anatomy. With advances in understanding the hepatic plate and anatomical structures at the hilum, the secondary bile ducts are no longer considered important anatomical landmarks. Therefore, modifications to the BC classification are needed to align with modern anatomical improvements and advancements in surgical techniques. Herein, we propose a modification to the BC classification. In this new system, the boundary of the hilar plate is considered as limit of the proximal ductal margin and used as an anatomical landmark, rather than the concept of “secondary bile ducts” in the BC classification.

INO80 function is required for mouse mammary gland development, but mutation alone may be insufficient for breast cancer.

The aberrant function of ATP-dependent chromatin remodeler INO80 has been implicated in multiple types of cancers by altering chromatin architecture and gene expression; however, the underlying mechanism of the functional involvement of INO80 mutation in cancer etiology, especially in breast cancer, remains unclear. In the present study, we have performed a weighted gene co-expression network analysis (WCGNA) to investigate links between INO80 expression and breast cancer sub-classification and progression. Our analysis revealed that INO80 repression is associated with differential responsiveness of estrogen receptors (ERs) depending upon breast cancer subtype, ER networks, and increased risk of breast carcinogenesis. To determine whether INO80 loss induces breast tumors, a conditional INO80-knockout (INO80 cKO) mouse model was generated using the Cre-loxP system. Phenotypic characterization revealed that INO80 cKO led to reduced branching and length of the mammary ducts at all stages. However, the INO80 cKO mouse model had unaltered lumen morphology and failed to spontaneously induce tumorigenesis in mammary gland tissue. Therefore, our study suggests that the aberrant function of INO80 is potentially associated with breast cancer by modulating gene expression. INO80 mutation alone is insufficient for breast tumorigenesis.

Concomitant cancer at another site may be a new prognosticator in patients with branch duct intraductal papillary mucinous neoplasm who are not suitable candidates for surgical treatment

Concomitant cancer at another site may be a new prognosticator in patients with branch duct intraductal papillary mucinous neoplasm who are not suitable candidates for surgical treatment

Factors predicting technical failure of endoscopic transpapillary gallbladder drainage for acute cholecystitis.

Endoscopic transpapillary gallbladder drainage (ETGBD) is a highly technical procedure, but few studies have evaluated factors that predict its technical success. Therefore, in this study, we sought to identify predictors of technically successful ETGBD. One hundred and eighty-two patients who underwent ETGBD for acute cholecystitis at our hospital were retrospectively investigated. Factors associated with technical failure were identified by focusing on clinical characteristics, anatomical features (direction of the cystic duct branch and course of the cystic duct), and procedural factors (cystic duct and gallbladder with or without contrast and cystic duct injury). The technical success rate was 84.6% (154/182) and the clinical success rate was 96.1% (148/154). The adverse event rate was 11.0% (20/182; cystic duct injury in 13 patients, pancreatitis in six, and liver abscess in one. Univariate and multivariate analyses identified the right cranial direction and spiral-type course of the cystic duct to be significant anatomical features and cystic duct injury to be a significant procedural feature contributing to the technical failure of ETGBD. ETGBD is a highly practical procedure for patients with acute cholecystitis. However, difficulty is encountered in some cases because of anatomical and procedural factors. Our results suggest that ETGBD may be difficult and thus should not be performed in cases with the right cranial direction or spiral-type course of the cystic duct or those with cystic duct injury.

Long-Term Outcomes and Risk of Pancreatic Cancer in Intraductal Papillary Mucinous Neoplasms

Intraductal papillary mucinous neoplasms (IPMNs) are pancreatic cysts that can give rise to pancreatic cancer (PC). Limited population data exist on their prevalence, natural history, or risk of malignant transformation (IPMN-PC). To fill knowledge gaps in epidemiology of IPMNs and associated PC risk by estimating population prevalence of IPMNs, associated PC risk, and proportion of IPMN-PC. : This retrospective cohort study was conducted in Olmsted County, Minnesota. Using the Rochester Epidemiology Project (REP), patients aged 50 years and older with abdominal computed tomography (CT) scans between 2000 and 2015 were randomly selected (CT cohort). All patients from the REP with PC between 2000 and 2019 were also selected (PC cohort). Data were analyzed from November 2021 through August 2023. CIs for PC incidence estimates were calculated using exact methods with the Poisson distribution. Cox models were used to estimate age, sex, and stage-adjusted hazard ratios for time-to-event end points. The CT cohort included 2114 patients (1140 females [53.9%]; mean [SD] age, 68.6 [12.1] years). IPMNs were identified in 231 patients (10.9%; 95% CI, 9.7%-12.3%), most of which were branch duct (210 branch-duct [90.9%], 16 main-duct [6.9%], and 5 mixed [2.2%] IPMNs). There were 5 Fukuoka high-risk (F-HR) IPMNs (2.2%), 39 worrisome (F-W) IPMNs (16.9%), and 187 negative (F-N) IPMNs (81.0%). After a median (IQR) follow-up of 12.0 (8.1-15.3) years, 4 patients developed PC (2 patients in F-HR and 2 patients in F-N groups). The PC incidence rate per 100 person years for F-HR IPMNs was 34.06 incidents (95% CI, 4.12-123.02 incidents) and not significantly different for patients with F-N IPMNs compared with patients without IPMNs (0.16 patients; 95% CI, 0.02-0.57 patients vs 0.11 patients; 95% CI, 0.06-0.17 patients; P = .62). The PC cohort included 320 patients (155 females [48.4%]; mean [SD] age, 72.0 [12.3] years), and 9.8% (95% CI, 7.0%-13.7%) had IPMN-PC. Compared with 284 patients with non-IPMN PC, 31 patients with IPMN-PC were older (mean [SD] age, 76.9 [9.2] vs 71.3 [12.5] years; P = .02) and more likely to undergo surgical resection (14 patients [45.2%] vs 60 patients [21.1%]; P = .003) and more-frequently had nonmetastatic PC at diagnosis (20 patients [64.5%] vs 130 patients [46.8%]; P = .047). Patients with IPMN-PC had better survival (adjusted hazard ratio, 0.62; 95% CI, 0.40-0.94; P = .03) than patients with non-IPMN PC. In this study, CTs identified IPMNs in approximately 10% of patients aged 50 years or older. PC risk in patients with F-N IPMNs was low and not different compared with patients without IPMNs; approximately 10% of patients with PC had IPMN-PC, and they had better survival compared with patients with non-IPMN PC.

Accompanying cancer of other site may be a new prognosticator in patients with branch duct intraductal papillary mucinous neoplasm unfit for surgical treatment

Accompanying cancer of other site may be a new prognosticator in patients with branch duct intraductal papillary mucinous neoplasm unfit for surgical treatment

A retrospective study of magnetic resonance sialography imaging applied in the prognostic evaluation of chronic obstructive parotitis.

Magnetic resonance sialography (MRS) can be used to clearly examine the main duct of the parotid and is widely applied in the diagnosis of chronic obstructive parotitis (COP). However, there are few studies on the classification, treatment options and prognosis of COP using MRS. Clinical and imaging data were retrospectively collected from 41 patients with COP between January 2010 and December 2020 at the Ninth People's Hospital affiliated with Shanghai Jiao Tong University School of Medicine. All patients underwent MRS and were treated with intraductal irrigation. The patients were divided into 2 groups according to the presence or absence of symptomatic relapse during the 6-month follow-up period. The imaging features of parotid MRS included three parts: gland volume, stenosis classification and dilatation classification. The location/length of dilatation, the widest diameter of the dilated duct, and the condition of the branch ducts were also recorded and compared between the groups. A mean of 14.8±12.3 irrigations were performed. There were 15 patients with recurrence and 26 without recurrence. There was no significant difference in the parotid volume (P=0.460), stenosis grade (P=0.738) or maximum diameter of dilatation of the branch duct (P=0.723) between the recurrence and non-recurrence groups. Statistically significant differences were found in dilatation classification (P=0.009), length of dilatation (P=0.043), condition of the branch ducts (P=0.017) and dexamethasone use (P=0.031). MRS is an available diagnostic and grading modality for COP. The imaging features and classification of the parotid main duct in MRS could be helpful for treatment selection. Patients who accept irrigation could be less likely to experience recurrence with a low dilatation grade and no branch duct dilatation.

S66 Elevated Serum Carbohydrate Antigen 19-9 Correlates With Presence of High-Grade Dysplasia or Focal Adenocarcinoma in Branch Duct Intrapapillary Mucinous Neoplasms: A Systematic Review and Meta-Analysis

S66 Elevated Serum Carbohydrate Antigen 19-9 Correlates With Presence of High-Grade Dysplasia or Focal Adenocarcinoma in Branch Duct Intrapapillary Mucinous Neoplasms: A Systematic Review and Meta-Analysis

Induction of lactation in a patient with complete androgen insensitivity syndrome.

With rising rates of adoption and surrogacy, induced lactation is likely to become increasingly relevant, allowing women who did not undergo pregnancy to breastfeed. We describe the case of a woman with complete androgen insensitivity syndrome (CAIS) on conventional oestrogen therapy who was expecting a child via surrogacy and who wished to breastfeed. The woman was commenced on supplementary oestrogen therapy, domperidone and breast stimulation by mechanical breast pump 8 weeks prior to the delivery of her child. Following delivery, the patient produced a small, unquantified amount of milk, allowing her to suckle the infant for a short period of time. Induced lactation is possible in chromosomally XY individuals. It has been most successful in cis-women and transwomen, both of whom have had progesterone/progestogen exposure to the breast. We suggest that the addition of a progestogen to our patient's treatment regimen, either as part of her original hormone therapy or part of the lactation induction program, would have improved her changes of establishing successful lactation. Induced lactation is possible in chromosomally XY individuals with the use of pharmacological and non-pharmacological therapies. There are no standardised guidelines regarding the optimal regimen for induced lactation. Progesterone exposure to the breast is essential for ductal branching and alveolar maturation. In the published literature, induced lactation is more successful in transwomen and other XY individuals who have had prior progesterone exposure. The addition of progestogen to our patient's treatment regimen would have improved her chances of establishing successful lactation.

Are the screening guidelines for branch duct intraductal papillary mucinous neoplasms cost-effective in an Australian setting?

Intraductal papillary mucinous neoplasms (IPMN) are cystic neoplasms of the pancreatic ductal system. These incidental cystic lesions are increasingly found on radiological imaging and screened for malignant transformation. The Fukuoka consensus guidelines recommend screening with computed tomography, magnetic resonance imaging or endoscopic ultrasound. Branch duct IPMN (BD-IPMN) have significantly lower malignancy and mortality rates compared to main duct IPMN. Our aim was to assess the cost-effectiveness of guideline's recommendations for BD-IPMN screening of cysts between 2 and 3 cm in an Australian context. Markov model decision analysis was used to calculate the incremental cost-effectiveness ratio (ICER) of screening. The ICER was compared to a willingness to pay (WTP) threshold of $50 000. We performed scenario analysis to examine the effect of cyst size and non-linearity of malignancy rate on ICER. Probabilistic sensitivity analyses (PSA) were performed on our input parameters. Screening resulted in 586 quality adjusted life years gained and a net present value of $20 379 939, resulting in a base-case ICER of $34 758. After scenario analysis for non-linearity of malignancy rate the ICER increases to $64 555, which is above the WTP threshold. PSA indicates that ICER is most susceptible to the pre-test malignancy rate. This cost analysis demonstrates that screening of 2-3 cm BD-IPMN according to current guidelines is unlikely to be cost-effective in an Australian context. To determine the true ICER, a cost analysis on real-world data is required.