Branch-type Intraductal Papillary Mucinous Neoplasm Research Articles

Intraductal papillary mucinous neoplasm complicated with intraductal bleeding in a young woman mimicked a cystic solid pseudo-papillary tumor: a case report

BackgroundThere are only 6 cases of intraductal papillary mucinous neoplasm (IPMN) complicated with intraductal hemorrhage have been reported in English literatures. All these 6 cases of IPMN occurred in the old people. The present rare case of IPMN complicated with intraductal hemorrhage occurred in a young woman, and mimicked a cystic solid pseudo-papillary neoplasm (SPN) on preoperative imaging findings.Case presentationA 29-year-old young woman complained of a sustained mild right upper quadrant abdominal pain. CT and MRI showed a lobulated, partly ill-defined cystic lesion located in the pancreatic head. Spotted calcification within cystic wall was seen on CT. The lesion was demonstrated as predominantly homogeneous hyperattenuation on CT and homogeneous high signal without decreased signal on fat suppression sequence on T1WI. After contrast administration, the cystic wall and septa of lesion was showed gradually mild to moderate degree of enhancement over time both on CT and MRI. No communication between lesion and the main duct was found on MRCP and the main pancreatic duct and common bile duct were not dilated. Considering patient’s age, gender and manifestations of lesion on CT and MRI (calcification, bleeding and gradually enhanced pattern), the present case mimicked as a cystic SPN. The lesion was pathologically confirmed a branch type IPMN after surgical resection.ConclusionWe propose that IPMN may need to be taken into account in the differential diagnosis when pancreatic cystic lesions occur in young women with bleeding, calcification, progressive enhancement of cystic wall and no communication with the main pancreatic duct.

Branch duct-type intraductal papillary mucinous neoplasm presenting as paraneoplastic small plaque para-psoriasis

To present and discuss a novel association between branch duct-type intraductal papillary mucinous neoplasm and paraneoplastic parapsoriasis. We present the case of a middle-aged male presenting with skin lesions that were suggestive of parapsoriasis, resistant to treatment, and in whom a diagnosis of branch-type intraductal papillary mucinous neoplasm of the pancreas was eventually made. A curative Whipple's surgery led to complete resolution of the skin lesions within 3 weeks. Paraneoplastic parapsoriasis in association with intraductal papillary mucinous pancreatic neoplasm has never been reported before.

Minimally invasive central pancreatectomy and pancreatogastrostomy: current surgical technique and outcomes.

Recent improvements in imaging techniques and more frequent use of cross-sectional imaging have led to an increase in the identification of benign and low-grade lesions of the pancreas. Patients with resectable cancers are commonly treated by either a Whipple procedure or distal pancreatectomy (DP) based on the location of the tumor. Central pancreatectomy (CP) is a less commonly performed operation that has recently been utilized for resection of these now more frequently diagnosed low-grade and benign lesions located in the mid pancreas. Lesions that may have a relatively more indolent nature include branch-type intraductal papillary mucinous neoplasm (IPMNs), mucinous cystic neoplasms, neuroendocrine tumors, and solid pseudopapillary tumors. The goal of a CP is complete extirpation of the lesion, while preserving pancreatic parenchyma to reduce the risks of developing diabetes and exocrine insufficiency (EI). Although open CP has been shown to be safe and efficacious, the outcomes of a minimally invasive approach are still relatively underreported and therefore unknown. In this paper, we describe our surgical approach to performing a CP with an accompanying video demonstration of the key portions of the operation.

Intraductal papillary neoplasms of the pancreas. An analysis of clinicopathologic features and outcomes at the hospital nacional guillermo almenara irigoyen. Lima – Perú

Introduction: Intraductal papillary mucinous neoplasm (IPMN) is a mucin producing neoplasm that arises in the main pancreatic duct and/or its branches. The objective of this study is to analyze retrospectively the clinical, radiologic and pathologic features as well as the surgical results of the patients with diagnosis of IPMN. Methods: Patients with diagnosis of IPMN who underwent surgery were identified from January 2006 to September 2015, using the prospective data base of the Pancreas service at HNGAI. Results: A total of 16 patients were found (12 females and 4 males). The mean age was 67.68 years. 3 were main duct type IPMN, 7 branch type and 6 mixed type. The pain was the most frequent symptom (87.5%), 25% had pancreatitis. For the diagnosis 100% had CT scan, 90% MRI. 11 patients underwent pancreaticoduodenectomy, 4 distal pancreatectomy (1 laparoscopic) and 1 exploratory laparotomy. 2 patients had type C pancreatic fistula. 2 patients underwent reoperation, 1 had prolonged ICU stay (because of an intrahospitalary pneumonia), and 1 died. 7 patients had low grade dysplasia, 2 moderate dysplasia, 1 high grade dysplasia, 5 invasive carcinoma and 1 patient had lesion with low grade dysplasia and one concomitant adenocarcinoma of the pancreas. Conclusions: This entity is present in our country being more common in women. The branch type IPMN is the most frequent type. The pancreatic fistula is the most important complication and the mortality rate is low. The IPMN's malignacy potential founded was high.

Cystic and micropapillary epithelial changes of peribiliary glands might represent a precursor lesion of biliary epithelial neoplasms

A tumorigenic role of peribiliary glands (PBGs) has been suggested recently. This study was performed to clarify the histological characteristics of PBGs showing cystic and micropapillary epithelial changes. From histological sections of a total of 938 autopsy livers, cases with cystic and micropapillary changes of the epithelial cells of intrahepatic PBGs were collected. PBGs with cystic change that lacked micropapillary epithelial changes were referred to as cystic lesion. Mucin staining and immunohistochemical analysis were performed, and the results were compared between cystic and micropapillary (C-P) lesions and cystic lesions. C-P and cystic lesions were observed in 9 (1%) and 40 (4%) , respectively. The atypia of micropapillary epithelium was usually mild, but in a single case, invasive adenocarcinoma accompanied a C-P lesion. Abundant mucin expression was observed in all cases of C-P lesion, which was similar to mucinous acini of normal PBGs rather than serous acini. Immunohistochemical analysis showed that MUC5AC was more frequently expressed in C-P lesions than in cystic lesions. Immunohistochemical expression of cyclin D1 and S100P was characteristically found in C-P lesions. Mean Ki-67 labeling index of C-P lesions was significantly higher than that of cystic lesions. The immunoprofile of C-P lesions was similar to that of the branch-type intraductal papillary mucinous neoplasm of the pancreas. These results suggest that C-P lesions may have neoplastic features and might represent a precursor of biliary epithelial neoplasms, including branch-type intraductal papillary neoplasm of the bile duct as well as mucin-producing cholangiocarcinoma, a concept that we have recently proposed.

False pancreas divisum: a complication of post-endoscopic retrograde pancreatography pancreatitis

Pancreas divisum (PD) and meandering main pancreatic duct (MMPD) are common developmental variants of the pancreatic ductal system. They always appear in the head of the pancreas and are associated with idiopathic pancreatitis. The condition of these variants is rarely reported to have changed after birth. We present a rare case of false PD that occurred with alteration of loop-type MMPD after endoscopic retrograde pancreatography (ERP) and brush cytology followed by post-procedural pancreatitis. A 76-year-old female underwent pre-surgical ERP and brush cytology for an incidentally detected, expanding branch-type intraductal papillary mucinous neoplasm in the body of pancreas. The guidewire was inserted along the main pancreatic duct (MPD) and had uncoiled the loop-shaped MPD into a linear shape; soon afterwards, the patient developed post-procedural acute pancreatitis. Follow-up magnetic resonance cholangiopancreatography study 1 month later revealed the morphology of PD with an absent ventral duct. We hypothesize that inflammatory synechia had occluded the uncoiled ventral duct. This single case provides evidence that pancreatic ductal anatomy is flexible in some situations.

Laparoscopic single-branch resection of the pancreas for intraductal papillary mucinous neoplasm.

Although laparoscopic pancreatic resections have become more common, laparoscopic minimally invasive and function-preserving pancreatic resections have not been widely accepted. Branch-type intraductal papillary mucinous neoplasm (IPMN) has a low-grade malignant potential and shows a favorable prognosis. In branch-type IPMN, minimal resection techniques with preservation of the pancreatic functional reserve have advantages over the more conventional pancreaticoduodenectomy. We describe herein laparoscopic single-branch resection of the pancreas for branchtype IPMN. This surgical procedure is a novel and an ideal minimally invasive method for the resection of branch-type IPMN. In addition, our endoscopic nasopancreatic drainage (ENPD) tube-guided technique is useful for precise resection of the tumor and for the prevention of pancreatic fistula.

Comparison of International Consensus Guidelines Versus 18-FDG PET in Detecting Malignancy of Intraductal Papillary Mucinous Neoplasms of the Pancreas

To assess the reliability of the International Consensus Guidelines (ICG) and 18-fluorodeoxyglucose positron emission tomography (PET) in distinguishing benign from malignant intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. Since 2006 the ICG have been used to choose immediate surgery or surveillance for IPMN patients, but their low specificity increases the number of benign IPMNs that undergo resective surgery. PET has proved highly sensitive and specific in detecting malignancy in cystic neoplasms of the pancreas, including IPMNs. Patients suspected with IPMNs of the pancreas seen at our Department from January 1989 to July 2010 were identified and classified as cases of main duct, mixed type and branch type IPMN. The indication for resection or surveillance was verified a posteriori for all patients according to the ICG. PET was considered positive for a Standardized Uptake Value ≥2.5. Surveillance included clinical examination, laboratory tests, CA 19-9 serum levels, and computed tomography and/or magnetic resonance and magnetic resonance cholangiopancreatography every 6 months for 2 years and yearly thereafter. Endoscopic ultrasound was rarely performed. PET was repeated in clinically or radiologically suspect cases, or if tumor markers increased. Sixty-one main duct or mixed type and 101-branch type IPMNs were included in the study. A histological diagnosis was available for 81 of 162 patients, missing for 1 locally advanced IPMN, whereas 62 patients are under surveillance and it proved impossible to contact 18. Conservative surgery was performed in 16 of 68 patients with benign IPMNs. The sensitivity, specificity, positive and negative predictive value, and accuracy of the ICG in detecting malignancy were 93.2, 22.2, 59.4, 72.7, and 61.2, whereas for PET they were 83.3, 100, 100, 84.6, and 91.3. PET is more accurate than the ICG in distinguishing benign from malignant (invasive and noninvasive) IPMNs. Prophylactic IPMN resection in young patients fit for surgery should be guided by the ICG, whereas PET should be performed in older patients, cases at increased surgical risk, or when the feasibility of parenchyma-sparing surgery demands a reliable preoperative exclusion of malignancy.

Branch-Type Intraductal Papillary Mucinous Neoplasms: An Update

Background/Aims: Branch-type intraductal papillary mucinous neoplasms (BT-IPMNs) are a subset of non-inflammatory mucinous lesions of the pancreas. Selected BT-IPMNs can be managed conservatively by surveillance because of their lower malignant potential. This review aims to update the reader on advances in our knowledge of BT-IPMNs since the consensus guidelines published in 2006. Methods: A Pubmed search for BT-IPMNs was undertaken and relevant papers were reviewed. Results: Due to the relative scarcity of this condition, still little is known about the natural history, the best method of surveillance or the surgical and non-surgical options. Conclusion: A national database of BT-IPMNs would enable a large enough cohort of patients to be followed up and valid conclusions drawn regarding the best method of treatment or surveillance.

Incidental Cystic Neoplasms of Pancreas: What Is the Optimal Interval of Imaging Surveillance

The optimal interval of imaging studies for surveillance of incidental pancreatic cystic neoplasms is not known. A retrospective analysis of longitudinal medical records of patients with pancreatic cystic neoplasms was performed to examine the natural history of incidentally detected cystic pancreatic neoplasms with respect to the development of significant growth and to identify predictors of such growth. After excluding patients with small (<10 mm) cysts (N = 144) and inadequate clinical follow-up of less than 6 months (N = 79) and those with a clinical diagnosis of pancreatic pseudocysts, serous cystadenoma, main duct intraductal papillary mucinous neoplasm (N = 29), and neuroendocrine tumor (N = 3), in total, 166 cysts in 150 patients were available for analysis. The working diagnoses on these cysts (based on clinical, radiological features, aspiration cytology, cyst fluid analysis, and surgical pathology data when available) were mucinous cystic neoplasm in 117 and branch-type intraductal papillary mucinous neoplasm in 49. The mean standard error (SE) initial size of these cysts was 2 (0.1) cm. Over a median period of follow-up of 32 (IQR [inter-quartile range] 19-48) months, 89% of all the cysts did not show significant growth during the follow-up. In a multivariate Cox proportional hazards model, the initial size of the cystic lesion was an independent predictor of significant growth during follow-up (relative risk 1.28, 95% confidence interval [CI] 1.08-1.61, P= 0.01); the only other significant variable was the presence of intracystic or mural nodule (relative risk 38.6, 95% CI 2.3-654, P= 0.01). Most incidentally detected cystic neoplasms of the pancreas did not have significant growth during follow-up. Such growth is unlikely to occur before 2 yr of the baseline evaluation, and we suggest that the optimal imaging interval during follow-up of these patients should be at 2 yr from the baseline evaluation, particularly in cystic lesions 3.0 cm or less in size and without intracystic or mural nodules.

MANAGEMENT STRATEGIES FOR BRANCH DUCT INTRADUCTAL PAPILLARY‐MUCINOUS NEOPLASMS

Management strategies for branch duct intraductal papillary‐mucinous neoplasms (IPMN) have been discussed. The authors’ clinical criteria with special attention to the size of cystic lesion, the diameter of main pancreatic duct, and the size of mural nodule established in 2001 is useful for managing branch duct IPMN. A total of 55 of 60 cases with branch duct IPMN had no radiologic progression during an average follow up of 701 days. In addition, no case out of 27 cases with branch duct IPMN followed up for 3 years changed to positive in cytological examination using pancreatic juice. There were four cases of branch type IPMN with some changes in their image findings. There were two cases of branch type IPMN with pancreatic symptoms. A total of three out of these five cases were surgically resected. The ordinary‐type ductal carcinoma was detected in two cases with branch duct IPMN at 3 or 4 years later. These results suggest that a long‐term careful follow‐up study by computed tomography or ultrasonography at every 6 months would be needed in the management of branch duct IPMN. Further studies will be needed to dissolve this problem in the future.

Clinicopathological features and medical management of intraductal papillary mucinous neoplasms

Intraductal papillary mucinous neoplasms (IPMN) are a clinicopathological entity that is being diagnosed with increasing frequency. However, the best approach to medical management of IPMN needs to be clarified. The aim of the present study was to identify preoperative features that may be predictors of malignant IPMN, and to define the medical management of IPMN of the pancreas. A total of 23 patients who underwent surgical resection for IPMN of the pancreas at Kochi Medical School between 1982 and 2004 were examined. Multivariate Cox regression analysis was used to identify factors independently associated with IPM carcinoma. Among the 23 patients, 12 had IPMN adenoma, three had borderline IPMN, four had IPMN with carcinoma in situ, and four had IPMN with invasive carcinoma. In multivariate analysis, elevated serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 levels were found to be preoperative predictors of malignant IPMN. These results suggest that the following IPMN of the pancreas should be resected: (i) IPMN of the pancreas situated in the main duct; (ii) IPMN located in the branch duct if the size of the cystic lesion is >30 mm and the mural nodules are >5 mm in height by endoscopic ultrasound (EUS); and (iii) the diameter of the main pancreatic duct is >10 mm by endoscopic retrograde pancreatography (ERP). Careful observation of patients with branch-type IPMN with small cysts and/or without mural nodules is recommended as a management strategy. The present study reinforces the need for immediate surgical resection of malignant IPMN and suggests indicators for IPMN that should assist physicians in making decisions on treatment options.

Endoscopic naso-pancreatic stent-guided single-branch resection of the pancreas for multiple intraductal papillary mucinous adenomas

In benign or low-grade malignant pancreatic tumors, complete removal of the lesion is sufficient for a cure, and thus minimal resection techniques with preservation of the pancreatic functional reserve have advantages over more extended pancreatic resections. However, a high incidence of postoperative pancreatic fistula in such procedures has been reported. Moreover, branch-type intraductal papillary mucinous neoplasms of the pancreas tend to locate in the head of the pancreas, and show less malignant potential. We describe an endoscopic naso-pancreatic stent-guided single-branch resection of the pancreas for branch-type multiple intraductal papillary mucinous adenomas, along with a gastric wall-covering method for the prevention of pancreatic leakage.

Outcome of Duodenum-Preserving Resection of the Head of the Pancreas for Intraductal Papillary-Mucinous Neoplasm

Background: The standard surgical procedure for intraductal papillary-mucinous neoplasm of the pancreatic head is pylorus-preserving pancreatoduodenectomy. A less extensive resection may be justified because most intraductal papillary-mucinous neoplasms are benign or of low-grade malignancy. Aims and Methods: The outcome of duodenum-preserving pancreatic head resection with preservation of the main bile duct was evaluated retrospectively in 13 patients with a branch-type intraductal papillary-mucinous neoplasm in the head of the pancreas and with a median (range) follow-up of 60.0 (0.3–99.5) months. Results: Post-operative complications included anastomotic leakage (n = 3), bile duct perforation (n = 1), intra-abdominal bleeding (n = 3), delayed gastric emptying (n = 2) and death (n = 2). All the resection margins were clear of tumour on histological examination. Ten of 11 patients maintained over 90% of their pre-operative body weight. Glucose tolerance improved in 4 of 11 evaluable patients, was unchanged in 6 and worsened in 1 patient. Biliary scintigraphy showed that bile flow was delayed compared with that before surgery (8.8 ± 1.1 vs. 19.6 ± 4.6 min; p = 0.03). Neither recurrence nor metastasis was observed. Conclusion: The results of duodenum-preserving pancreatic head resection for branch duct-type intraductal papillary-mucinous neoplasm were satisfactory and provided a good quality of life.

Intraductal papillary mucinous neoplasm of the pancreas: diagnosis and treatment.

Intraductal papillary mucinous neoplasm (IPMN) is characterized by cystic dilatation of the main and/or branch pancreatic duct. Only one-third of all patients are symptomatic, and others are diagnosed by chance. IPMNs are classified into 3 types: main duct, branch duct, and mixed IPMN. Most branch-type IPMNs are benign, while the other 2 types are frequently malignant. The presence of large mural nodules increases the possibility of malignancy in all types. Presence of a large branch-type IPMN and marked dilatation of the main duct indicate, at the very least, the existence of adenoma. Ultrasonography, endosonography, and intraductal ultrasonography clearly demonstrate ductal dilatation and mural nodules, and magnetic resonance pancreatography best visualizes the entire outline of IPMN. Not infrequently, synchronous or metachronous malignancy develops in various organs, including the pancreas. Prognosis is excellent after complete resection of benign and noninvasive malignant IPMNs. Asymptomatic branch-type IPMNs without mural nodules may be followed up without resection. Malignant IPMNs displaying acquired aggressiveness after parenchymal invasion require adequate lymph node dissection. Total pancreatectomy is needed for some IPMNs; its benefits, however, must be balanced against operative and postoperative risks because most IPMNs are slow growing and affect elderly people, and prognosis is favorable for IPMN patients with even malignant neoplasms.