Duct-type Intraductal Papillary Mucinous Neoplasm Research Articles

Predictors of early stages of histological progression of branch duct IPMN.

An appropriate timing for surgical resection of branch duct-type intraductal papillary mucinous neoplasm (BD-IPMN) to achieve sufficient postoperative survival is still unknown. Of 80 patients with histologically proven IPMNs, 61 patients who had BD-IPMN without pancreatic cancer concomitant with IPMN were enrolled in this study. We divided BD-IPMN into four groups according to disease progression: low to intermediate grade of dysplasia (LGD/IGD-IPMN), high grade of dysplasia (HGD-IPMN), minimally invasive IPMN (MI-IPMN: T1a), and invasive IPMN (IN-IPMN: ≥T1b). Indicators of surgical resection were investigated on the basis of pathological findings and postoperative prognosis. Postoperative survival was distinctly worse for patients with IN-IPMN than for patients with MI-IPMN, HGD-IPMN, and LGD/IGD-IPMN. Postoperative disease-specific 5-year survival rate was 100 % in patients with IN-IPMN, HGD-IPMN, and LGD/IGD-IPMN, by contrast, 40 % in patients with IN-IPMN. The presence of two of the three factors (pancreatitis, serum carbohydrate antigen [CA] 19-9 levels >13 U/mL, and mural nodules) could distinguish HGD-IPMN from LGD/IGD-IPMN with a sensitivity of 92.9 %, specificity of 90.2 %, positive predictive value of 76.5 %, negative predictive value of 97.4 %, and accuracy of 90.9 %. To manage patients with BD-IPMN and achieve a good postoperative prognosis, surgical resection should be performed before progression to IN-IPMN.

Surgical treatment and prognosis of 96 cases of intraductal papillary mucinous neoplasms of the pancreas: A retrospective cohort study

Introduction: The indications, the extent and type of surgery for intraductal papillary mucinous neoplasm (IPMN) are still controversial. This study aimed to investigate clinical manifestation, individualized surgical treatment, and prognosis of IPMN of pancreas. Methods: The clinical data of 96 IPMN cases treated in our hospital between January 2006 and December 2013 were retrospectively analyzed. Among the 96 patients (58 male and 38 female), 46 were main-duct type, 29 were branch-duct type, 21 were mixed type. Pancreatectomy was performed on 78 cases, including pancreaticoduodenectomy on 43 patients, distal pancreatectomy on 25, segmental pancreatectomy on 6, and total pancreatectomy on 4. A regular follow-up without surgical treatment was performed on 18 cases with asymptomatic side branch IPMN less than 3 cm in diameter. Results: The overall postoperative morbidity rate was 33.3%, and there was no perioperative mortality. 46 cases were non-invasive IPMN, 32 cases were invasive IPMN including 14 cases with lymph node metastasis. The five-year survival rate for patients with non-invasive and invasive carcinomas was 96.2% and 35.2%, respectively. The prognosis of invasive cases with lymph node metastasis was significantly worse than those without lymph node metastasis. No progression was found during the follow-up in 18 asymptomatic small branch duct type IPMN patients. Conclusion: IPMN has a relative good prognosis. Main duct type and mixed type IPMN have a higher malignant potential, and should receive surgical treatment. Patients of branch duct type IPMN with lesion <3 cm in diameter and without clinical manifestations can be managed with close follow-up.

Prediction of Malignancy With Endoscopic Ultrasonography in Patients With Branch Duct–Type Intraductal Papillary Mucinous Neoplasm

We evaluated the accuracy of a new endoscopic ultrasonography (EUS) scoring system to predict malignancy in branch duct-type intraductal papillary mucinous neoplasms (BD-IPMNs). We performed a retrospective multicenter study of patients who underwent EUS within 3 months before surgery and were diagnosed as having BD-IPMNs by postoperative pathologies at 8 hospitals in Korea from August 2002 to December 2011. To predict the malignancy, we applied the EUS scoring system consisting of pancreatic cyst size, height of mural nodules, main duct dilatation, septal thickening, and patulous orifice. We evaluated the diagnostic accuracy of the new EUS scoring system and compared it with previous individual risk factors. Eighty-four patients (male-to-female ratio, 55:29; mean [SD] age, 64.7 [7.1] years) had 68 benign BD-IPMNs and 16 malignant intraductal papillary mucinous neoplasms. The EUS scoring system showed 75.0% sensitivity and 94.1% specificity at 7 points. This system (area under the curve, 0.939; 95% confidence interval, 0.884-0.994) resulted in a more accurate prediction than the previous known other factors including Sendai criteria, dilatation of ducts, size of the cyst, and presence of septal thickening and mural nodules. The EUS scoring system predicted BD-IPMN malignancy more accurately than the Sendai criteria and individual risk factors.

Risk factors for malignancy in branched-type intraductal papillary mucinous neoplasms of the pancreas during the follow-up period.

The international consensus guidelines for the management of intraductal papillary mucinous neoplasm (IPMN) of the pancreas were revised in 2012 Tanaka (Pancreatology 12(3):183-197, 2012), making the indications for operation less aggressive. Therefore, the number of branch duct-type IPMN (BD-IPMN) patients requiring follow-up care is expected to increase in the future. The aim of this study was to identify risk factors for malignancy in BD-IPMN patients during the follow-up period. This study included 47 BD-IPMN patients without a mural nodule (MN) at the time of initial diagnosis and who subsequently underwent resection after a follow-up period of more than 3 months. Data for the patients were reviewed retrospectively, and the clinicopathological factors were investigated. In a univariate analysis, age (≧ 65 years), an increase in the main pancreatic duct (MPD) diameter, the MPD diameter at resection (≧ 5 mm), and the occurrence of MN were significantly associated with malignancy. The occurrence of MN was the only significant factor in a multivariate analysis. In addition, 7 of the 17 patients (41.2 %) who only exhibited an increase in the cyst diameter during the follow-up period were diagnosed as having malignancies. All 6 patients who exhibited an increase in the cyst diameter of 100 % or more were diagnosed as having carcinoma. During the follow-up period, the incidence of malignancy was higher among patients with BD-IPMNs and the occurrence of MN, an increase in the MPD diameter, or an increase ratio of 100 % or more in cyst diameter than the others; resection was recommended for these patients.

Mo1432 Smart Atlas for Supporting the Interpretation of Needle-Based Confocal LASER Endomicroscopy (nCLE) of Pancreatic Cysts: First Classification Results of a Computer-Aided Diagnosis Software Based on Image Recognition

nCLE enables microscopic imaging of pancreatic cysts, in vivo and in real time, during an EUS-FNA procedure. Differentiating branch duct-type Intraductal Papillary Mucinous Neoplasm (IPMN) and Serous Cystadenoma (SCA) of the pancreas can be difficult, especially in case of a solitary lesion without clear communication with the pancreatic duct. Recent studies (Konda et al., Endoscopy 2013; Napoléon et al., DDW 2013) have identified reliable nCLE descriptive features (superficial vascular network in SCA; finger-like projections in IPMN), allowing endoscopists to discriminate between SCA and IPMN.

Validation of international consensus guidelines for the resection of branch duct-type intraductal papillary mucinous neoplasms

Classifications of intraductal papillary mucinous neoplasm (IPMN) remain ambiguous, especially for the mixed type. Factors predicting malignancy remain unclear. The aim of this study was to evaluate the usefulness of factors predicting malignancy in the new international consensus guidelines for resection of branch duct-type (BD)-IPMN and to compare them with those in the previous version. A prospectively collected database of patients with biopsy-proven BD-IPMN was analysed to compare factors between the first and second consensus guidelines, particularly as predictors of malignancy. Of 350 patients with BD-IPMN, sensitivity (0.724) and balanced accuracy (0.751) of the second guidelines were superior to those (0.639 and 0.730) in the first version at the expense of slightly reduced specificity (0.779 versus 0.822 for the first version) by random forest models. Multiple logistic regression analysis showed that main pancreatic duct dilatation greater than 5 mm (hazard ratio (HR) 4.54, 95 per cent confidence interval 2.45 to 8.41; P < 0.001), mural nodules (HR 6.27, 3.27 to 12.01; P < 0.001) and carbohydrate antigen 19-9 level above 37 units/ml (HR 4.03, 1.83 to 8.90; P = 0.001) were independent predictors of BD-IPMN malignancy. The new consensus guidelines provide better sensitivity, performance of factors predicting malignancy, and balanced accuracy in the diagnosis of BD-IPMN malignancy. Size alone was limited in predicting malignancy. Variability in clinical significance of the individual factors associated with a risk of malignancy indicates the need for a tailored approach in the management of patients with BD-IPMN.

A Case of Acute Recurrent Pancreatitis Caused by Branch Duct Type IPMN and Ampulla of Vater Adenoma with High Grade Dysplasia

Acute pancreatitis is an inflammatory disease that can extend to extra-pancreatic tissues and distant organs. Detecting the underlying cause is important because it helps provide an appropriate treatment plan and improve prognosis. An underlying cause cannot be identified after initial evaluation in 10-30% of patients with acute pancreatitis, and they are diagnosed with idiopathic acute pancreatitis. Here, we report a case of a 77-year-old woman with acute recurrent pancreatitis caused by a branch duct-type intraductal papillary mucinous neoplasm (IPMN) and an ampulla of Vater adenoma. Abdominal computed tomography and magnetic resonance cholangiopancreatography revealed only IPMN. However, endoscopic retrograde cholangiopancreatography revealed a mucosal abnormality of the ampulla of Vater. The mucosal abnormality was documented to be an ampulla of Vater adenoma with high-grade dysplasia. (Korean J Med 2014;87:579-584)

Imaging pitfalls of pancreatic serous cystic neoplasm and its potential mimickers.

The aim of this article is to clarify diagnostic pitfalls of pancreatic serous cystic neoplasm (SCN) that may result in erroneous characterization. Usual and unusual imaging findings of SCN as well as potential SCN mimickers are presented. The diagnostic key of SCN is to look for a cluster of microcysts (honeycomb pattern), which may not be always found in the center. Fibrosis in SCN may be mistaken for a mural nodule of intraductal papillary mucinous neoplasm (IPMN). The absence of cyst wall enhancement may be helpful to distinguish SCN from mucinous cystic neoplasm. However, oligocystic SCN and branch duct type IPMN may morphologically overlap. In addition, solid serous adenoma, an extremely rare variant of SCN, is difficult to distinguish from neuroendocrine tumor.

O2–023 - The Clinical Features of Branch Duct Type Ipmns of the Pancreas with Classification of Histological Subtypes

Background: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are divided into two types, the main duct type and the branch duct type. Generally, the branch duct type grows slowly and has a good prognosis compared to the main branch type. According to International consensus guidelines for the management of IPMN, if lesion is < 10mm in size, the interval between follow-up examination would appear reasonable to be every 2-3 years. However, there were reportedly some cases of the branch duct type IPMNs were known to show rapidly growing and progression to malignancy. Recently, IPMNs of the pancreas are classified into 4 types-gastric (G type), intestinal (I type), pancreatobiliary (PB type), and oncocytic (O type) on the basis of their morphology and immunohistochemistry. The G types and I types are known to have less malignant potential than that of the PB type, and invasive carcinomas derived from two types is known to be less invasive and slower growing than those derived from the PB type. But we have had no minute examination of the clinical features of each type. So, we investigated the resected cases of 22 patients with branch duct type IPMNs, which were classified into 4 types and compared with the speed of cystic lesion with IPMNs and the frequency of invasive carcinoma of each type. Methods: We classified the 22 patients with branch duct type IPMNs resected between January 2005 and February 2012 in our institutes, into 4 types on the basis of their morphology and immunohistochemistry, and revealed the speed of cystic lesion with IPMNs and the frequency of invasive carcinoma of each type. Results: Fifteen patients (68%) were G type, 4 patients (18%) were I type, 3 patients (14%) were PB type. There is no patient of O type. Their median age was 73.2 years (range 57-84), 77 years (range 64-84), and 71.3 years (range 59-79), respectively. The frequency of invasive adenocarcinoma derived from IPMN was 2/15 (13%), 1/4 (25%), and 3/3 (100%) respectively. The growing speed of cystic lesion of patients who could be observed over 1 year (mean ± SD mm/year) was 3.0 ± 0.9, 3.54 ± 1.6, and 15.2 ± 9.2 respectively (p < 0.05). Conclusion: PB type showed rapid growing and high frequent progression to malignancy compared to G and I type. Our findings suggest that PB type should be followed for shorter period.

Invasive carcinoma derived from branch duct-type IPMN may be a more aggressive neoplasm than that derived from main duct-type IPMN

The present study aimed to evaluate the long-term follow-up results of patients with intraductal papillary mucinous neoplasm (IPMN) and to estimate the degree of IPMN malignancy based on pathological and molecular features of resected specimens. The detection rate of IPMN has increased over the last decade; however, the management of this neoplasm remains controversial. This is particularly so for branch duct-type IPMN, which carries a high potential for malignancy and risk of recurrence. We retrospectively reviewed a single institution’s prospective pancreatic resection database to identify IPMN patients who underwent pancreatectomy with curative intent. The clinicopathological variables of 100 patients resected for IPMN were analyzed with a detailed review of histopathological results (borderline lesions, non-invasive carcinoma and invasive carcinoma) to determine the grade of IPMN malignancy based on transforming growth factor (TGF)-β/SMAD4 signaling. The incidence of malignant change was significantly higher in patients with main duct-type IPMN (69.7%) compared with branch duct-type IPMN cases (17.9%). However, patients with an invasive carcinoma had a significantly worse outcome if it was derived from branch duct-type IPMN compared with those derived from main duct-type IPMN, and TGF-β mRNA expression was significantly increased in the former patient group. Immunohistochemistry also showed higher numbers of SMAD4-positive cells in patients with carcinoma derived from branch duct-type IPMN. Our results demonstrated that invasive carcinoma derived from branch duct-type IPMN is more aggressive than that derived from main duct-type IPMN, once invasive morphological change takes place. Determining TGF-β and/or SMAD4 status at initial diagnosis may be useful for stratifying IPMN patients into treatment regimens.

Localized type 1 autoimmune pancreatitis superimposed upon preexisting intraductal papillary mucinous neoplasms

A 70-year-old woman was found to have 2 cystic lesions in the head of the pancreas on abdominal ultrasonography during a routine medical examination. Endoscopic ultrasonography (EUS) and magnetic resonance cholangiopancreatography showed multilocular cysts in the head of the pancreas without dilation of the main pancreatic duct. The patient was followed-up semiannually with imaging studies for suspected branch duct-type intraductal papillary mucinous neoplasm (IPMN). At 3 years after initial presentation, hypoechoic lesions were observed around each pancreatic cyst by EUS. Diffusion-weighted imaging showed high-intensity regions corresponding to these lesions. Therefore, a diagnosis of invasive carcinoma derived from IPMN could not be excluded, and subtotal stomach-preserving pancreaticoduodenectomy was performed. The macroscopic examination of the surgical specimen showed whitish solid masses in the head of the pancreas, with multilocular cysts within each mass. Microscopically, each solid mass consisted of inflammatory cells such as lymphocytes and plasma cells. Furthermore, immunochemical staining revealed immunoglobulin G4-positive cells, and many obliterating phlebitides were observed. The cysts consisted of mucus-producing epithelial cells and showed a papillary growth pattern. Based on these findings, we diagnosed multiple localized type 1 autoimmune pancreatitis occurring only in the vicinity of the branch duct-type IPMN.

Predictive Factors for the Increase in Size of Branch Duct-type Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Retrospective Cohort Study with a 6-year Follow-Up

Predictive Factors for the Increase in Size of Branch Duct-type Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Retrospective Cohort Study with a 6-year Follow-Up

Malignant Transformation of Branch Duct–Type Intraductal Papillary Mucinous Neoplasms of the Pancreas Based on Contrast-Enhanced Endoscopic Ultrasonography Morphological Changes

The natural history of branch duct-type intraductal papillary mucinous neoplasms (BD-IPMNs) of the pancreas remains unclear. We conducted a retrospective long-term follow-up study for malignant transformation (MT) of BD-IPMNs focusing on morphological changes. The subjects consisted of 142 patients who underwent contrast-enhanced endoscopic ultrasonography for initial diagnosis from January 2001 with more than 12 months of follow-up. The MT rate, including the co-occurrence of invasive ductal cancer, was evaluated by univariate and multivariate analysis. In addition, on the basis of morphological changes in patients who underwent surgery, the predictive factors for malignant IPMNs were evaluated. Median follow-up term was 42.5 months (range, 12-105 months). Thirty patients who exhibited morphological changes underwent surgery. Malignant transformation occurred in 9 patients (6.3%), and 5-year MT rate was 10.7%. The co-occurrence of invasive ductal cancer was seen in 5 patients. Multivariate analysis showed that the existence of mural nodules at initial diagnosis and involvement of main pancreatic duct were significant predictors of MT of BD-IPMN. Malignant transformation of BD-IPMN is not rare. The observation of morphological changes of main pancreatic duct and nodules, mainly on contrast-enhanced endoscopic ultrasonography, is practical and useful for predicting MT of BD-IPMN itself.

Surgical Strategy for Main Pancreatic Duct-Type Intraductal Papillary Mucinous Neoplasm of the Pancreas

Although surgical resection is recommended for all main duct-type intraductal papillary mucinous neoplasms (IPMNs), controversies remain over the precise surgical strategy that should be adopted. This study thus aimed to investigate the appropriate surgical strategy for main duct IPMNs. We retrospectively evaluated 46 patients with main duct-type IPMNs who underwent surgical resection at a single center between 1991 and 2010. Only 1 patient underwent total pancreatectomy (TP). Three patients underwent repeated pancreatectomy; TP was performed after distal pancreatectomy (DP) in 2 of these patients and after pylorus-preserving pancreaticoduodenectomy (PPPD) in the remaining patient. There current histology indicated minimally invasive carcinoma in all 3 of these patients. Among the 6 patients who died in the present study, no deaths occurred due to local recurrence of the remnant pancreas. Total pancreatectomy should be considered very selectively in the presence of a malignant lesion spreading to the whole pancreas.

Mo1196 Risk Factors for the Development of Pancreatic Ductal Adenocarcinoma During the Follow-up of Branch Duct-Type Intraductal Papillary Mucinous Neoplasms of the Pancreas

Background: Branch duct-type intraductal papillary mucinous neoplasm (BD-IPMN) is a risk factor for pancreatic ductal adenocarcinoma (PDAC), but the groups at high risk for developing PDAC during the follow-up period of BD-IPMN are not clear. Objectives: To identify the risk factors for PDAC development during the follow-up period of BD-IPMN. Subjects and Methods: We investigated 230 patients undergoing follow-up of BD-IPMN; the median follow-up period was 56.9 months, and the range was 3-276 months. Among these patients, 10 developed pancreatic cancer (PDAC, 7; intraductal papillary mucinous carcinoma [IPMC], 3). The 230 patients were divided into 2 groups: PDAC group, which included 7 patients; and non-PDAC group, which included 223 patients. The PDAC and non-PDAC groups were compared with respect to the following factors: sex; age; follow-up period; number of BD-IPMNs; size of BD-IPMNs; diameter of the main pancreatic duct (MPD); size of mural nodules; family history of pancreatic cancer (within the second degree of relationship); family history of digestive organ cancer, except pancreatic cancer (within the second degree of relationship); diabetes mellitus; adiposis (body mass index [BMI] ≥ 30 kg/m2); chronic pancreatitis; and history of smoking. A chi-square test and a t test were used for univariate analysis, and logistic regression was used for multivariate analysis. Results:Univariate analysis showed that adiposis (p = 0.016), chronic pancreatitis (p = 0.038), and a family history of pancreatic cancer (p = 0.006) were the factors significantly associated with PDAC development. Multivariate analysis of these 3 factors showed that adiposis (p = 0.000, odds ratio = 60.93, 95% confidence interval [CI] = 6.18-599.92), chronic pancreatitis (p = 0.023, odds ratio = 13.0, 95% CI = 1.42-119.35), and a family history of pancreatic cancer (p = 0.003, odds ratio = 21.1, 95% CI = 2.87-156.49) were independently associated with PDAC development. Conclusions: Our results showed that adiposis (BMI ≥ 30 kg/ m2), chronic pancreatitis, and a family history of pancreatic cancer (within the second degree of relationship) were risk factors for PDAC development during the follow-up period of BD-IPMN patients.

Mo1197 PRSS1 G208a and SPINK1 Ivs3+2t>C Were Prevalent in Korean Patients With Idiopathic or Familial Pancreatitis

Background: Branch duct-type intraductal papillary mucinous neoplasm (BD-IPMN) is a risk factor for pancreatic ductal adenocarcinoma (PDAC), but the groups at high risk for developing PDAC during the follow-up period of BD-IPMN are not clear. Objectives: To identify the risk factors for PDAC development during the follow-up period of BD-IPMN. Subjects and Methods: We investigated 230 patients undergoing follow-up of BD-IPMN; the median follow-up period was 56.9 months, and the range was 3-276 months. Among these patients, 10 developed pancreatic cancer (PDAC, 7; intraductal papillary mucinous carcinoma [IPMC], 3). The 230 patients were divided into 2 groups: PDAC group, which included 7 patients; and non-PDAC group, which included 223 patients. The PDAC and non-PDAC groups were compared with respect to the following factors: sex; age; follow-up period; number of BD-IPMNs; size of BD-IPMNs; diameter of the main pancreatic duct (MPD); size of mural nodules; family history of pancreatic cancer (within the second degree of relationship); family history of digestive organ cancer, except pancreatic cancer (within the second degree of relationship); diabetes mellitus; adiposis (body mass index [BMI] ≥ 30 kg/m2); chronic pancreatitis; and history of smoking. A chi-square test and a t test were used for univariate analysis, and logistic regression was used for multivariate analysis. Results:Univariate analysis showed that adiposis (p = 0.016), chronic pancreatitis (p = 0.038), and a family history of pancreatic cancer (p = 0.006) were the factors significantly associated with PDAC development. Multivariate analysis of these 3 factors showed that adiposis (p = 0.000, odds ratio = 60.93, 95% confidence interval [CI] = 6.18-599.92), chronic pancreatitis (p = 0.023, odds ratio = 13.0, 95% CI = 1.42-119.35), and a family history of pancreatic cancer (p = 0.003, odds ratio = 21.1, 95% CI = 2.87-156.49) were independently associated with PDAC development. Conclusions: Our results showed that adiposis (BMI ≥ 30 kg/ m2), chronic pancreatitis, and a family history of pancreatic cancer (within the second degree of relationship) were risk factors for PDAC development during the follow-up period of BD-IPMN patients.

The Carcinoembryonic Antigen Level in Pancreatic Juice and Mural Nodule Size Are Predictors of Malignancy for Branch Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas

Identification of predictors of malignancy for branch duct type intraductal papillary mucinous neoplasms (IPMN). Main duct type IPMN has been recommended for resection. However, the indications for resection of the branch duct type IPMN have been controversial. We retrospectively analyzed the clinicopathological factors of 134 patients undergoing resection for branch duct type IPMN, excluding main duct type IPMN, to identify predictors of the malignant behavior of this neoplasm. The cutoff values of tumor size, main pancreatic duct (MPD) size, mural nodule size, and carcinoembryonic antigen (CEA) level in the pancreatic juice obtained during preoperative endoscopic retrograde pancreatography (ERP) were analyzed using receiver-operator characteristic curves. We found 7 significant predictors for malignancy in the branch duct type IPMN in a univariate analysis; jaundice, tumor occupying the pancreatic head, MPD size >5 mm, mural nodule size >5 mm, serum carbohydrate antigen (CA)19-9 level, positive cytology in the pancreatic juice, and CEA level in the pancreatic juice >30 ng/mL. In a multivariate analysis, a mural nodule size >5 mm and a CEA level in the pancreatic juice >30 ng/mL were independent factors associated with malignancy. The positive predictive value of a mural nodule size >5 mm and a CEA level in the pancreatic juice >30 ng/mL was 100%, and the negative predictive value was 96.3%. We identified 2 useful predictive factors for malignancy in branch duct type IPMN; a mural nodule size >5 mm and a CEA level in the pancreatic juice obtained by preoperative ERP >30 ng/mL.

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.

Mural nodule in branch duct–type intraductal papillary mucinous neoplasms of the pancreas is a marker of malignant transformation and indication for surgery

BackgroundThe management of branch duct–type intraductal papillary mucinous neoplasms (IPMNs) remains controversial. This study aimed to elucidate the preoperative clinical factors that identify high-risk malignant transformation in branch duct–type IPMN. MethodsWe retrospectively evaluated 38 patients diagnosed with branch duct–type IPMN who underwent pancreatectomy, identifying different preoperative factors between adenoma (intraductal papillary mucinous adenoma [IPMA]) and carcinoma (intraductal papillary mucinous carcinoma [IPMC]). ResultsTwelve patients were diagnosed with IPMC. The mean tumor size was 31.9 ± 11.8 mm for IPMA and 35.7 ± 17.1 mm for IPMC (P = .467). No significant differences were found between IPMA and IPMC patients with regard to age, sex, symptoms, and tumor number. The mean diameter of the main pancreatic duct was significantly larger in IPMCs (8.3 ± 5.9 mm) compared with IPMAs (4.7 ± 2.3 mm; P = .011). The mural nodule was a good predictor of malignancy (P = .0002) and was identified as the only independent and significant marker of IPMC in multivariate analysis. ConclusionsThe presence of mural nodules is a potentially suitable marker for differentiating IPMC from IPMA, and is important for making decisions about surgical interventions.

Use of endoscopic ultrasound scoring to estimate the malignant potential of branch duct type intraductal papillary-mucinous neoplasms of the pancreas.

182 Background: Intraductal papillary-mucinous neoplasms (IPMNs) of the pancreas are characterized by intraductal papillary epithelial growth, mucin hypersecretion, and cystic dilation of main or branch pancreatic ducts. However, it is still difficult to differentiate between benign and malignant, when it only involves the branch duct. The purpose of this study was to evaluate the role of endoscopic ultrasound (EUS) scoring in predicting malignancy in branch-duct type IPMNs, thus providing a convenient guideline to a clinician before considering surgical resection. Methods: We retrospectively reviewed all patients between Dec 1997 and April 2010 who underwent diagnostic and/or preoperative EUS for IPMNs. Borderline malignancy and invasive carcinoma were defined as a malignancy. Results: Of the 32 patients (mean age, 62 years), 13 male and 19 female were identified. Twelve people underwent operation, and there were 23 benign cases, and 9 malignant cases (borderline, n=6; invasive carcinoma, n=3). Among the six parameters (age, cyst size, mural nodule, associated main pancreatic duct dilation, patulous opening, thick septum) that have been known as important parameters for predicting malignancy in main duct type IPMNs, four were significant by Fisher's exact tests—namely, cyst size (p=.002), mural nodule (p =.003), associated main pancreatic duct dilation (p =.001), patulous opening (p =.05). In sizing the cysts, we scored 0 (cyst size ≤10 mm), 1 (11-20 mm), 2 (21-30 mm), 3 (&gt;30 mm). In sizing the mural nodules, we scored 0 (no mural nodule), 1 (&lt;5 mm), 2 (5-&lt;10 mm), 3 (≥10 mm). For main pancreatic duct dilation, we scored 2, if there presented any associated main pancreatic duct dilation, and 0 if not. For the patulous opening, we scored 1 for present, 0 for not. Patients were dispersed from the highest score nine, to the lowest score zero. Mean score for benign cases was 2.47 (±1.59 SD), and 6.33 (±1.87 SD) for malignant cases (p =.001). Conclusions: We strongly recommend a radical surgery for patients scoring above 7(score 7, 8, 9), and a consideration of operation for scoring between 4 and 6, and careful follow up for scoring below 3. No significant financial relationships to disclose.