Intraductal Growth Research Articles

Intrahepatic cholangiocarcinoma: macroscopic type and stage classification.

The Liver Cancer Study Group of Japan established a classification of macroscopic type and the TNM staging of intrahepatic cholangiocarcinoma (ICC). With the observation of more than 240 resected cases of ICC, three fundamental types were established. They were: (1) mass-forming (MF) type, (2) periductal-infiltrating (PI) type, and (3) intraductal growth (IG) type. The MF type forms a definite mass, located in the liver parenchyma. The PI type is defined as ICC which extends mainly longitudinally along the bile duct, often resulting in dilatation of the peripheral bile duct. The IG type proliferates toward the lumen of the bile duct papillarily or like a tumor thrombus. The TNM classification of ICC was then designed, using 136 cases of the MF type resected curatively between 1990 and 1996 at member institutes. Univariate and multivariate analyses showed: (1) tumor 2 cm or less, (2) single nodule, and (3) no vascular and serous membrane invasion as prognostic factors. T factors were defined as follows: T1 is an ICC that meets all requirements of factors (1), (2), and (3); T2 meets two of the three requirements, T3 meets one of the three requirements and T4 meets none of the three requirements. Our data did not support the idea that the hepatoduodenal lymph node is regional. The N factors were defined as N0 no lymph node metastasis; and N1, positive at any nodes. Thus, the stages of ICC were defined as stage I, T1N0M0; stage II, T2N0M0; stage III, T3N0M0; stage IVA, T4N0M0 or any TN1M0; and stage IVB, any T any NM1.

Extended hepatic resection and outcomes in intrahepatic cholangiocarcinoma.

The aim of this report was to assess the outcome of aggressive surgical treatment for intrahepatic cholangiocarcinoma. From 1984 to 2001, we encountered 64 patients with intrahepatic cholangiocarcinoma. Of the 64 patients, 50 patients who underwent surgical resection with macroscopically curative objectives (78%) were reviewed for surgical procedures and outcomes. Hemi- or more extensive hepatectomy was required for surgical resection in 40 patients (80%). Overall hospital morbidity and mortality rates were 50% and 8%, respectively. Curative resection with pathological free margins was achieved in 34 patients (68%). The 1-, 3-, and 5-year patient survival and tumor-free survival rates were 61.6%, 37.6%, and 22.5%; and 55%, 11%, and 11%, respectively. Among the macroscopic types, all 9 patients with intraductal growth type are alive 11-75 months after surgery. Survival rates among patients who had undergone curative resection were significantly better than those in patients who had undergone noncurative resection, even when patients with the intraductal growth type were excluded. Nodal status did not affect patient survival. Although the overall survival rate after surgical resection remains unsatisfactory, long-term survival is possible through extended surgical resection with pathological free margins. Patients with the intraductal growth type of intrahepatic cholangiocarcinoma might have the best chance of being cured by surgical treatment.

Neuroendocrine differentiated carcinomas of the breast: a distinct entity

Some primary carcinomas of the breast have been classified as neuroendocrine. In this paper we report on 12 cases of neuroendocrine carcinoma of the breast displaying common and uncommon histological features.Materials and methods: All patients were aged from 43 to 79 (median 66.5) years. The tumors were unilateral and ranged from 0.8 to 7cm (median 2.35cm) in diameter. Four tumors were classified as solid cohesive, two as solid papillary, one as Merkel cell-like, two as cellular mucinous, two as cellular mucinous with micropapillary features and one as cellular mucinous with prominent signet ring cells. The tissues were fixed in formalin and routinely processed. All materials were stained with PAS, Alcian blue and also hematoxylin and eosin. Immunohistochemical examination was carried out by the avidin–biotin method using the following antibodies: estrogen receptor protein, progesterone receptor protein, p53, cerbB-2, Ki67, neuron-specific enolase, chromogranin, and synaptophysin.Results: In all cases the tumor cells were stained positively with NSE. Synaptophysin and chromogranin positivity was detected in 11 and five cases, respectively. The prominent histological features were: extensive intraductal growth, pseudorosettes and palisades, low-grade cytologic atypia, plasmacytoid appearance of the tumor cells, and intracellular and extracellular mucin.Conclusion: Neuroendocrine-differentiated carcinoma of the breast is a rare and distinct category with different histological subtypes.

Results of surgical treatment for intrahepatic cholangiocarcinoma and clinicopathological factors influencing survival.

The results of surgical treatment for intrahepatic cholangiocarcinoma (ICC) and specific factors influencing survival are still unclear. Between 1984 and 2001, 62 patients with ICC underwent laparotomy, with a 77 per cent (48 patients) resectability rate. The tumours in these 48 patients were reviewed retrospectively to examine the relationship between gross appearance (mass forming, periductal infiltrating, intraductal growth, and mass forming plus periductal infiltrating) and patient survival, as well as the manner of recurrence. In patients with mass-forming and mass-forming plus periductal infiltrating types, univariate and multivariate analyses of potential prognostic factors were performed. The 1-, 3- and 5-year survival rates were 62, 38 and 23 per cent respectively. All patients with the intraductal growth type remained alive after intervals ranging from 8 to 72 months. Univariate analysis showed multiple hepatic lesions, liver capsule invasion, presence of cancer cells in the resection margin, and high serum carbohydrate antigen (CA) 19-9 level to be significant negative prognostic factors. Lymph node involvement, however, was not identified as a significant prognostic factor. With multivariate analysis, multiple hepatic lesions and high serum CA19-9 concentration were found to be significantly related to prognosis. The most frequent recurrence site was the remnant liver. These results suggest that the intraductal growth type of tumour should be treated as a distinct entity compared with other types of ICC. Multiple tumours and high serum CA19-9 level were signs of dismal prognosis, whereas not all patients with lymph node involvement had a poor prognosis.

Clinical outcomes and apomucin expression of intrahepatic cholangiocarcinoma according to gross morphology.

The clinicopathologic characteristics and the expression of apomucin (MUC) in intrahepatic cholangiocarcinoma (ICC) with respect to gross morphology have not been comprehensively examined. We reviewed the clinical data of 98 patients with ICC who underwent resection at Seoul National University Hospital from 1980 to 1998. We also examined the expression profiles of MUC1 and MUC2 in 30 ICC tissues by immunohistochemistry using mouse monoclonal antibodies. Of 98 cases, 42 were of the mass-forming type of ICC, 22 were of the periductal-infiltrating type, 21 were of the intraductal-growth (IG) type, and 13 were of the mixed type, and the overall 5-year cumulative survival rate was 23.3% in the mass-forming type, 0% in the periductal-infiltrating type, and 76.2% in the IG type. MUC1 was expressed in all types (mass-forming type 75.0%, periductal-infiltrating type 100%, and IG type 73.3%), but significantly, MUC2 was expressed only in the IG type (80.0%), which had better prognosis than the other types. It is apparent that the IG type of ICC should be distinguished from the other types of ICC because a favorable prognosis can be expected after complete surgical resection.

Hepatic intraductal oncocytic papillary carcinoma.

There has been an increasing incidence and mortality from peripheral cholangiocarcinoma (PC) in the United States over the past 24 years. PC has been classified into two principal types, a mass-forming type and a periductal-infiltrating type, with a significant difference in the clinical behavior between the two. A third type, demonstrating a noninvasive intraductal growth of PC, was described as papillary PC. Rarely, papillary hepatic tumors composed of oncocytic cells have been described. Intraductal oncocytic papillary carcinomas (IOPCs) of the liver present as large, mucin-filled, cystic lesions lined by noninvasive or focally microinvasive oncocytic tumors. From June 1999 to August 2001, three patients with hepatic IOPCs were identified in the files of the Hepatobiliary Service, Department of Surgery, and the Department of Pathology at Memorial Sloan-Kettering Cancer Center. They form the basis of this study. We report the clinicopathologic presentation, as well as the outcome, with a review of the literature. All three cases presented with well defined intrahepatic cystic masses ranging in size from 7.2 to 21.1 cm. The most prominent cells of the lining epithelium were columnar with oncocytic features showing abundant eosinophilic granular cytoplasm and centrally located nucleoli. All three patients underwent resection with one demonstrating local bile duct recurrence that was managed with stenting. Review of the literature has identified 39 patients with papillary PC and 2 patients with IOPC. The biology of these reported cases has been variable with overall survival better than that of nonpapillary PC patients, with recurrence in 15% of the reported cases. Papillary PC is a rare type of cholangiocarcinoma that includes an interesting variant: IOPC. These tumors are predominantly found in men, who present with large (> 5 cm) mucinous cystic lesions of the bile duct. A noninvasive histology is seen, and long-term survival may be achieved with complete resection. Invasive variants of IOPC have been reported in the literature and have a worse overall prognosis.

Salivary duct carcinoma: cytokeratin 14 as a marker of in-situ intraductal growth.

The aim of this study was to determine the immunoprofile of salivary duct carcinoma and to differentiate intraductal growth from invasive growth. We applied a panel of antibodies (cytokeratins 7, 8, 13, 14, 19, vimentin and alpha-smooth muscle actin) in five cases of salivary duct carcinoma. This panel is currently used for identification of different components of salivary gland tumours in our laboratory. All tumour cells were positive for cytokeratins 7 and 8. Few neoplastic structures expressed cytokeratin 14 in cells surrounding tumour islands. The finding of cytokeratin 14 was important to confirm the in-situ intraductal growth, which probably characterizes this low-grade neoplasm.

Hepatobiliary and pancreatic: Commentary

Journal of Gastroenterology and HepatologyVolume 17, Issue 9 p. 1037-1038 Free Access Hepatobiliary and pancreatic: Commentary First published: 07 August 2002 https://doi.org/10.1046/j.1440-1746.2002.02820.xAboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat interpretation of fig. 1 see page 1032 This sonogram shows an ill-defined gallbladder with multiple small hyperechoic objects casting an acoustic shadow. Clearly, they represent small stones in the gallbladder. The gallbladder wall is obscure. The liver parenchyma anterior to and left to the gallbladder is hypoechoic (arrows). The gallbladder seems to be compressed by the hypoechoic tissue. Judging from the shape of the gallbladder, the presence of stones, and the surrounding hypoechoic tissue, this most likely represents gallbladder carcinoma infiltrating into the liver parenchyma. The high CA19-9 level is compatible with the diagnosis. diagnosis: gallbladder carcinoma infiltrating into liver parenchyma Enhanced CT scan (Fig. 2) shows two low density lesions with peripheral enhancement (arrows). The anteriorly situated lesion contains the stone harboring gallbladder. Adenocarcinoma is usually enhanced in the periphery upon contrast injection because the periphery is more vascular and growing compared to the interior of the mass. Approximately 80% of gallbladder carcinomas are adenocarcinoma, and 75% of the patients are female.1 MRCP (Fig. 3) shows dilated intrahepatic bile ducts and occlusion of the common hepatic duct (arrow). The serum bilirubin level in this patient rose to 22.7 mg/dL in 3 weeks, and a drainage catheter was introduced percutaneously into the common bile duct for drainage. However, the catheter did not encounter much resistance and readily entered the common bile duct (Fig. 4), suggesting that this obstruction was due to external compression rather than intraductal tumor growth. The bilirubin level dropped to 12.7 mg/dL in 1 week. Figure 2Open in figure viewerPowerPoint CT scan with enhancement. Figure 3Open in figure viewerPowerPoint MRCP. The common hepatic duct is obstructed at the arrow. Figure 4Open in figure viewerPowerPoint Percutaneous drainage catheter is in place. According to a cooperative survey on surgical treatment for carcinoma of the biliary tract conducted in 3000 patients in Japan, the modes of gallbladder carcinoma spread were direct hepatic invasion in 65%, liver metastasis in 25%, bile duct invasion in 51%, portal vein invasion in 23% and lymph node metastasis in 76%.2 In Fig. 2, the posteriorly situated lesion is perhaps intrahepatic metastasis. The presence of stones in the gallbladder is an important risk factor for carcinoma; 75% of patients who develop gallbladder cancer have cholelithiasis, and patients with stones have a risk of carcinoma seven times higher than that of those without stones.3 References 1 Weeden D. Diseases of the gallbladder. In: MacSween, RNM, Anthony, PP, Scheuer, PJ, Burt, AD, Portman, BC, eds. Pathology of the Liver. London: Churchill Livingston 1994, 513 – 34. 2 Ogura YN, Ezumoto R, Isaji S et al. Radical operations for carcinoma of the gallbladder: Recent status in Japan. World Jurg 1991; 15: 337 – 47. 3 Bengmark S, Jeppsson B. Tumors of the Gallbladder. In: Haubrich, W, Schaffner, F, Berk, JE, eds. Bockus Gastroenterology. Philadelphia: Saunders 1995, 2739 – 44. Volume17, Issue9September 2002Pages 1037-1038 FiguresReferencesRelatedInformation

Prognostic factors of intrahepatic cholangiocarcinoma after surgical treatment

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary liver cancer, and survival after surgical treatment is unfavorable due to the advanced clinical stage. Therefore, the prognostic factors after surgical treatment should be clarified in terms of clinicopathological aspects. We analyzed seven patients who underwent operations for ICC between 1990 and 1999. The patients were classified according to the Japan Liver Cancer Study Group and International Union Against Cancer (UICC) TNM classification: we clarified the prognostic factors to determine the disease-free interval. All patients had ICC at an advanced clinical stage at the time of operation. The modes of tumor spread were: the mass-forming type, the periductal infiltrating type, and the combination type without intraductal growth. The majority of patients had poor prognosis after operation. We found that there was a correlation between the disease-free interval after operation and the number of positive factors, including microscopic examination of operative specimens, preoperative serum levels of tumor markers, and the histological type of the tumor (r=0.859; p<0.01). Aggressive surgical therapy may allow long-term survival if the tumor spread is limited to local regions and tumors are the intraductal growth type.

Biliary papillary neoplasm of the liver.

Biliary papillary neoplasia of the liver characterized by intraductal papillary growth of neoplastic biliary epithelia with a fine fibrovascular stalk has been sporadically reported, and includes intraductal growing cholangiocarcinoma and biliary papillomatosis. In addition, biliary papillary dysplasia and in situ and microinvasive carcinoma with papillary configuration reported in hepatolithiasis and in other chronic biliary diseases, could be included in this category. Usually, they arise in the intrahepatic large bile ducts, and the neoplastic and non-neoplastic parts of the intrahepatic biliary tree show saccular and segmental dilatation with mucin hypersecretion. This neoplasia frequently shows intraductal spreading and peribiliary glandular involvement. Acute repeated episodes of cholangitis or obstructive jaundice are a frequent clinical manifestation. Gastroenteric metaplasia with aberrant expression of cytokeratin 20, MUC2, MUC5AC, and/or MUC6, is frequent in the neoplastic parts, and biliary epithelial dysplasia with such metaplasia may give rise to in situ and then invasive carcinoma in hepatolithiasis. Interestingly, this type tends to contain foci of mucinous carcinoma elements, and this element may be predominant (mucinous carcinoma). Some may progress to "mucinous biliary cystadenocarcinoma" without ovarian mesenchymal stroma and with intraluminal continuous growth into the neighboring bile duct lumens. Interestingly, the biliary papillary neoplasm resembles histologically, phenotypically and clinically intraductal papillary mucinous neoplasm of the pancreas which is now being established as an infrequent, slow-growing pancreatic neoplasm. Recognition of such biliary papillary neoplasm with respect to the pancreatic equivalent may lead to a better understanding and further studies of the intrahepatic biliary neoplasm.

Value of lymph node dissection during resection of intrahepatic cholangiocarcinoma.

Hepatectomy with extensive lymph node dissection is the standard operation for intrahepatic cholangiocarcinoma (IHCC). However, lymph node dissection may not always be effective at reducing tumour recurrence. Forty-nine patients with IHCC who underwent hepatectomy were investigated to determine patterns of tumour recurrence and to estimate the value of lymph node dissection during resection. At hepatectomy most metastatic lymph nodes were identified at least to the level of group 2 lymph nodes. Among 23 patients who developed recurrence, 17 had liver metastases and the other six had recurrence at other sites, mainly in the peritoneum. Poorly differentiated histology was related to the development of liver metastases. No patient with the intraductal growth type of IHCC had tumour recurrence. Lymph node dissection did not appear to improve patient survival. Histological findings of lymph node metastases and intrahepatic metastases were independent indicators of poor prognosis. Lymph node metastases were seldom limited to the regional lymph nodes; most tumour recurrence occurred in the liver. Lymph node dissection did not appear to improve patient survival. Lymph node dissection alone is not likely to improve the prognosis without further control of liver metastases.

Intraductal papillary neoplasia of the liver associated with hepatolithiasis.

Intraductal papillary growth of neoplastic biliary epithelia with a fine fibrovascular stalk (intraductal papillary neoplasia of liver [IPN-L]) resembling intraductal papillary mucinous neoplasm of pancreas is occasionally associated with hepatolithiasis. In this study, 136 cases of hepatolithiasis in Taiwan, between January 1998 and March 2000, and an additional 21 cases of IPN-L before December 1998, were examined histologically. IPN-L was found in 41 of 136 hepatolithiasis cases (30.1%). Sixty-two IPN-L cases (42 women and 20 men; age range, 59.8 +/- 10 years) were divided into 4 types (type 1, IPN-L with low-grade dysplasia, 23 cases; type 2, IPN-L with high grade dysplasia, 11 cases; type 3, IPN-L with in situ and microinvasive carcinoma, 13 cases; and type 4, IPN-L of types 2 and 3 with distinct invasive carcinoma, 15 cases). Intraductal spreading and glandular involvement were commonly observed in all types. About half of types 3 and 4 cases had mucobilia, and mucinous carcinoma was variably found in two thirds of group 4 patients. IPN-L frequently showed variable gastroenteric differentiation such as goblet cells and foveolar and colon-like metaplasia. IPN-L with goblet cells and colon-like metaplasia was frequently associated with overproduction of mucin and mucobilia (P <.01). In Japan, IPN-L was not frequent in hepatolithiasis (12 of 135 cases). In conclusion, IPN-L forms a spectrum of biliary neoplasm in hepatolithiasis. It often displays variable gastroenteric metaplasia and significant intraductal spread. IPN-L tends to progress to mucinous carcinoma. Formerly reported "mucin-producing intrahepatic cholangiocarcinoma" with a favorable prognosis is included in IPN-L.

Radiologic spectrum of cholangiocarcinoma: emphasis on unusual manifestations and differential diagnoses.

Most cholangiocarcinomas are ductal adenocarcinomas that arise from both intra- and extrahepatic bile duct epithelium, and their typical growth pattern can be classified as exophytic, infiltrative, polypoid, or a combination of these. Those of unusual histologic type (eg, mucin-hypersecreting cholangiocarcinoma, squamous adenocarcinoma, biliary cystadenocarcinoma, and mucinous carcinoma) show a growth pattern different from that of the typical ones (ie, ductal). Cholangiocarcinomas frequently develop in patients with any of a variety of preexisting bile duct diseases, some of which are considered precursors of cholangiocarcinoma (eg, biliary lithiasis, clonorchiasis, recurrent pyogenic cholangitis, and primary sclerosing cholangitis). Some bulky hepatic tumors of either primary or secondary origin mimic exophytic peripheral cholangiocarcinoma. Some variants of hepatocellular carcinoma, such as sclerosing, fibrolamellar, and cholangiohepatocellular carcinoma, resemble exophytic peripheral cholangiocarcinoma, while that with intraductal growth resembles polypoid cholangiocarcinoma. Among benign bile duct diseases, tumorous conditions (eg, benign biliary tumors) may mimic polypoid cholangiocarcinoma, whereas benign stricture of various causes (eg, cholangitides, traumatic and postsurgical sequelae, chronic pancreatitis, papillary stenosis) usually mimics infiltrative cholangiocarcinoma.

Predictive factors for long-term survival in patients with intrahepatic cholangiocarcinoma

Background: In order to elucidate the predictive factors for long-term survival in patients with intrahepatic cholangiocarcinoma (ICC), we evaluated 7 patients who survived for more than 5 years (5-year survivors). Methods: We examined the clinicopathologic and biologic factors of the 5-year survivors, and these findings were then compared with those in 20 patients who died within 5 years after surgery (control group). Results: In the 5-year survivors, the gross appearance of the tumors included a mass-forming (MF) type in 5 cases, an intraductal growth (IG) type in 1, and another type (microcarcinoma with hepatolithiasis) in 1. No case demonstrated a periductal infiltrating (PI) type. Except for 1 case with an IG type tumor, no lymph node metastasis was seen in any patients. All of the 5-year survivors were classified from stage I to III, and all also underwent a curative resection. The clinicopathologic factors demonstrating significant differences between the 5-year survivors and the control group included the gross type of the tumor, lymph node involvement, the surgical margin, curability, and pTNM stage. Conclusion: The predictive factors for long-term survival in patients with ICC are thus suggested to include not only tumor staging and curability, but also lymph node metastasis and the gross type of the tumors.

Recurrence after surgical resection of intrahepatic cholangiocarcinoma.

We aimed to assess the patterns of recurrence after surgery for intrahepatic cholangiocarcinoma (ICC) and the outcomes of treatment in patients with recurrence. From 1981 to 1999, 123 patients with ICC underwent hepatectomy. The 3-year and 5-year survival rates were significantly higher in patients after curative resection (n = 56; 53%, 50%) than in patients after noncurative resection (n = 67; 7%, 2%; P < 0.0001). In 54 patients followed-up after curative resection, the rate of recurrence after surgery was 46%. The recurrences were in the liver (56%), abdomen (disseminated; 24%), and lymph nodes (20%). The rates of recurrence were significantly higher in patients with various classifications of mass-forming ICC tumors (P = 0.039) than in those with other types of tumors, and in patients with tumors over 3 cm in greatest diameter than in those with tumors 3 cm or less (P = 0.006). Hepatic recurrence, abdominal dissemination, and intraductal recurrence were significantly related to tumors that included mass-forming ICC (P = 0.002), tumors that included periductal infiltrating ICC (P = 0.009), and tumors that included intraductal growth ICC (P = 0.038), respectively. Seven patients with recurrence underwent radiation, chemotherapy, immunotherapy, or surgical resection. Only 2 patients, with intrahepatic metastasis and intraductal recurrence, respectively, had good outcomes after surgery. The effectiveness of other treatments has not been established.

胆管内発育型肝細胞癌の３切除例

腫瘍栓が肝外胆管内に進展した肝細胞癌の3切除例を経験した. 3例とも男性でHBV (+) であり, うち1例は肝硬変であった. 全例, 胆管造影にて肝外胆管に特徴的な鋳型状の陰影欠損を認め腫瘍栓と診断され, また原発巣は切除可能であったため手術を施行した. 肝外の胆管内腫瘍栓は浸潤傾向がなく胆管切開することにより容易に摘出可能であった. それぞれ術後5か月, 6か月, 12か月現在, 無再発生存中である. 胆管内発育型肝細胞癌は進行した状態で診断されることが多いが, 正確な術前診断を行い, 切除可能なものは積極的に肝切除とともに腫瘍栓摘出を行うことが予後向上に重要であると思われた.

Mammary Endocrine Ductal Carcinoma in Situ: A Case Report

Endocrine differentiation represents a pathway of neoplastic development available to a range of breast cancers. This pattern occurs in tumors with different morphological appearances as ductal carcinoma in situ (DCIS), mucinous carcinoma, a variant of lobular carcinoma, and low-grade invasive ductal carcinoma. Endocrine ductal carcinoma in situ is an uncommon entity. It occurs in older women with a mean age of 70 years. Histologically it shows expansile intraductal growth forming solid sheets and festoons transversed by delicate fibrovascular septa. Conventional microscopy permits the diagnosis in most cases. Specialized techniques such as immunohistochemistry and electron microscopy can serve as the basis of diagnosis in the absence of the appropriate morphological features. We present a 68-year-old female with a 1.5-cm firm mobile nodule of the left breast. Mammography and ultrasounds showed a 15 x 15-mm circumscribed solid lobulated nodule. The mass was excised and pathology was positive for endocrine DCIS. Although endocrine DCIS has a biologic marker profile similar to that of well-differentiated or noncomedo DCIS it may constitute a different histogenetic pathway of carcinogenesis in the breast. The tumor may exhibit the invasive characteristics of a neuroendocrine neoplasm. Larger studies and longer follow-up are needed for the determination of the clinical behavior.

Pathogenesis of urticaria in autoimmune gastritis

Background: Surgery is considered treatment of choice of papillary adenomas. However, morbidity and mortality is high after Whipple's operation and local resection may be associated with recurrence. Literature on endoscopic treatment is scanty and mostly involved laser coagulation, which precludes histological examination. Aim: To evaluate the results of endoscopic snare resection (papillectomy) of benign papillary tumors. Methods: Papillectomy was performed using a therapeutic duodenoscope and a monofilament snare with cutting current. Sessile lesions were excised by piecemeal resection, small remnants were coagulated. A 7 F pancreatic stent was placed to prevent pancreatitis and removed when follow-up endoscopy showed complete resection. Benign recurrences were re-treated. Patients with invasive carcinoma (CA) and those with intraductal growth not amenable for endoscopy were operated. Results: From 2/85 to 8/99, 57 pts, 40 f, 17 m, median age 73 yrs (31-93) underwent papillectomy. Median size of the adenomas was I cm (0.5-6). Median no. of sessions was I (1-4). 24 pts were treated by snare resection alone, additional coagulation was used in 33. Complications were severe pancreatitis in I and mild pancreatitis in 5 pts, all managed conservatively, and bleeding in 7 pts managed endoscopically during the treatment session. There was no delayed bleeding. Histology was adenoma (45), hyperplastic/inflammatory (10), lymphangioma (I) and invasive CA (I). 40 adenomas had mild! moderate dysplasia, 5 had severe dysplasia. The pt with CA, I pt with severe dysplasia and I pt with intraductal growth underwent subsequent surgery. Over a median follow-up of 24 mos (r:0-159), 12 pts (21%) had a benign recurrence. 3 underwent surgery, Ipt died of apoplexia after 6 mos without further therapy and 8 were managed endoscopically. Among these, complete removal was achieved in 6, 2 inoperable pts with intraductal growth are also managed by stenting. Intraductal growth was present in II pts. Of these, 10 were managed endoscopically (resection: 7, stenting: 3) and I underwent surgery. 3 pts refused endoscopic controls and are well at 42, 98 and 107 rnos, 2 pts were lost to follow-up and 3 died of unrelated disease. All other pts are well without recurrence or malignancy. Overall, 88% were treated by endoscopy only. Conclusions: Endoscopic papillectomy can be performed safely with a low complication rate. The high recurrence rate warrants regular endoscopic controls. In this study, only 12% of the pts ultimately required surgery.

7125 How best to diagnose ipmt.

The purpose of the study was to review a single institutional experience of intraductal papillary mucinous tumors (IPMT) and compare different diagnostic modalities. Background: IPMT or mucinous ductal ectasia is a rare neoplasm of the pancreas. It is characterized by extensive intraductal growth with slow invasion and metastasis having a much better prognosis. Diagnosis is usually made by ERCP showing dilated main and side branches with multiple filling defects that represent mucus and often mucus extruding from the papilla. The value of brush cytology and biopsy is unknown. Methods: The medical records, endoscopic findings, brushing results, surgical findings and surgical pathology of 22 patients over a 6 year period were reviewed. Results: The mean age at presentation was 63.1 years. There were 15 females and 7 males. The prevalence of abdominal pain was 86%, h/o pancreatitis 64%, wt loss 23%, diabetes 18%, cholangitis 9%, steatorrhea 5%. CT scan was done in 11 (50 %) and showed cystic dilation in 1, cystic mass in 5, solid mass in 3, and was negative in 2. Three (14%) were found to have pancreas divisum with mucus in the dilated dorsal duct. Nineteen (86%) had tumor involvement in the head of the pancreas and 3 (14%) in the tail. Brushing of the pancreatic duct was performed in 17, biopsy in 8 with only 2 positive for mucinous neoplasm in each (using strict criteria). Pancreatoscopy was performed in 2 patients and revealed the intraductal papillary growth and white gelatinous mucus in both patients. Endoscopic ultrasound was performed on one patient and showed hyperechogenic collection in the dilated pancreatic duct. Eight patients underwent surgery; 4 pancreaticoduodenectomy, 2 pylorus preserving pancreaticoduodenectomy, 1 distal pancreatectomy and 1 total pancreatectomy. Invasive carcinoma was present in 2 (25%). Conclusion: IPMT which has malignant potential, presents with nonspecific symptoms. Non-invasive imaging may be misleading. ERCP is the procedure of choice in making the diagnosis. Brushings or biopsies of the pancreatic duct are insensitive. Pancreatoscopy is useful in determining the extent of the lesion to help guide surgical resection.

Biliary Obstruction: Findings at MR Cholangiography and Cross-sectional MR Imaging

Twenty-two patients with malignant biliary obstruction and 21 patients with suspected obstruction of biliary-enteric anastomoses were evaluated over a 12-month period with magnetic resonance (MR) cholangiography and cross-sectional MR imaging. In patients with malignant obstruction, MR cholangiography helped accurately determine the status of the biliary ductal system by identifying the exact location and extent of the obstruction and the severity of duct dilatation. In so doing, MR cholangiography helped determine whether percutaneous transhepatic cholangiography with antegrade stent placement or retrograde cholangiography with stent placement constituted the more suitable treatment. Cross-sectional MR imaging was necessary to identify the organ of tumor origin, define the tumor margins, and determine the stage of disease. This information helped evaluate the appropriateness of curative surgical therapy versus palliative drainage procedures. In patients with biliary-enteric anastomoses, MR cholangiography clearly depicted the site of the anastomosis and demonstrated the status of the intrahepatic ducts, thereby helping determine which patients would benefit from undergoing antegrade duct cannulation with a drainage procedure or perhaps balloon dilation. In some of these patients, MR cholangiography was sufficient to help plan therapeutic intervention. MR cholangiography also demonstrates the presence and size of biliary stones and associated findings such as intraductal tumor growth. In addition, MR cholangiography may obviate retrograde cholangiography, which can be technically difficult to perform.