Intraductal Neoplasm Research Articles

Comparison of five-phase computed tomography images of type 1 autoimmune pancreatitis and pancreatic cancer: Emphasis on cases with atypical images

Background/objectivesInternational consensus diagnostic criteria (ICDC) include characteristic images of autoimmune pancreatitis (AIP); however, reports on atypical cases are increasing. The aims of this study were to compare CT findings between AIP and pancreatic cancer (PC), and to analyze type 1 AIPs showing atypical images. MethodsFive-phase CT images were compared between 80 type 1-AIP lesions and 80 size- and location-matched PCs in the case-control study. Atypical AIPs were diagnosed based on the four ICDC items. ResultsICDC items were recognized in most AIP lesions; pancreatic enlargement (87.7%), narrowing of the main pancreatic duct (98.8%), delayed enhancement (100%), and no marked upstream-duct dilation (97.5%). CT values of AIPs increased rapidly until the pancreatic phase and decreased afterward, while those of PCs gradually increased until the delayed phase (P < 0.0001). Atypical images were recognized in 14.8% of AIPs, commonly without pancreatic enlargement (18.5 mm) and sometimes mimicking intraductal neoplasms. The CT values and their ratios were different between atypical AIPs and size-matched PCs most significantly in the pancreatic phase, but similar in the delayed phase. ConclusionsOrdinary type 1 AIPs can be diagnosed with the ICDC, but atypical AIPs represented a small fraction. “Delayed enhancement” is characteristic to ordinary AIPs, however, “pancreatic-phase enhancement” is more diagnostic for atypical AIPs.

Intrahepatic Intraductal Papillary Cystic Neoplasm of the Bile Duct: A Case Report

Abstract Introduction and importance Intraductal papillary neoplasm of the bile duct (IPNB) is a tumour with a very low incidence in the Western world, characterised by a high risk of malignant transformation and unknown prognosis. It is a new entity which was adopted by the WHO in 2010 as a precursor lesion of cholangiocarcinoma. Intrahepatic bile duct is the most common site of origin for IPNB. Case presentation Hereby, we present a case of an asymptomatic 63- year-old man, referred to our department after routine ultrasonography showing a multifocal cystic lesion on the left hepatic lobe. Further screening modalities (CT, MRI abdo) confirmed a complex cystic liver lesion with atypical features. The patient underwent left hepatectomy. Histopathology showed a cystic type intrahepatic IPNB, which was completely resected (R0). The follow up in 2 yrs post-operation showed no signs of recurrence. Clinical discussion The diagnosis and management of IPNB remain challenging. A multimodality imaging approach is essential in order to diagnose IPNB, assess tumour location and extent and plan the optimal treatment strategy. Conclusion Complete surgical resection (R0) with close postoperative follow-up offers long-term survival.

Tips and tricks in Kimura-type distal pancreactectomy

Introduction: This video shows the Kimura-type pancreatectomy with spleen preservation as a safe technique to perfom laparoscopically. Methods: We present two cases, a 2 cm intraductal mucinous papillar tumour and a 1.5 cm neuroendocrine tumour, both located in the pancreatic body. Laparoscopic distal Kimura pancreatectomy was performed in both cases, mantaining splenic irrigation by the preservation of the splenic vessels, as it is described originally. Results: The standardized technique we usually follow starts by the identification of the splenic artery at its origin in the superior margin of the pancreatic neck. Then, we idenfiticate the splenic vein in the posterior side of the glandule. This allows us to perform a careful dissection of them until we reach the splenic hilium. As final step, we make the section in the neck of the glandule. The specimen is taken out trough a Pfannestiel incision. Postoperative period was favourable in both cases. Conclusion: The Kimura distal pancreatectomy assures a correct splenic irrigation; in our experience, this surgery, done laparoscopically, turns out to be safe and has favourable outcomes, as long as a standardized technique is followed.

A case of intraductal tumor of the liver incidentally found with diarrhea symptom

A case of intraductal tumor of the liver incidentally found with diarrhea symptom

Collagen production and niche engineering: A novel strategy for cancer cells to survive acidosis in DCIS and evolve.

Growing tumors are dynamic and nonlinear ecosystems, wherein cancer cells adapt to their local microenvironment, and these adaptations further modify the environment, inducing more changes. From nascent intraductal neoplasms to disseminated metastatic disease, several levels of evolutionary adaptations and selections occur. Here, we focus on one example of such an adaptation mechanism, namely, “niche construction” promoted by adaptation to acidosis, which is a metabolic adaptation to the early harsh environment in intraductal neoplasms. The avascular characteristics of ductal carcinoma in situ (DCIS) make the periluminal volume profoundly acidic, and cancer cells must adapt to this to survive. Based on discovery proteomics, we hypothesized that a component of acid adaptation involves production of collagen by pre‐cancer cells that remodels the extracellular matrix (ECM) and stabilizes cells under acid stress. The proteomic data were surprising as collagen production and deposition are commonly believed to be the responsibility of mesenchymally derived fibroblasts, and not cells of epithelial origin. Subsequent experiments in 3D culture, spinning disk and second harmonic generation microscopy of DCIS lesions in patients’ samples are concordant. Collagen production assay by acid‐adapted cells in vitro demonstrated that the mechanism of induction involves the RAS and SMAD pathways. Secretome analyses show upregulation of ECM remodeling enzymes such as TGM2 and LOXL2 that are collagen crosslinkers. These data strongly indicate that acidosis in incipient cancers induces collagen production by cancer cells and support the hypothesis that this adaptation initiates a tumor‐permissive microenvironment promoting survival and growth of nascent cancers.

A Nomogram to Predict the Probability of Breast Intraductal Tumors in Patients with Nipple Discharge: A Real-World Study Based on Our 13-Year Clinical Experience.

IntroductionNipple discharge is a common symptom of breast disease. We aimed to perform a descriptive statistical analysis of the cases we evaluated and establish a model to predict intraductal tumors.Materials and MethodsWe conducted a retrospective study of patients from 2007 to 2019. In total, 1333 patients who completed the fiberoptic ductoscopy (FDS) were evaluated. The variables were analyzed by χ2 test. Logistic regression was used to analyze the relationship between the patient’s clinical characteristics and intraductal tumors and establish a predictive model. Receiver operating characteristic (ROC) curve analysis was used to assess the sensitivity and specificity of the predictive ability of the model. Calibration curves and decision curve analysis (DCA) were used to evaluate the model.ResultsPatients with spontaneous, single-duct, bloody discharge and a smooth ductal wall were more likely to be diagnosed with tumors by ductoscopy. A model was established based on five variables: age, side of discharge, spontaneous discharge status, duration of discharge, and color of discharge. The model was subsequently validated in 183 patients with complete data on the variables in the validation cohort. The area under the ROC curve (AUC) was calculated to be 0.716, indicating good predictive ability.ConclusionPatients with the clinical characteristics of unilateral, bloody, single-duct, spontaneous discharge and a smooth ductal wall were more likely to have intraductal tumors by ductoscopy. Our nomogram can effectively predict intraductal tumors in patients with nipple discharge.

Intraductal Pancreatic Mucinous Neoplasms: A Tumor-Biology Based Approach for Risk Stratification.

Pancreatic ductal adenocarcinoma is one of the most lethal human cancers. Its precursor lesions include pancreatic intra-epithelial neoplasia, mucinous cystic neoplasm, and intraductal papillary mucinous neoplasm (IPMN). IPMNs usually present as an incidental finding at imaging in 2.6% of the population and, according to the degree of dysplasia, they are classified as low- or high-grade lesions. Since the risk of malignant transformation is not accurately predictable, the management of these lesions is based on morphological and clinical parameters, such as presence of mural nodule, main pancreatic duct dilation, presence of symptoms, or high-grade dysplasia. Although the main genetic alterations associated to IPMNs have been elucidated, they are still not helpful for disease risk stratification. The growing body of genomic and epigenomic studies along with the more recent development of organotypic cultures provide the opportunity to improve our understanding of the malignant transformation process, which will likely deliver biomarkers to help discriminate between low- and high-risk lesions. Recent insights on the topic are herein summarized.

Peribiliary glands pathology in a large series of end-stage alcohol-related liver disease.

The peribiliary glands are intramural or extramural structures with multiple functions related to bile secretion. The peribiliary glands can develop cystic alterations in several conditions, such as alcohol addiction. Peribiliary cysts can enlarge till being radiologically visible and mimic cancer. We studied 217 consecutive explanted livers for end-stage alcohol-related liver disease from the Pathology Unit of the Liver Unit at the King's College Hospital in Denmark Hill, with particular focus on peribiliary glands. Our cohort consisted of 31 females and 186 males, with a median age of 51 and of 56years respectively. 92,2% had established cirrhosis, 73,3% had only alcohol-induced liver disease, whilst 26,7% had other co-morbidities. We found a mild ectasia of the peribiliary glands (<2mm) in 37,8% and peribiliary cysts (> = 2mm) in 22,6% of cases. The diameter of the peribiliary glands varied from 1mm to 8mm. Inflammation of the peribiliary glands was found in the majority of cases with dilatation (p value = 0,000). 4,6% of the peribiliary cysts had low-grade intraductal papillary neoplasm of the bile ducts confined to the peribiliary glands. Pancreatic heterotopia was found in 10,6% and associated with the presence of ectasia. Our findings fit with what is reported in literature, such as the alcohol-induced damage at the peribiliary glands. Moreover these results underline the possible role of peribiliary glands in the development of the intraductal papillary neoplasm of the bile ducts, the biliary counterpart of the branch type intraductal mucinous neoplasm of the pancreas.

Fibrolamellar Carcinoma

This liver tumor in a young adult was diagnosed by pathology as fibrolamellar carcinoma. What is different about fibrolamellar carcinoma compared with conventional hepatocellular carcinoma?a.Fibrolamellar carcinoma usually affects patients in their sixth and seventh decadesb.Fibrolamellar carcinoma almost always occurs in a background of liver cirrhosisc.Fibrolamellar carcinoma is strongly associated with DNAJB1-PRKACA oncogenic fusiond.Fibrolamellar carcinoma almost exclusively occurs in females Answer: c. Fibrolamellar carcinoma is strongly associated with DNAJB1-PRKACA oncogenic fusion Fibrolamellar carcinoma is an uncommon malignancy, comprising 1% to 5% of liver cancers. This tumor occurs in younger patients, usually less than 40 years of age, and affects males and females. Conventional hepatocellular carcinoma most often affects older adults. Most conventional hepatocellular carcinomas occur in livers affected by cirrhosis, while fibrolamellar carcinoma occurs in noncirrhotic livers. Fibrolamellar carcinoma is strongly associated with DNAJB1-PRKACA oncogenic fusions, which were also recently reported in intraductal oncocytic neoplasms of the pancreas and bile duct.1Honeyman J.N. Simon E.P. Robine N. et al.Detection of a recurrent DNAJB1-PRKACA chimeric transcript in fibrolamellar hepatocellular carcinoma.Science. 2014; 343: 1010-1014Crossref PubMed Scopus (292) Google Scholar,2Singhi A.D. Wood L.D. Parks E. et al.Recurrent rearrangements in PRKACA and PRKACB in intraductal oncocytic papillary neoplasms of the pancreas and bile duct.Gastroenterology. 2020; 158: 573-582Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar

Endoscopic papillectomy of benign papillary tumors: A single-center experience.

Endoscopic treatment of duodenal papillary tumors is well described. This study aims to provide new evidence for the treatment of benign papillary tumors through comparisons between endoscopic snare papillectomy (ESP) and endoscopic mucosal resection (EMR).Between May 2010 and December 2017, 72 patients were enrolled. Diagnosis and treatment procedures were ESP and EMR. Endoscopic follow-up evaluation was done periodically as a surveillance measurement for recurrence.Seventy-two patients with ampullary tumors were enrolled, of which 66 had adenomas including 9 high-grade intraepithelial neoplasias and 2 carcinomas in adenoma. Complete resections with tumor-free lateral and basal margins were achieved in all patients. Postoperative complications were bleeding (9.5% in EMR vs 10% in ESP) and pancreatitis (2.4% in EMR and 3.3% in ESP), with no occurrence of perforation, cholangitis or papillary stenosis. Adenoma recurrence was found in 7 patients (14.3% in EMR vs 3.3% in ESP) at 1 year.The ESP procedure is safe and effective for benign ampullary adenoma, high-grade intraepithelial neoplasias, and noninvasive cancer without intraductal tumor growth, which has a shorter procedural duration, as well as lower complication, recurrence rates and hospitalization costs.

A nomogram to predict the probability of breast intraductal tumors in patients with nipple discharge: A report based on our 13-year clinical experience.

e13582 Background: Nipple discharge is a common symptom of breast disease. Our aim was to perform a descriptive statistical analysis of the cases we collected and to establish a model to predict intraductal tumors. Methods: We conducted a retrospective study of patients from 2007 to 2019. The variables were analyzed by the c2 test. Univariate binary logistic regression was used to analyze the relationship between clinical features of patients. Receiver operating characteristics (ROC) were used to assess the sensitivity and specificity of the predictive ability of the model. Results: Patients with spontaneous, single duct, bloody discharge and smooth ductal wall were more likely to diagnose with tumor by ductoscopy. A model was established based on seven variables: age, side of discharge, spontaneous or not, duration of discharge, ductal wall and characteristics of discharge. It was subsequently validated in 178 patients with complete data on variables in the validation cohort. The area under ROC curve (AUC) were calculated to be 0.7024 indicating a good predictive ability. Conclusions: Patients with clinical characteristics of unilateral, bloody, single duct, spontaneous discharge and smooth ductal wall were more likely to have intraductal tumors by ductoscopy. Our nomogram can effectively predict intraductal tumors in patients with nipple discharge.

Upregulation of follistatin and low apoptotic activity in intraductal oncocytic papillary neoplasm of the pancreatobiliary system

Intraductal oncocytic papillary neoplasm (IOPN) is a rare intraductal tumor of the pancreatobiliary system. Currently, little is known about its distinct characteristics, unlike intraductal papillary mucinous neoplasms (IPMN) and intraductal papillary neoplasms of the bile duct (IPNB). The present study compared 22 IOPNs (18 pancreatic and 4 biliary) with those of 61 IPMNs/8 IPNBs. IOPNs were classified into pure and combined types, depending on the coexistence of IPMN/IPNB. Multiple gene expression analysis (nCounter system) was performed, and hierarchical clustering analysis separated IOPNs(n = 4) and IPMNs(n = 3)/ IPNBs(n = 3), and pathway score analysis supported the result. Volcano plot identified follistatin (FST) as the most upregulated mRNA in IOPN in comparison to the gastric subtype (log2 fold change of 5.34) and the intestinal subtype (that of 5.81) of IPMN/IPNB. The expression of FST in IOPN was also high in quantitative polymerase chain reaction and immunohistochemical analysis. We also found lower apoptotic activity in IOPN, particularly in pure type, compared to high-grade or invasive IPMN/IPNB using immunohistochemistry for cleaved caspase 3. But, combined type IOPN was more similar to IPMN/IPNB than pure IOPN. In conclusion, we proved that IOPN, particularly pure IOPN, is distinct from IPMN/IPNB in FST mRNA overexpression and exhibits lower apoptotic activity.

Biliary intraductal tubule-forming neoplasm: a whole exome sequencing study of MUC5AC-positive and -negative cases.

Biliary intraductal tubular neoplasms that are non-mucinous and negative for mucin 5AC (MUC5AC) are called intraductal tubulopapillary neoplasms (ITPNs). Intraductal tubular neoplasms with mucinous cytoplasm and MUC5AC positivity also occur and their nature remains unclear, although some pathologists may classify these as 'intraductal papillary neoplasms of the bile duct (IPNBs) of gastric type'. This study aimed to elucidate genetic features of biliary intraductal tubular neoplasms. Six resected cases of biliary intraductal neoplasm with>70% tubular configuration were characterised by clinicopathological examination and whole exome sequencing, and the findings obtained were compared between MUC5AC-negative (n=2) and -positive cases (n=4). The intraductal tumours consisted of the pancreatobiliary-type epithelium with high-grade dysplasia arranged in back-to-back tubules. Both of the two MUC5AC-negative cases were non-invasive neoplasms and developed in the liver, whereas all MUC5AC-positive cases had invasive carcinoma and were present in the intrahepatic (n=2), perihilar (n=1) and distal bile ducts (n=1). In an exome-sequencing study, MUC5AC-negative cases harboured mutations in CTNNB1, SF3B1, BAP1 and BRCA1 (one case each). KRAS mutations were observed in three of four MUC5AC-positive cases (75%) but none of the MUC5AC-negative neoplasms. Compared to published data, known driver genes of other intraductal neoplasms of the pancreatobiliary system (e.g. APC, CTNNB1, STK11, GNAS and PIK3CA) were wild-type in all but one MUC5AC-negative case with CTNNB1 mutation. Chromatin modifiers (ARID1A, BAP1 and KMT2C) were also altered in MUC5AC-positive cases, similar to usual cholangiocarcinomas. This exome-sequencing study suggested that MUC5AC-negative biliary ITPNs are genetically distinct from pancreatic ITPNs and IPNBs. They may also biologically differ from MUC5AC-positive tubular neoplasms despite morphological resemblance.

Intraoperative pancreatoscopy for surgical planning in a patient with ansa pancreatica and mixed-type intraductal pancreatic mucinous neoplasm

Intraoperative pancreatoscopy for surgical planning in a patient with ansa pancreatica and mixed-type intraductal pancreatic mucinous neoplasm

Risk factors and pathological characteristics for intraductal tumor spread of submucosal gland in early esophageal squamous cell neoplasia

The esophageal gland duct may serve as a pathway for the spread of early esophageal squamous cell neoplasia (ESCN) to a deeper layer. Deep intraductal tumor spreading cannot be completely eradicated by ablation therapy. However, the risk factors of ductal involvement (DI) in patients with ESCNs have yet to be investigated. We consecutively enrolled 160 early ESCNs, which were treated with endoscopic submucosal dissection. The resected specimens were reviewed for the number, morphology, resected margin, distribution and extension level of DI, which were then correlated to clinical factors. A total of 317 DIs (median:3, range 1–40 per-lesion) in 61 lesions (38.1%) were identified. Of these lesions, 14 have DIs maximally extended to the level of lamina propria mucosa, 17 to muscularis mucosae, and 30 to the submucosa. Multivariate logistic regression analysis showed that tumors located in the upper esophagus (OR = 2.93, 95% CI, 1.02–8.42), large tumor circumferential extension (OR = 5.39, 95% CI, 1.06–27.47), deep tumor invasion depth (OR = 4.12, 95% CI, 1.81–9.33) and numerous Lugol-voiding lesions in background esophageal mucosa (OR = 2.65, 95% CI, 1.10–6.37) were risk factors for DI. The maximally extended level of ducts involved were significantly correlated with the cancer invasion depth (P < 0.05). Notably, 245 (77%) of the involved ducts were located at the central-trisection of the lesions, and 52% of them (165/317) revealed dilatation of esophageal glandular ducts. Five (1.6%) of the involved ducts revealed cancer cell invasion through the glandular structures. In conclusion, DI is not uncommon in early ESCN and may be a major limitation of endoscopic ablation therapy.

Identification of key lncRNAs in the tumorigenesis of intraductal pancreatic mucinous neoplasm by coexpression network analysis.

Intraductal papillary mucinous neoplasm (IPMN) is an intraepithelial precancerous lesion of pancreatic ductal adenocarcinoma (PDAC) that progresses from adenoma to carcinoma, and long noncoding RNAs (lncRNA) might be involved in the tumorigenesis. In this study, we obtained the expression profiles of more than 4000 lncRNAs by probe reannotation of a microarray dataset. As a correlation network‐based systems biology method, weighted gene coexpression network analysis (WGCNA) was used to find clusters of highly correlated lncRNAs in the tumorigenesis of IPMN, which covered four stepwise stages from normal main pancreatic duct to invasive IPMN. In the most relevant module (R2 = −0.75 and P = 5E‐05), three hub lncRNAs were identified (HAND2‐AS1, CTD‐2033D15.2, and lncRNA‐TFG). HAND2‐AS1 and CTD‐2033D15.2 were negatively correlated with the tumorigenesis (P in one‐way ANOVA test = 1.45E‐07 and 1.39E‐0.5), while lncRNA‐TFG were positively correlated with the tumorigenesis (P = 3.99E‐08). The validation set reached consistent results (P = 2.66E‐03 in HAND2‐AS1, 1.47E‐04 in CTD‐2033D15.2 and 6.23E‐08 in lncRNA‐TFG). In functional enrichment analysis, the target genes of microRNAs targeting also these lncRNAs were overlapped in multiple biological processes, pathways and malignant diseases including pancreatic cancer. In survival analysis, patients with higher expression of HAND2‐AS1‐targeted and CTD‐2033D15.2‐targeted microRNAs showed a significantly poorer prognosis in PDAC, while high expression of lncRNA‐TFG‐targeted microRNAs demonstrated an obviously better prognosis (log‐rank P < .05). In conclusion, by coexpression network analysis of the lncRNA profiles, three key lncRNAs were identified in association with the tumorigenesis of IPMN, and those lncRNAs might act as early diagnostic biomarkers or therapeutic targets in pancreatic cancer.

First experience of intraductal photodynamic Klatskin tumor therapy by using SpyGlass ™ DS technology in Russia

The bile duct tumors diagnostics is very challenging due to the long asymptomatic course of the disease, complexity of early diagnosis and morphological verification of oncological process. In the vast majority of cases, the development of obstructive jaundice and the absence of pain syndrome are the only reasons that make it possible to suspect intraductal cholangiocarcinoma. CT, MRI and US examinations make it possible to suspect the localization of the tumor process in proximal regions and confluence of bile ducts. Morphological confirmation of the diagnosis can be obtained by performing a blind biopsy during ERCP and by performing intraoperative or oral cholangioscopy. The results of Klatskin tumor surgical treatment are unsatisfactory and tend to have high mortality rates. Chemotherapy and radiotherapy also do not meet the modern requirements of treatment. Oral cholangioscopy makes it possible to differentiate genesis of extrahepatic bile duct strictures with high accuracy, to perform targeted biopsy and to conduct a photodynamic therapy, which has shown high efficiency according to foreign studies. It the first time in Russia the authors have applied photodynamic therapy method using digital video choledochoscope of SpyGlass™ DS technology to treat a patient with Klatskin tumor.

Improving the Detection of Cholangiocarcinoma: In vitro MRI-Based Study Using Local Coils and T2 Mapping.

AimCholangiocarcinoma is endemic in southeast Asia, generally developing from liver fluke infestation. However, diagnostic imaging of early-stage disease is challenging. The aim of this work is to investigate relaxometry (specifically, T2 mapping) as a method of exploiting the higher signal-to-noise ratio (SNR) of internal coils for improved reception of magnetic resonance signals, despite their non-uniform sensitivity.MethodsEx vivo T2 mapping was carried out at 3T on fixed resection specimens from Thai cholangiocarcinoma patients using an mGRASE sequence and an endoscope coil based on a thin-film magneto-inductive waveguide and designed ultimately for internal use.ResultsDisease-induced changes including granulomatous inflammation, intraepithelial neoplasia and intraductal tumours were correlated with histopathology, and relaxation data were compared with mono- and bi-exponential models of T2 relaxation. An approximately 10-fold local advantage in SNR compared to a 16-element torso coil was demonstrated using the endoscope coil, and improved tissue differentiation was obtained without contrast agents.ConclusionThe performance advantage above follows directly from the inverse relation between the component of the standard deviation of T2 due to thermal noise and the SNR, and offers an effective method of exploiting the SNR advantage of internal coils. No correction is required, avoiding the need for tracking, relaxing constraints on coil and slice orientation and providing rapid visualization.

Total pancreatectomy for multifocal pancreatic cancers

Presenter: Hiromichi Ito | Cancer Institute Hospital, Japanese Foundation for Cancer Research Background: It is not uncommon that intraductal neoplasm of the pancreas including intraductal papillary mucinous neoplasm (IPMN) and intraductal tubulopapillary neoplasm (ITPN) involves the entire pancreas, and total pancreatectomy is necessary for patients with such tumors to achieve cure.Herein, we illustrate the case of the patient with multifocal pancreatic cancers who underwent total pancreatectomy. The disease turned out to be derived from IPMN by histologic examination in the resected specimen. Methods: The patient was an 82-year-old woman who presented with epigastric pain and CT showed large pancreatic body mass. The staging work-up revealed at least 5 PET-avid lesions throughout the entire pancreas without extra-pancreatic metastasis, and EUS-FNA confirmed them as adenocarcinoma. Thus, total pancreatectomy was recommended. Results: Upon the exploration, there was no evidence of metastatic disease, and IOUS confirmed all pancreatic lesions identified by preoperative scans. Total pancreatectomy was completed uneventfully in 560 minutes with blood loss of 430 cc. Her postoperative course was uncomplicated. The pathology showed multifocal pancreatic cancers derived from IPMN. ITPN was ruled out by presence of MUC5AC expression on immunohistochemistry. Conclusion: The video described the technical detail of our total pancreatectomy and some useful tricks including SMA-first approach and left kidney mobilization to minimize blood loss and to maintain good exposure for dissection plane in the left side.

Cystic Pancreatic Lesions: A Review of Diagnosis and Management

AbstractPancreatic cysts are commonly seen with increasing use of cross-sectional imaging. They range from a benign inflammatory process that can produce pseudocysts to malignant lesions such as mucinous cystadenocarcinoma. Other common pancreatic cysts include intraductal pancreatic mucinous neoplasms and serous cystadenomas. Optimized imaging protocol dedicated to imaging the pancreas is required, such as multiphasic computed tomography, magnetic resonance imaging/magnetic resonance cholangiopancreatography, or endoscopic ultrasound, to fully detect and characterize the lesions. A confident diagnosis can be made on imaging when features such as calcifications, pancreatic duct diameter, main duct communication, and mural nodules are assessed. Additionally, pathologic evaluation from fluid/tissue sampling aid in diagnosis. Optimal management of pancreatic cysts is achieved based on the imaging features, conveying key findings in the radiology report, pathologic evaluation, and clinical factors.