Intraductal Papillary Mucinous Neoplasm Of The Pancreas Research Articles

Multifocal intraductal papillary mucinous neoplasm of the pancreas-A case report

Cystic neoplasms of the pancreas are relatively rare, comprising 10 percent of pancreatic cysts and only 1 percent of pancreatic cancers. Cystic neoplasms include mucinous cystic neoplasms, serous cystadenomas, papillary cystic tumors, cystic islet cell tumors and intraductal papillary mucinous neoplasms of the pancreas (IPMNs). IPMN was first described in 1982. It has been most commonly described in 60 to 70 years old males, and represents a relatively "new" but increasingly recognized disease. The improvement and widespread use of modern imaging equipments and heightened awareness of physicians contribute to the increasing incidence of IPMN. The majority of IPMNs are located in the pancreatic head (75%) while the rest involves the body/tail regions. Multifocal IPMNs have been hypothesized, but the true presence of multifocality is unknown. Here we present a 72-year-old male diagnosed with IPMN (carcinoma in situ) in the pancreatic head and a branch duct type IPMN (duct atypia) in the pancreatic body and tail. The patient underwent a Whipple intervention and a distal pancreatectomy. A three-year disease-free survival has been observed so far.

Extrapancreatic Tumors in Intraductal Papillary Mucinous Neoplasm of the Pancreas

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas has a favorable prognosis, but seems to be associated with a high incidence of extrapancreatic tumors. The purpose of this study was to evaluate the incidence and clinicopathological features of extrapancreatic tumors associated with IPMN. Thirty-seven patients with IPMN of the pancreas, confirmed by surgical resection and typical findings of endoscopic ultrasonography and CT imaging between October 1, 1998 and August 31, 2006 were included. Seventeen patients were diagnosed with surgical resection and biopsy, and others by typical imaging findings of IPMN. These patients were examined for the development of extrapancreatic tumors. Of 37 patients with IPMN, 14 (38%) had 18 extrapancreatic tumors, and 10 (27%) had 13 extrapancreatic malignancies. Five, six, and two extrapancreatic malignancies had been diagnosed before, during, and after the diagnosis of IPMN. Gastric adenocarcinoma (3 patients, 23%) and colorectal carcinoma (3 patients, 23%) were the most common neoplasms. Other extrapancreatic tumors included lung cancer (n=2), prostatic cancer (n=1), renal cell carcinoma (n=1), cholangiocellular carcinoma (n=1), urinary bladder cancer (n=1), and gallbladder cancer (n=1), respectively. As benign tumor, there were two gallbladder adenoma, one gastric adenoma, one colonic adenoma and one benign ovarian cystic neoplasm, respectively. IPMN is associated with high incidence of extrapancreatic tumors, particularly gastric and colorectal neoplasms. Upper gastrointestinal endoscopy and colonoscopy should be done, and systemic surveillance for the possible occurrence of other tumors may allow early detection of extrapancreatic tumor in patients with IPMN.

A Case Report of Intraductal Papillary-Mucinous Neoplasm of the Pancreas Showing Morphologic Transformation during Followup Periods

A 64-year-old man underwent MRCP for further examination of gallbladder stones and IPMN of branch-type (IPMN-Br) was pointed out. Yearly MRCP had revealed the gradual increase of the cystic components, marked dilation of the main pancreatic duct (MPD), and filling defects in the MPD. After follow-up for three years, he underwent pancreatoduodenectomy. Histologically, the dilated MPD and connecting dilated branch ducts were filled with nodular growth of tumor cells consisting of gastric-type adenoma with pyloric gland-like structures. In the MPD, a transition from gastric-type adenoma to intestinal-type carcinoma was observed. In addition, in a dilated branch duct, some components of intestinal-type carcinoma with marked arborizing structures were observed. A minimally invasion was observed around branch ducts. Immunohistochemistry revealed diffuse nuclear accumulation of PCNA and Ki67 in the tumor cells of branch dusts. Our observations suggest that the secondary infiltration to the MPD of IPMN-Br and IPMN-Br possesses malignant potential for microinvasion.

Preoperative Evaluation of Invasive and Noninvasive Intraductal Papillary-Mucinous Neoplasms of the Pancreas

We aimed to investigate preoperative findings that are useful to distinguish intraductal papillary-mucinous neoplasm (IPMN) subtypes. One hundred twenty-three patients who underwent pancreatectomy for IPMN were analyzed clinicopathologically and radiologically. Invasive IPM carcinomas (IPMCs) were subdivided into early-stage nonaggressive (minimally invasive IPMC [MI-IPMC]) and more advanced and aggressive (invasive carcinoma originating in IPMC [IC-IPMC]) subtypes according to our recently proposed pathological criteria. The lesions consisted of 27 IPMNs with low-grade dysplasia, 14 IPMNs with moderate dysplasia, 21 IPMNs with high-grade dysplasia, 30 MI-IPMCs, and 31 IC-IPMCs. Multidetector-row computed tomography detected a component of invasive carcinoma in IC-IPMC with 86% sensitivity and 100% specificity. In patients with IPMNs other than IC-IPMC, multivariate analysis demonstrated 3 significant predictive factors of malignancy: IPMN size (>40 mm), IPMN duct type (main pancreatic duct or mixed type), and the presence of a mural nodule or thick septum. The diagnostic score obtained using these 3 factors showed a strong correlation with the presence of malignancy. For preoperative evaluation of patients with IPMN, it is recommended to rule out IC-IPMC using multidetector-row computed tomography and then to categorize IPMN other than IC-IPMC according to malignant potential based on the diagnostic score.

18F-FDG PET Findings and GLUT-1 Expression in IPMNs of the Pancreas

TO THE EDITOR: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are tumors characterized by the intraductal proliferation of neoplastic mucinous cells in the main pancreatic duct or its major branches ( [1][1],[2][2] ). IPMNs are classified as noninvasive or invasive, and noninvasive

Synchronous and Metachronous Extrapancreatic Malignant Neoplasms in Patients with Intraductal Papillary-Mucinous Neoplasm of the Pancreas

Background/Aims: Patients with intraductal papillary-mucinous neoplasm (IPMN) of the pancreas are likely to have a better prognosis than those with conventional pancreatic ductal adenocarcinoma. Recently there have been some reports on extrapancreatic malignant neoplasms (EPM) occurring in patients with IPMN. The purpose of this study was to discover the characteristic features of IPMN with EPM compared with IPMN without EPM. Methods: 61 patients with IPMN who underwent surgery at Tohoku University Hospital between 1988 and 2006 were retrospectively analyzed. Results: The 61 patients with IPMN in this study comprised 25 with intraductal papillary-mucinous adenomas (IPMA) and 36 with intraductal papillary-mucinous carcinomas (IPMC) including 6 with invasive carcinomas. Synchronous and metachronous EPM were observed in 15 out of the 61 patients (24.6%). Three of these patients, including 2 with IPMA and 1 with invasive carcinoma associated with IPMC, died of the EPM. None of the features, including sex, age, smoking, family history, macroscopic types (main duct type or branch duct type), histological types (gastric, intestinal, pancreatobiliary or oncocytic), and aberrant expression of molecules including CDKN2A, TP53, SMAD4 and DUSP6, except for the histological diagnoses were associated with the occurrence of EPM, i.e., the EPM occurred more often in patients with IPMA (10 out of 25) than in those with IPMC (5 out of 36) in our series (p = 0.0199 by the χ2 test, p = 0.0330 by Fisher's exact probability test, p = 0.0422 by Yates' correction). Conclusion: Patients with IPMA were more likely to have EPM than those with IPMC. Patients with IPMA are usually expected to have a fair prognosis but EPM could be fatal in some of them, so it must be noted during follow-up.

Ultrasonographic findings and natural history of intraductal papillary-mucinous neoplasms of the pancreas.

It is clear that the prevalence of malignancy is high in the main-duct type of intraductal papillary-mucinous neoplasm (IPMN). Branch-duct IPMNs include several histologic conditions such as carcinoma, adenoma, and hyperplasia. Intraductal papillary adenocarcinoma and papillary adenoma are characterized by papillary protrusions and thick septum-like structures in dilated ducts as delineated by ultrasonography. A solid mass showing a mixedecho pattern in the pancreatic parenchyma is a characteristic finding of invasive types of IPMN. The international guidelines for the management of branch-duct IPMNs suggest that the appearance of symptoms attributable to the cyst, the presence of intramural nodules, a cyst size greater than 30 mm, and dilation of the main pancreatic duct (>6 mm) are indications for resection. Based on the relationship between the height of a papillary protrusion and the diameter of a cystic dilated branch as well as on histological findings, branch-duct IPMNs with papillary protrusions more than 10 mm in height as shown by imaging should be resected, and it is not adequate to differentiate carcinoma from other lesions based on the diameter of cystic branches alone. A follow-up study on branch-duct IPMNs revealed that most papillary protrusions showed a slow increase in size or development of lateral spread, and that there was no development of cancer with stromal invasion during an average follow-up of 46 months. Therefore, the presence of intramural nodules alone should not be an indication for surgery. Also, patients without papillary protrusions or thick septum-like structures are not immediate candidates for surgery. Invasive adenocarcinoma can develop at a pancreatic site different from the area of interest showing cystic changes, with such invasion possibly being multicentric. Therefore, in patients with branch-duct IPMNs, attention should be paid to the entire pancreas when performing follow-up examinations.

Outcome of Invasive and Noninvasive Intraductal Papillary‐Mucinous Neoplasms of the Pancreas (IPMN): A 10‐year Experience

Intraductal papillary-mucinous neoplasms (IPMN) were officially introduced into the TNM classification in 1996. Based on a two-center database, we reevaluated histopathological findings, clinicopathological pattern, predictive markers for malignancy, and outcome. Between 1996 and 2006, a total of 1424 pancreatic resections were performed in the University Hospitals Dresden and Mannheim. Pathologists of both institutions reviewed the IPMN diagnoses and other with cystic or solid tumor diagnoses. All possible markers, such as diabetes, jaundice, etc., were analyzed for prediction of malignancy. We performed a survival analysis based on the morphologic classification to determine the prognosis of IPMN. There were 43 patients of primarily diagnosed IPMN along with 1174 patients with diagnoses, such as ductal adenocarcinoma. In 207 patients, the diagnoses revealed other cystic or small solid tumors. A histopathological review of the latter patients revealed 54 IPMNs, resulting in a total of 97 IPMN patients (29 noninvasive, 68 invasive). All IPMN patients had a median survival of 36 months. Recurrence occurred more frequently in invasive IPMN. Predictive markers of malignancy were pain, preoperative weight loss, jaundice, and elevated CA 19.9. The strongest independent prognostic factor was invasive growth. The survival analysis revealed excellent prognosis for noninvasive IPMN. Since the introduction of IPMN in 1996, even specialized centers have had to deal with a learning curve. By reevaluating all cystic or small solid tumors, centers can improve and their patients' treatment can be optimized. Because the preoperative diagnostic methods are not sensitive enough to differentiate between benign and malignant lesions, surgery is advocated for all main duct IPMN, because they have a high malignant potential. For branch duct IPMN, surgery is advocated if the lesion is symptomatic, >3 cm, or has enlarged nodules.

Experience With 208 Resections for Intraductal Papillary Mucinous Neoplasm of the Pancreas

Intraductal papillary mucinous neoplasm (IPMN) is an increasingly recognized disease of the pancreas. We report our experience with pancreatic resection for IPMN. Retrospective review from 1992 through 2005 with additional independent histopathologic confirmation. Mayo Clinic Rochester, a tertiary care center. All patients who underwent primary resection for pancreatic IPMN. Disease-specific operative outcomes, survival, and recurrence patterns. Of 208 patients (mean age, 66 years) with IPMN of the pancreas, 168 underwent partial pancreatectomy, and 40 underwent total pancreatectomy; 88 were classified as having adenoma, 38 as having borderline neoplasm, 19 as having carcinoma in situ, and 63 as having invasive carcinoma. The prevalence of a malignant neoplasm was 64% in patients with main duct IPMN compared with 18% in patients with branch duct IPMN. Re-resection of the initial pancreatic margin was necessary in 21% of patients. Final negative margins were achieved in 89% of patients. Five-year survival with noninvasive IPMN was 94%. Patients with invasive IPMN had a similar 5-year survival compared with a matched cohort with ductal adenocarcinoma (31% vs 24%; P = .26). In patients with invasive IPMN, 58% experienced disease recurrence. In patients with noninvasive IPMN, 10% experienced disease recurrence after partial pancreatectomy and 0% experienced disease recurrence after total pancreatectomy. Patients with main duct IPMN or high-risk branch duct IPMN should be considered for targeted pancreatectomy. Invasive IPMN behaves as aggressively as ductal adenocarcinoma, but resection seems to provide the only potential for cure. Even with negative resection margins, the pancreatic remnant harbors a risk of recurrence and, thus, careful long-term surveillance is warranted.

Usefulness of Contrast-Enhanced Endoscopic Ultrasonography (CE-EUS) in the Diagnosis of Mural Nodule of Intraductal Papillary Mucinous Neoplasms of the Pancreas. The Comparison of the CE-EUS Findings with the Pathological Findings

Background: Intraductal papillary mucinous neoplasms of the pancreas (IPMNs) vary histopathologically from benign to malignant lesions. Diagnostic and therapeutic strategies still remain unresolved in the international consensus guidelines for management of IPMNs, (proposed on 2006). The purpose of this study is to define “mural nodules” by the comparison of CE-EUS findings with the pathological findings. (Patients and Methods) Two hundred ninety-four patients with IPMNs examined by CE-EUS as the initial diagnostic modality since January, 2001 were enrolled. Eighty-seven cases were surgically treated. Our indications for resection were as follows: the case of main-duct type, existence of nodular projection “mural nodule” with blood flow signal in CE-EUS and coexistence of ductal cancer cases. We classified “mural nodule” into 4 types on the basis of morphological EUS findings. Type1 (low papillary type): low papillary projection spreading along the cystic wall or main pancreatic duct. Type2 (polypoid type): polypoid projection with smooth surface sparsely existing. Type3 (villous type):thickened cyst wall or main duct with villous or irregular surface structure. Type4 (invasive type):.hypoechoic blurred area located between pancreatic parenchyma and lesions (Type1-3). Target lesions were observed by EUS, then, CE-EUS were examined to identify the “mural nodule” with color signals. . Contrast agent (Levovist; Schering, Japan) was injected intravenously, and enhancement effect (color Doppler flow imaging) was estimated. The endoscopes used were EG-3630UR/EG-3760URK (Pentax) and ultrasound systems were EUB-8500,HV-900 (Hitachi). (Results)Eighty seven patients were resected (main-duct type, 14; mixed type, 25; branch-duct type, 48). There were 42 with adenoma, 25 with carcinoma in situ, 16 with invasive carcinoma derived from IPMN, and 3 with coexistence ductal cancer and no hyperplastic case. Malignant cases were 11/14 (78.6%) in main-duct type, 14/25 (56.0%) in mixed type and 21/48 (43.8%) in branch-duct type. In comparison of CE-EUS findings with pathological findings, papillary projection observed by EUS represented the epithelial change at least 500-750μm in diameter . Malignant cases were Type1(25%), Type2 (38.5%), Type3 (93.1%),and Type4 (91.7%), respectively. When IPMNs with Type3/4 were diagnosed as malignant, accuracy was up to 75.9%. Conclusion: “Mural nodules” diagnosed by CE-EUS represents very fine epitherial changes in IPMNs. CE-EUS is very useful in the diagnosis of malignant potential and the distribution of IPMNs.

T1735 Management of Intraductal Papillary-Mucinous Neoplasms of the Pancreas (IPMN) - a 10-Years Experience in Two Pancreatic Centers in Germany

T1735 Management of Intraductal Papillary-Mucinous Neoplasms of the Pancreas (IPMN) - a 10-Years Experience in Two Pancreatic Centers in Germany

W1413 Proteomic Assessment of Markers for Malignancy in the Mucus of Intraductal Papillary Mucinous Neoplasms of the Pancreas (IPMN)

W1413 Proteomic Assessment of Markers for Malignancy in the Mucus of Intraductal Papillary Mucinous Neoplasms of the Pancreas (IPMN)

404 Acute Pancreatitis (AP) in Patients with Intraductal Papillary Mucinous Neoplasms of the Pancreas (IPMN): Frequency, Severity and Correlation with Tumors Characteristics

404 Acute Pancreatitis (AP) in Patients with Intraductal Papillary Mucinous Neoplasms of the Pancreas (IPMN): Frequency, Severity and Correlation with Tumors Characteristics

Pancréatite auto-immune mimant une tumeur intracanalaire papillaire et mucineuse : une observation originale et trompeuse

In recent years, autoimmune pancreatitis (AIP) has been increasingly recognized. It can be associated with diabetes mellitus and other systemic autoimmune diseases, or with bile ducts lesions, which are also responsive to steroid therapy as pancreatic lesions. We report the case of a 34-year-old man with a history of a first acute pancreatitis, attributed to an intraductal papillary-mucinous neoplasm of the pancreas (IPMN) with segmental involvement of the main pancreatic duct. A spleno-pancreatectomy was performed, and pathological examination of the specimen diagnosed autoimmune pancreatitis. A treatment with corticosteroids was carried out. To our knowledge, this is the first reported case of AIP mimicking IPMN of the main pancreatic duct.

Characteristic Clinicopathological Features of the Types of Intraductal Papillary-Mucinous Neoplasms of the Pancreas

Intraductal papillary-mucinous neoplasm (IPMN) of the pancreas encompasses a spectrum of neoplasms with both morphological and immunohistochemical variations of mucin glycoproteins. Recently, a consensus nomenclature and criteria were histologically defined for classifying these variants of IPMNs into gastric, intestinal, pancreatobiliary, and oncocytic types. The purpose of this study was to determine associations between the histological types and clinicopathological features in patients with IPMN. Sixty-one patients with IPMN operated upon at Tohoku University Hospital between 1988 and 2006 were retrospectively analyzed. Our series included 27 gastric-, 29 intestinal-, 4 pancreatobiliary-, and 1 oncocytic-type IPMNs. Statistically, the types of IPMN were significantly associated with the histological diagnoses, macroscopic types, and survival of the patients. Characteristically, the gastric-type IPMNs were likely to be diagnosed as benign, to be confined to branch ducts, and to have fair prognoses. On the other hand, the intestinal-type IPMNs were likely to be diagnosed as malignant, occupy the main duct, and have poor prognoses. Because of the small number of pancreatobiliary-type IPMNs and only 1 case of oncocytic-type IPMN, we were unable to determine any of their clinicopathological characteristics in our series. Evaluation of the histological types of IPMN may help to predict the clinical course of patients with IPMN and to design improved clinical management for these patients.

Poorly differentiated endocrine carcinoma and intraductal papillary-mucinous neoplasm of the pancreas: Description of an unusual case

Neuroendocrine tumors and intraductal papillary-mucinous neoplasms constitute histologically distinctive but relatively rare entities among pancreatic tumors. Collision of these tumors is extremely rare and causes several diagnostic problems regarding the histopathologic differential diagnosis of other pancreatic epithelial tumors. The question of whether the neoplastic populations originate from common progenitor cell or whether they represent only a fortuitous association has not been sufficiently explained. Here, we describe a new case of poorly differentiated endocrine carcinoma combined with an intraductal papillary-mucinous neoplasm. To disclose the relationship between the two histologic components, neuroendocrine differentiation was studied by confocal laser scanning microscopy using double immunofluorescence labeling with chromogranin-A and CD57 antibodies. Our results revealed a co-localization of both antigens in neuroendocrine cells of the intraductal papillary-mucinous neoplasm. The finding has previously been described in non-neoplastic neuroendocrine cells. Cells forming poorly differentiated endocrine carcinoma showed a wide heterogeneity in immunoreactions. Our results do not indicate a potential histogenetic similarity between these two neoplasms, which are dissimilar histologically, and underline the previous thesis that cells in intraductal papillary-mucinous neoplasm revealing neuroendocrine differentiation represent only a non-neoplastic cell admixture.

Intraductal papillary mucinous neoplasm of the pancreas; resection and cancer prevention

Surgical indications or method of resection for intraductal papillary mucinous neoplasm of the pancreas (IPMN) are controversial. The aim of the current study was to evaluate surgical indications including cancer prevention and selection of specific surgical procedures. A group of 244 patients who underwent pancreatectomy for IPMN from 1981 to 2005 was examined retrospectively for clinicopathologic features. Carcinomas (carcinoma in situ + invasive carcinoma) were observed in 72% of the patients with main duct IPMN. The mural nodules for patients with carcinomas were larger than 3 mm. The maximum diameter of branch duct IPMN for patients with borderline atypia was larger than 30 mm. Lymph node metastasis and extrapancreatic invasion were observed only in patients with invasive carcinoma. In limited pancreatic resection, pancreatic fistulae were observed in 7.9% of patients. The indication for IPMN resection, including for cancer prevention, is lesions above IPMN with borderline atypia (main duct IPMN, mural nodule ≥3 mm, maximum diameter of branch duct IPMN ≥30 mm). A pancreatectomy with lymph node dissection should be performed for invasive IPMNs and a limited pancreatic resection has a role for noninvasive IPMNs.

Proposed new score predicting malignancy of intraductal papillary mucinous neoplasms of the pancreas

Background Our objective was to predict malignancy for intraductal papillary mucinous neoplasms of the pancreas (IPMN) before operation. Methods Sixty-four resected patients with IPMN were examined and 17 parameters were investigated for their relation to malignancy by univariate and multivariate analysis. Results Multivariate logistic regression analysis showed that IPMN type, the size of main pancreatic duct, and serum carbohydrate antigen 19-9 were significant for malignancy. Size of the main pancreatic duct ≥6.5 mm and serum carbohydrate antigen 19-9 ≥35 U/mL scored 3 points, main duct type scored 2 points, and patulous papilla, jaundice, diabetes mellitus, and tumor size ≥42 mm scored 1 point. When IPMNs with 3 and more than 3 points using the new score were diagnosed as malignant, accuracy was 90.6%. Conclusion This scoring system for IPMN is feasible to detect malignancy and useful for selecting an appropriate treatment.

Natural history of branch duct intraductal papillary-mucinous neoplasms of the pancreas without mural nodules: long-term follow-up results

Background and aim:Although branch duct intraductal papillary-mucinous neoplasms (IPMNs) of the pancreas without mural nodules are frequently observed in asymptomatic subjects, the natural history of these lesions has never been...

Molecular genetics of intraductal papillary–mucinous neoplasms of the pancreas

Intraductal papillary-mucinous neoplasms of the pancreas show characteristic clinicopathological and molecular pathobiological features which are distinct from those of conventional ductal adenocarcinomas. Alterations of KRAS, AKT/PKB, CDKN2A, TP53, SMAD4, STK11/LKB1, and DUSP6, and other molecular alterations, including global expression studies as well as their clinical implications, are discussed.