Main Duct Intraductal Papillary Mucinous Neoplasms Research Articles

Intraductal Papillary Mucinous Neoplasm of the Minor Pancreatic Duct in Pancreas Divisum: A Case Report

Intraductal papillary mucinous neoplasms (IPMN) are potentially malignant intraductal epithelial neoplasms that are composed of mucin-producing columnar cells. The lesions show papillary proliferation, cyst formation, and may involve the main pancreatic duct, the branch ducts, or both. IPMNs have varying degrees of malignant potential based on anatomic location, with main duct lesions progressing in 38-68% of cases. Therefore, surgical removal is indicated for these types of lesions. Most patients are asymptomatic and incidental diagnosis is made with advances in imaging and endoscopic procedures. Here we report a case of a 66-year-old male with a history of pancreas divisum and family history of pancreatic cancer who presented with pancreatitis. Initial symptoms were progressively worsening mid-epigastric pain with elevated amylase and lipase levels. After initial medical treatment for his pancreatitis, further evaluation with upper endoscopy showed a patulous minor papilla with a “fish eye” appearance that excreted mucin. Endoscopic ultrasound identified a markedly dilated pancreatic duct in addition to an anatomic variation called pancreas divisum. Subsequent ERCP with SpyGlass DS pancreatoscopy revealed a papillary lesion at the junction of the head and body of the pancreas. Biopsy confirmed the diagnosis of this main duct IPMN. Pancreatic divisum is an anatomic variant which results when the embryologic dorsal and ventral pancreatic ducts fail to fuse properly. Our background research revealed only a few reported cases of IPMN and pancreas divisum occurring in tandem. It has been noted that IPMN in the setting of pancreas divisum carries a higher rate of malignancy. Surgical intervention based on the Sendai and Fukuoka consensus is appropriate for IPMNs and is indicated in main duct IPMN in the setting of pancreas divisum, since these patients have better survival with surgical removal. This case emphasizes the need to appropriately evaluate patients presenting with pancreatitis, as there is a possibility of an underlying malignant process.

A Rare Plug in the Pipe: Intraductal Tubular Adenoma of the Pancreas

Background: Intraductal lesions of the pancreas are uncommon but increasingly recognized because of advances in radiological technology. Intraductal tubular (IT) adenoma are extremely rare and are incompletely understood. These lesions have similar clinical, and radiological presentations and therefore a definitive histological diagnosis is crucial for appropriate management, surveillance and outcomes. Case: A 79-year-old man presented with abdominal discomfort. Contrast CT of the abdomen revealed a 1.7x2.2 cm pancreatic body mass with upstream ductal dilation concerning for a pancreatic neoplasm. Endoscopic ultrasound demonstrated a 1.8 cm x 2.1 cm intraductal mass in the body of the pancreas with upstream ductal dilation suspicious for a main duct IPMN with mural nodularity. FNA revealed ductal epithelium without dysplasia or malignant cells. Extracellular mucin was present. He underwent a distal pancreatectomy and splenectomy. Surgical pathology (Image 3) was consistent with IT adenoma, pyloric gland type with mild dysplasia and a minor component of IPMN with focal moderate dysplasia. His postoperative course was unremarkable. Discussion: Pancreatic intraductal tumors are divided into IPMNs and IT neoplasms. IT neoplasms are further divided into IT adenoma and IT carcinoma as based on histological epithelial atypia that is present. IT adenomas have no gender predilection and the lesions occur in those within the 5th to 7th decade of life. Most patients are asymptomatic or have nonspecific symptoms. Imaging can show a dilated duct with filling defect and varying amounts of mucin. EUS may show a protruding/nodular mass, which is regarded as a malignant feature in lesions like IPMN. Grossly, they appear polyploid, often occluding the lumen resulting in cystic dilation of the duct. Histologically, ITAs have epithelial lining, which is columnar with apical mucin and basally oriented nuclei, which show low-grade cytological atypia. ITAs share similarities with IPMN. They have similar Mucinex brush and profiles, which include MUC6 and MUC5AC. They may also share common mutations of GNAS and KRAS. However, there is a difference, which may help to differentiate ITA from IPMN. ITA pyloric type lesions tend to occur in the main pancreatic duct whereas gastric type IPMNs are mainly in the branch ducts. Limited information exists on intraductal lesions such as IPMNs, ITAs and ITCs. Appropriate workup will help with accurate diagnosis, management and surviellance.Figure 1

Pancreatic juice cytology under ERCP for main duct or mixed type IPMN is feasible in view of post-ERCP pancreatitis rate and sensitivity of cytology

Pancreatic juice cytology under ERCP for main duct or mixed type IPMN is feasible in view of post-ERCP pancreatitis rate and sensitivity of cytology

Helicobacter pylori is undetectable in intraductal papillary mucinous neoplasm

BackgroundAbout half of the world population is infected with Helicobacter pylori (H. pylori), a bacterium associated with gastric cancer and considered to be a risk factor for pancreatic ductal adenocarcinoma. Whether the bacterium is associated with intraductal papillary mucinous neoplasm, believed to be a precursor of pancreatic ductal adenocarcinoma, is unknown. The aim of this study was to investigate the presence of H. pylori DNA in tissue sections of intraductal papillary mucinous neoplasm. MethodsThe presence of H. pylori DNA was tested in a retrospective controlled study of formalin-fixed, paraffin-embedded pancreatic tissues from 24 patients who underwent surgery for intraductal papillary mucinous neoplasm. Histologically normal tissues surrounding neoplasms were used as control. H. pylori DNA was evaluated after deparaffinization, DNA extraction, and purification, and results were evaluated statistically. ResultsSamples were collected from 13 males and 11 females with mean age 59 years (range 44–77), and consisted of 19 cases of main-duct and three cases of branched-duct intraductal papillary mucinous neoplasm. Two patients were diagnosed with pancreatic cancer and main-duct intraductal papillary mucinous neoplasm. H. pylori DNA was not detected either in intraductal papillary mucinous neoplasm tissue, or in surrounding normal tissue. ConclusionsAlthough H. pylori has been implicated in pancreatic ductal adenocarcinoma, it may not play a key role in the development of intraductal papillary mucinous neoplasm.

Improving Technology Permits Accurate Diagnosis and Localization of Main Duct IPMN

Improving Technology Permits Accurate Diagnosis and Localization of Main Duct IPMN

Pancreatic cyst epithelial denudation: a natural phenomenon inthe absence of treatment.

The presence and significance of epithelial denudation among treatment-naïve pancreatic cystic lesions (PCLs) remain undetermined. The aims of this study were to determine the prevalence, extent, and predictors of epithelial denudation in treatment-naïve PCLs. Single-center retrospective study including patients who underwent EUS preceded by cross-sectional imaging and who subsequently underwent surgical resection of treatment-naïve PCLs. Surgically resected PCLs were reviewed by a pathologist in a fashion that allowed evaluation from evenly distributed regions of the cyst. A total of 140 patients were identified (60% female, mean age 63 years). Eighty-five cysts (60.7%) were classified as intraductal papillary mucinous neoplasms (IPMNs), 33 (23.5%) as main duct IPMNs (m-IPMNs), 11 (7.9%) as serous cystadenomas (SCAs), and 11 (7.9%) were composed of other cyst subtypes. A greater extent of epithelial denudation was seen in mucinous cystic neoplasm (MCN) compared with IPMN and SCA (mean percentage of denuded epithelium 45.1%, 10.8%, and 22.4%, respectively [P< .0001]). An association existed between the extent of denuded epithelium and degree of cyst epithelial dysplasia for IPMN and MCN combined (mean percentage of denuded epithelium for low-, moderate-, and high-grade dysplasia being 23.3%, 4.5%, and 1.2%, respectively; P= .02). PCLs resected from the neck and/or body and/or tail of the pancreas were associated with a greater extent of mean percentage of denuded epithelium than PCLs resected from the head and/or uncinate of the pancreas (23.9% vs 13.4%; P= .035). The presence and extent of cyst epithelial denudation of treatment-naïve PCLs vary with cyst histology and other factors. The observation of denudation after intracystic ablative therapy may not provide an adequate metric of successful intervention. Further studies are needed to validate these findings.

Recurrence and Survival After Resection of Small Intraductal Papillary Mucinous Neoplasm-associated Carcinomas (≤20-mm Invasive Component): A Multi-institutional Analysis.

Early invasive carcinoma may be encountered in association with intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. The natural history of these early invasive lesions is unknown. Pancreatic surgical databases from 4 high-volume centers were queried for IPMNs, with invasive components measuring 20 mm or less. All cases were reviewed by GI gastrointestinal pathologists, and pathologic features were analyzed to identify predictors of recurrence and survival. A total of 70 small IPMN-associated invasive carcinomas (≤20-mm invasion) were identified, comprising 25% of resected IPMN-associated carcinomas (n = 280). Most of these small invasive cancers were multifocal (66%), less than 10 mm in size (73%), and arose in the setting of a main duct IPMN (96%). The most common adenocarcinoma subtypes were tubular (57%) and colloid (29%). Lymph node metastases were present in 19% of cases and 23% were T3 lesions. The overall recurrence rate was 24% (n = 17), and the median time to recurrence was 16 months (range: 4-132 months). Median and 5-year survival rates were 99 months and 59%. Recurrence patterns of invasive disease were local in 35%, distant in 47%, and both in 18%. Lymphatic spread and T3 stage were predictive of recurrence (univariate, P = 0.006), whereas tubular carcinoma type was the most predictive of poor overall survival (multivariate hazard ratio = 3.7, P = 0.04). This study represents the largest multi-institutional experience of resected small IPMN-associated carcinoma. Although these malignancies may frequently be cured with resection, recurrence risk is significant. Lymphatic spread, increased T stage, and tubular type carcinoma were associated with the poorest outcome.

Validity of the management strategy for intraductal papillary mucinous neoplasm advocated by the international consensus guidelines 2012: a retrospective review.

The aim of this study was to investigate the validity of the management strategy for intraductal papillary mucinous neoplasms (IPMNs) advocated by the international consensus guidelines 2012 (ICG2012). The medical records of 49 patients who underwent pancreatectomy for IPMN were retrospectively reviewed. According to preoperative imaging, 10 patients (20%) had main-duct IPMNs, 20 (41%) had mixed IPMNs, and 19 (39%) had branch-duct IPMNs, with malignancy frequencies of 80, 15, and 37%, respectively. Twenty-seven patients had high-risk stigmata and 21 had worrisome features, with malignancy frequencies of 59 and 10%, respectively. The sensitivity, specificity, and positive and negative predictive values of high-risk stigmata for malignancy were 88, 65, 59, and 91%, respectively. Lesions were malignant in 88% of patients with an enhanced solid component, which was significantly correlated with the prevalence of malignancy (P<0.01). However, of the 10 patients who underwent pancreatectomy solely due to a main pancreatic dilation of ≥10mm, 9 (90%) had benign IPMNs. Many mixed IPMNs defined according to ICG2012 are benign. Although the management strategy advocated by ICG2012 has been improved relative to the Sendai criteria, the different high-risk stigmata carry unequal weights. Consequently, ICG2012 remains suboptimal for predicting malignant IPMN.

Intraductal papillary mucinous neoplasms of the pancreas with concurrent pancreatic and periampullary neoplasms

BackgroundIntraductal papillary mucinous neoplasms (IPMN) have been reported to be associated with concurrent, distinct pancreatic ductal adenocarcinoma (con-PDAC) in about 8% (range, 4–10%) of resected branch duct (BD) lesions. In addition, other pancreatic and ampullary tumors are occasionally diagnosed with IPMN in patients undergoing pancreatic surgery. The objective of this study is to describe the prevalence, clinicopathologic characteristics and prognosis of IPMN with concurrent pancreatic and ampullary neoplasms, especially con-PDAC. MethodsThe combined databases of pancreatic resections from the Massachusetts General Hospital and the Negrar Hospital, Italy, were analyzed for patients who had been diagnosed with IPMN and concurrent pancreatic or ampullary neoplasms. Results2762 patients underwent pancreatic surgery from January 2000 to December 2012. Sixteen percent (n = 441) had pathologically confirmed IPMN and 11% of these (n = 50) had a different distinct synchronous pancreatic neoplasm. The majority of these, 62%, were con-PDAC, followed by neuroendocrine neoplasms (10%) and ampullary carcinoma (10%). Less frequently, mucinous (6%) as well as serous cystic neoplasms (6%), adenosquamous carcinoma (4%) and distal bile duct cancer (2%) were diagnosed. Among all patients with synchronous neoplasms, 66% harbored BD-IPMN, 28% combined IPMN and 6% main duct IPMN. Abdominal pain and/or jaundice were the leading symptoms in half of patients. ConclusionIPMN, mainly BD-IPMN, are associated with con-PDAC in about 7% of patients and account for 62% of all concurrent pancreatic/ampullary neoplasms. Other synchronous neoplasms may be found sporadically with IPMN without a suspected association.

Main-duct Intraductal Papillary Mucinous Neoplasm: High Cancer Risk in Duct Diameter of 5 to 9 mm.

The 2012 international consensus guidelines for the management of intraductal papillary mucinous neoplasms (IPMN) recommend surgical treatment in main-duct IPMN patients with a main pancreatic duct (MPD) diameter of ≥10 mm. Aim of the present study was to analyze cancer risk in patients with an MPD diameter of less than 10 mm. All consecutive patients (prospective data protocol) with histological proof of IPMN who underwent surgery between January 2004 and December 2013 were included in the study. Clinical characteristics, particularly preoperative imaging with regard to morphology of the MPD, were correlated with final histopathology. Among a total of 605 patients who underwent surgery for IPMN, there were 320 patients with MPD involvement, 238 patients with mixed-type IPMN, and 82 patients with main-duct IPMN alone. The total malignancy rate including high-grade dysplasia and invasive carcinoma in IPMNs with MPD involvement was 68%. When the MPD diameter was 5 to 9 mm, malignancy rate was 59%, whereas in MPD diameter more than 10 mm, it was 73%. No statistical correlations were observed between MPD diameter and clinical and/or IPMN features such as age, cyst location, mural nodules, serum tumor markers, or bilirubin. Main-duct IPMNs with a MPD between 5 and 9 mm already bear a significant risk of malignancy. Therefore, surgical treatment is clearly indicated in patients with a MPD diameter of ≥5 mm and the 2012 guidelines should be discussed and adapted with regard to this topic.

Cystic Lesions of the Pancreas: Observe or Operate.

Cystic Lesions of the Pancreas: Observe or Operate.

Diffuse Involvement of Mixed-Type IPMN

Introduction: The malignant potential of intraductal papillary mucinous neoplasm (IPMN) of the pancreas is associated with involvement of the main pancreatic duct. We present a case of a multi-cystic IPMN involving the main pancreatic duct and its side branches. Case: A 72-year-old male with a medical history of stroke and tobacco use presented with a 3-week history of abdominal pain, along with unintentional weight loss of 40 lbs over the last year. A CT scan showed a grossly abnormal pancreas with a multi-macrocystic mass centered at the head of the pancreas, measuring approximately 5.7 cm x 7.0 cm. The extrahepatic and intrahepatic bile ducts demonstrated marked dilatation. Laboratory evaluation was significant for total bilirubin 3.8 mg/dL, alkaline phosphatase 758 U/L, AST 79 U/L and ALT 107 U/L. The patient underwent EUS showing multi-cystic replacement of the majority of the pancreas parenchyma. The pancreatic duct was dilated to 12 mm in the head of the pancreas. The common bile duct was dilated to 17 mm and abruptly terminated in the head of the pancreas due to the obstructing cyst. Cyst aspirate was performed and sent for analysis. Cytology of the cystic fluid showed acute inflammatory cells and proteinaceous debris, suggestive of a pseudocyst. The fluid amylase and CEA were elevated to 10,205 U/L and >1500 ng/mL, respectively. Serum CA 19-9 was elevated to 230 U/mL. These findings are consistent with a mixed-type IPMN, which has a similar risk for malignancy as a main-duct IPMN. According to the Fukuoka guidelines, this patient had high-risk stigmata of malignancy including obstructive jaundice and main pancreatic duct > 10 mm. Therefore, he underwent a total pancreatectomy with pathology revealing invasive mucinous carcinoma arising in the background of extensive IPMN. The surgical margins were free of involvement, and he is being treated with adjuvant chemotherapy. Discussion: Multi-cystic lesions of the pancreas can often appear as pseudocysts, but may in fact represent mixed-type IPMN. Most IPMNs are solitary, but 5-10% involve the entire gland. Further evaluation of these lesions is essential, as mixed-type IPMN carries a similar risk of malignancy as main-duct IPMN.Figure 1Figure 2Figure 3

Fistulizing/Perforating IPMN: Closure Using OVESCO over the Scope Clip

Introduction: Intraductal papillary mucinous neoplasm (IPMN) is a malignant cystic neoplasm of the pancreas involving the main pancreatic duct, the branch ducts or both. We describe a rare presentation of fistulizing/perforating IPMN and treatment course Methods: A 71-year-old obese Caucasian male presented with right upper quadrant (RUQ) abdominal pain and fever. A RUQ ultrasound showed 4 mm CBD and normal gallbladder. Labs showed mild leukocytosis, anemia, total bilirubin 1.4 mg/dL, normal liver function tests and lipase 22 U/L. CT scan of abdomen and pelvis showed ill-defined low-density linear collection extending from the posterior aspect of the duodenal bulb towards pancreas with specks of air suspicious for perforated duodenal ulcer and atrophic pancreas. Pancreatic duct however was massively dilated to 8 mm. These findings were confirmed by an MRI. Results: Upper endoscopy showed fistula/perforation in the duodenal bulb with mucin extruding. A side-viewing duodenoscope showed a patulous papilla with mucin extruding confirming main-duct IPMN. With radiological and endoscopic concern for duodenal perforation and resulting complication of pseudomyxoma peritonei, the site was closed using over the scope clip (OVESCO-OTSC) successfully (image 5). CEA was 3.9 ng/ml and CA 19-9 was 2418 U/mL. Patient declined surgical intervention and was discharged home. Conclusion: IPMN first described in 1982 is a malignant cystic neoplasm of pancreas involving the main pancreatic duct, the branch ducts or both. Histologically, IPMNs are classified as intestinal type, pancreatobiliary type, oncocytic type and gastric type. Risk of invasive carcinoma is 70% with main duct involvement v/s 2-20% with branch duct. Surgery is the definitive treatment. ERCP showing patulous papilla with mucin extruding is pathognomonic for IPMN. IPMN are often asymptomatic and an incidental radiological finding. Invasion of the tumor into nearby structures with fistula formation have been infrequently reported. The rates of internal fistulization are felt to be highest into the duodenum (50%), followed by bile duct (35%) and stomach (15%). Pathogenesis of fistulization/perforation is either due to mass effect or mechanical pressure created by either direct expansion or stromal invasion of tumour. Patients can also present with pancreatitis due mucin plugs in the pancreatic ducts. This case highlights the rare presentation of fistulizing/perforating IPMN and our treatment experience.Figure 1

A New Era in Digital Cholangio-Pancreatoscopy: A Case Series

FigureIntroduction: Intraductal biliary-pancreatic endoscopy has enhanced the diagnostic and therapeutic potential of ERCP. Image resolution and mechanical capabilities of available technologies were less than satisfactory. A new single operator, through the scope, high resolution digital cholangio-pancreatoscope (HRDCP) has just been introduced. We present 3 cases, highlighting the multifaceted capability of this new technology Methods: Case 1: 22 yr F presented with RUQ pain, elevated LFTs. Sonogram revealed gallstones, dilated CBD. EUS revealed CBD stone. ERCP revealed a large-faceted CBD stone. High resolution digital cholangioscopy (HRDC) with electrohydraulic lithotripsy (EHL) was performed with stone fragmentation/removal in single session. Easy maneuverability of the intraductal scope and high resolution imaging allowed effective and quick stone management. Patient discharged home same day, referred for cholecystectomy. Case 2: 90 yr F presented with weight loss, elevated alkaline phosphatase, new onset diabetes. MRI abdomen revealed dilated (10 mm) pancreatic duct (PD) and pancreatic head cystic lesion. EUS confirmed these findings. ERCP with high resolution digital pancreatoscopy revealed numerous papillary projections in the main PD, c/w IPMN. Intraductal biopsies confirmed main duct IPMN with dysplasia. Patient chose conservative management. Case 3: 64 yr M with decompensated cirrhosis presented with RUQ pain, elevated LFTs. Sonogram confirmed acute cholecystitis. Patient was non-surgical candidate due to advanced liver disease; he refused percutaneous Gallbladder drainage. ERCP with cystic duct cannulation was unsuccessful. HRDC was used to selectively cannulate the cystic duct, facilitate cystoscopy, enable successful gall bladder stentingdrainage. Patient was discharged home after 2 days. Results: The most recent and dramatic development in ERCP is the advent of high resolution/digital intraductal imaging. We present 3 patients with diverse pancreatico-biliary pathology, who were successfully managed at single session ERCP using the new digital cholangio-pancreatoscope. All procedures were performed under GA. There were no immediate or delayed complications in any patient. Conclusion: This new device represents a major advance in intraductal imaging and therapeutics, heralding a new era in ERCP with increased minimally invasive management options for our patients.

Are preoperative blood neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios useful in predicting malignancy in surgically-treated mucin-producing pancreatic cystic neoplasms?

The aim of this study was to determine if neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were predictive of malignancy in mucin-producing pancreatic cystic neoplasms (MpPCN). One hundred and twenty patients with MpPCN were retrospectively reviewed. Malignant neoplasms were defined as neoplasms harbouring invasive carcinoma or high grade dysplasia. A high NLR and PLR were defined as ≥2.551 and ≥208.1, respectively. High NLR was significantly associated with symptomatic tumors, larger tumors, solid component, main-duct IPMN, and Sendai high risk category. High PLR was significantly associated with jaundice and Sendai high risk category. On univariate analyses, symptomatic tumors, jaundice, solid component, dilated pancreatic duct, and both a high NLR and PLR were significant predictors of malignant and invasive MpPCN. On multivariate analyses, solid component and dilated pancreatic duct were independent predictors of malignant and invasive MpPCN. PLR was an independent predictor for invasive MpPCN. When MpPCN were stratified by the Fukuoka and Sendai Guidelines, both a high NLR and PLR were significantly associated with malignant neoplasms within the high risk categories. PLR is an independent predictor of invasive carcinoma. The addition of PLR as a criterion to the FCG and SCG significantly improved the predictive value of these guidelines in detecting invasive neoplasms.

Invasive, mixed-type intraductal papillary mucinous neoplasm: Superior prognosis compared to invasive main-duct intraductal papillary mucinous neoplasm

It is unclear whether the duct involvement subtypes of intraductal papillary mucinous neoplasm (IPMN), ie, main (MD), mixed (MT), and branch (BD), confer any survival advantage when invasive IPMN occurs. We hypothesized that invasive MT-IPMN was associated with a better prognosis than invasive MD-IPMN. A retrospective review of a prospectively maintained database was performed of patients who underwent resection for IPMN at a single academic institution from 1992 to 2014. Characterization of IPMN subtype was assessed on final operative pathology. Statistics included univariate analysis, Kaplan-Meier survival curves, and Cox regression for independent predictors of increased survival. Of 390 patients eligible for study, 74 had invasive IPMN (IPMC). Of these, 71 patients had complete data and were included in the analysis (17 MD-IPMC, 39 MT-IPMC, and 15 BD-IPMC). Median follow-up was 20 months (range, 2-174). MT-IPMC was associated with significantly greater overall survival (OS) (47 months) compared with MD-IPMC (12 months) (P = .049), but not with BD-IPMC (44 months) (P = .67). Multivariate Cox regression yielded a family history of pancreatic cancer, absence of jaundice, N0 status, negative margins, absence of lymphovascular invasion, and MT subtype as independent predictors of greater OS (P = .035, .015, .013, .036, .045, .043, respectively). No characteristic of IPMN (including MD diameter, solid component/mural nodule) was predictive of OS. MT-IPMC appeared to be associated with a greater OS compared with pure MD-IPMC. This begs the question of a different underlying biology of MT-IPMN and argues against classification of all main duct involved IPMN into a single category.

Pancreatic Resection for Side-Branch Intraductal Papillary Mucinous Neoplasm (SB-IPMN): a Contemporary Single-Institution Experience

BackgroundGiven the malignant potential of main duct intraductal papillary mucinous neoplasm (M-IPMN), surgical resection is generally indicated. With regard to side-branch intraductal papillary mucinous neoplasm (SB-IPMN), resection vs. observation is a topic of debate. Further review of SB-IPMN is necessary to clarify appropriate management. The primary focus of this project is to determine the incidence of malignant final pathology for patients undergoing surgery for isolated SB-IPMN with non-malignant fine-needle aspiration (FNA) cytology. We also sought to describe the relationship between factors considered in the international consensus guidelines and final pathologic outcome. MethodsThe study is a retrospective review of all patients who underwent surgical resection for intraductal papillary mucinous neoplasm (IPMN) from 2002 to 2013 at our institution. Patients with a preoperative diagnosis of isolated SB-IPMN and FNA results for non-malignant cytology were selected among this surgical cohort for further analysis of preoperative clinical characteristics and outcomes. ResultsA total of 137 patients undergoing resection for IPMN were identified. Of these, 81 patients (59 %) had a component of M-IPMN or invasive disease on FNA, leaving 66 (46 %) patients with SB-IPMN and non-malignant cytology. Invasive adenocarcinoma was found in 8/66 (12 %) patients and high-grade dysplasia (HGD) in 4/66 (8 %) patients. The mean [SD] diameter of benign SB-IPMN was 2.0 cm [1.1] (range 0.3–5.7) vs. that of HGD/invasive disease which was 3.1 cm [1.3] (range 1.5–6.0; P = 0.014). Of the 12 patients found to have HGD or invasive disease, symptoms, mural nodules, and septations were found in 7 (58 %), 5 (42 %), and 6 (50 %), respectively. Tumor staging were as follows: IA (2), IB (2), 2A (4), and 2B (1). ConclusionWith proper selection criteria, SB-IPMN is associated with a low rate of invasive pancreatic ductal adenocarcinoma at the time of resection. Nevertheless, given the demonstrated incidence of malignancy, appropriate operative candidates should undergo resection.

Potential indication of organ preserving surgery for main duct IPMN

Potential indication of organ preserving surgery for main duct IPMN

Does PET with CT Have Clinical Utility in the Management of Patients with Intraductal Papillary Mucinous Neoplasm?

Intraductal papillary mucinous neoplasms (IPMNs) are well-established pancreatic precancerous lesions. Indications for resection are outlined in the 2012 International Consensus Guidelines (ICG). Because of the low specificity of the ICG, many patients will undergo potentially unnecessary surgery for nonmalignant IPMNs. Several retrospective studies have reported that positron emission tomography (PET) with CT (PET/CT) is highly sensitive and specific in detecting malignant IPMNs. We hypothesized that PET/CT complements the ICG in identification of malignant IPMNs. From 2009 to 2013, patients with a suspected clinical or cytopathologic diagnosis of IPMN were prospectively enrolled in a clinical trial at a single center. Results of preoperative PET/CT on determination of IPMN malignancy (ie, high-grade dysplastic and invasive) was compared with surgical pathology. PET/CT uptake was considered increased if the standardized uptake value was ≥3. Of the 67 patients enrolled, 50 patients met all inclusion criteria. Increased PET/CT uptake was associated with significantly more malignant and invasive IPMNs (80% vs 13%; p < 0.0001 and 40% vs 3%; p = 0.004). When patients were divided into branch duct and main duct IPMNs, increased PET/CT uptake was also associated with more malignancy (60% vs 0%; p = 0.006 for branch duct IPMN and 100% vs 23%; p = 0.003 for main duct IPMN). Patients with ICG criteria (eg, worrisome features and high-risk stigmata) and increased PET/CT uptake had more malignant and invasive IPMNs than patients with ICG criteria, but no increased uptake (78% vs 17%; p = 0.001 and 33% vs 3%; p = 0.03). The sensitivity and specificity of the ICG criteria for detecting malignancy were 92% and 27%, respectively, and PET/CT was less sensitive (62%) but more specific (95%). When PET/CT was added to ICG criteria, the association resulted in 78% sensitivity and 100% specificity. The addition of PET/CT to preoperative workup improves the performance of the ICG for predicting malignant risk in patients with IPMN.

Per oral cholangiopancreatoscopy in pancreatico biliary diseases--expert consensus statements.

To provide consensus statements on the use of per-oral cholangiopancreatoscopy (POCPS). A workgroup of experts in endoscopic retrograde cholangiopancreatography (ERCP), endosonography, and POCPS generated consensus statements summarizing the utility of POCPS in pancreaticobiliary disease. Recommendation grades used validated evidence ratings of publications from an extensive literature review. Six consensus statements were generated: (1) POCPS is now an important additional tool during ERCP; (2) in patients with indeterminate biliary strictures, POCS and POCS-guided targeted biopsy are useful for establishing a definitive diagnosis; (3) POCS and POCS-guided lithotripsy are recommended for treatment of difficult common bile duct stones when standard techniques fail; (4) in patients with main duct intraductal papillary mucinous neoplasms (IPMN) POPS may be used to assess extent of tumor to assist surgical resection; (5) in difficult pancreatic ductal stones, POPS-guided lithotripsy may be useful in fragmentation and extraction of stones; and (6) additional indications for POCPS include selective guidewire placement, unexplained hemobilia, assessing intraductal biliary ablation therapy, and extracting migrated stents. POCPS is important in association with ERCP, particularly for diagnosis of indeterminate biliary strictures and for intra-ductal lithotripsy when other techniques failed, and may be useful for pre-operative assessment of extent of main duct IPMN, for extraction of difficult pancreatic stones, and for unusual indications involving selective guidewire placement, assessing unexplained hemobilia or intraductal biliary ablation therapy, and extracting migrated stents.