Side-branch Intraductal Papillary Mucinous Neoplasms Research Articles

Chronic immunosuppression does not potentiate the malignant progression of mucinous pancreatic cystic lesions

BackgroundPremalignant mucinous pancreatic cystic lesions (mPCLs) are increasingly identified. AimsIn this study, we aim to assess the effect of selected immunosuppressive therapies on the progression of mPCLs, including side-branch intraductal papillary mucinous neoplasms and mucinous cystic neoplasms. MethodsWe performed a retrospective cohort study of patients with mPCLs diagnosed over a 24-year period who received chronic immunosuppression. Controls were matched on age at cyst diagnosis (±11 yrs) and cyst size (±8 mm). Measured outcomes included increase in cyst size, development of “worrisome features” as defined by consensus guidelines, progression to malignancy, and rate of surgical resection. Results39 patients (mean age 60 yrs) with mPCLs were on immunosuppression. Leading indications for immunosuppression were solid organ transplant (n = 14), inflammatory bowel disease (n = 6), and rheumatoid arthritis (n = 5). 33% were on biologics, 77% on antimetabolites and 79% on multiple medications. Mean cyst size increased from 12.6 mm to 17.8 mm over a median of 16.5 months. 6 patients elected for surgical resection, and none ultimately developed malignancy. 26 cases with follow-up were matched to control subjects, with no significant differences among cases and controls in initial cyst size (12.8 mm vs 11.9 mm, P = 0.69), mean size increase (6.9 mm vs 5 mm, P = 0.47), follow-up interval (24.3 months vs 21.5 months, P = 0.44). No significant differences in the rate of worrisome features, malignancy, or surgical resection. ConclusionsPatients with mPCLs exposed to immunosuppressive medications did not have higher rates of malignancy or development worrisome features in the short term. This suggests that patients with mPCLs can be initiated or maintained on these agents without changes to surveillance practices.

Long-term follow-up of neoplastic pancreatic cysts without high-risk stigmata: how often do we change treatment strategy because of malignant transformation?

*Objective: Patients with potentially premalignant neoplastic pancreatic cysts without high-risk stigmata usually enter a surveillance program. Data on outcomes of such surveillance programs are scarce. We aimed to evaluate the resection rate and malignancy rate during follow-up.Material and methods: From our prospective database (2006–2015) of patients with pancreatic cysts, we analyzed patients with pancreatic cysts without high-risk stigmata with at least six months follow-up.Results: In total, 146 patients were followed for a median of 29 months (IQR 13.5–50 months). In 124 patients (84.9%), no changes in clinical or imaging characteristics occurred during follow-up. Thirteen patients (8.9%) developed an indication for surgery after a median follow-up of 25 months (IQR 12–42 months). Two patients did not undergo surgery because of comorbidity, 11 patients (7.5%) underwent resection. Indications for surgery were symptoms (n = 2), development of a pancreatic mass (n = 1), a new nodule (n = 2), thickened cyst wall (n = 1), pancreatic duct dilation (n = 3), and/or suspicion of mucinous cystic neoplasm (MCN) (n = 3). Postoperative histology showed one pancreatic malignancy not originating from the cyst, three mixed type-intraductal papillary mucinous neoplasm (IPMN), one side branch-IPMN, two MCN, one neuroendocrine tumor, one serous cystadenoma, one inflammatory cyst, and one lymphangioma. The highest grade of cyst dysplasia was borderline dysplasia.Conclusions: Most neoplastic pancreatic cysts without high-risk stigmata at initial presentation show no substantial change during 1–4-year follow-up. Only 7.5% of patients underwent surgery and less than 1% of patients developed pancreatic malignancy. This indicates that additional markers are needed to tailor treatment of pancreatic cysts.

Long interval radiological surveillance of side branch pancreatic duct-involved intraductal papillary mucinous neoplasm in selected patients

Aims: Side branch IPMN (SB-IPMN) of the pancreas has a malignancy rate between 10 to 20%. There remains a question on the interval for radiological surveillance for SB-IPMN. We hypothesized that surveillance at longer intervals on selected patients with SB IPMN might be indicated. Methods: This is a retrospective study of prospectively collected data of 276 patients observed from 2000 to 2010. Only patients with follow-up of more than 12 months were included. After 2007, we opted to screen our patients with longer intervals, initially at 12 months then 24 months using MR if no ‘worrisome features’ were present. Results: Of 276 patients, 261 had complete data for analysis and the patients were aged 78 (40–91) years. 232 patients had sole SB-IPMN and 29 had mixed type IPMN and were excluded. 92% of SB-IPMN’s were incidental (n = 209) with 8% symptomatic (n = 24). Single SB IPMN accounted for 84% (n = 195) of all cases with a maximum diameter of 15.5 (5–60) mm. The median of follow up duration was 46 (32–53) months. Short interval radiological surveillance (3–9 months), after the first scan was performed, was 39% (n = 90), while long interval surveillance (12–36 months) was performed in 61% (n = 142). The rate of pancreatic resection in the short and long interval surveillance groups was 4.4% (n = 4) and 5% (n = ) respectively; P = 0.78. Conclusions: Our data suggests that long interval MR surveillance of SB-IPMN patients may be safe and cost effective.

Meta-analysis of recent publications reveals underestimation of rates of malignancy in side branch IPMN

Meta-analysis of recent publications reveals underestimation of rates of malignancy in side branch IPMN

Use of a novel through-the-needle biopsy forceps in endoscopic ultrasound.

Background and aims: Pancreatic cysts are becoming more common. Their differential diagnosis includes benign, premalignant, and malignant lesions. Distinguishing the type of cyst helps in the management decision making. We report on a novel tissue acquisition device for pancreatic cysts. Methods: Data on two patients who underwent endoscopic ultrasound (EUS) – guided fine-needle aspiration with a new micro forceps device are presented. Results: Two patients had large pancreatic cystic lesions in the pancreatic head. Linear EUS was performed, and tissue samples were obtained with the Moray micro forceps through a 19-gauge needle. In both patients, mucinous columnar epithelium lined the cystic walls. One patient underwent surgical resection, and the other elected surveillance. Examination of the surgical specimen from the first patient confirmed the cyst was a side-branch intraductal papillary mucinous neoplasm (IPMN), gastric type. Conclusions: The Moray micro forceps is a new tool that can be used to help determine the nature of pancreatic cysts and aid in their risk stratification and management.

Management of acute hemorrhagic pancreatitis after EUS-guided FNA of a pancreatic cyst

An asymptomatic 72-year-old woman underwent EUS-guided FNA of an incidental side-branch intraductal papillary mucinous neoplasm (SB-IPMN) in the head of the pancreas at an outside facility. Forty-eight hours after the procedure, she presented to our institution with severe epigastric pain, fever, jaundice, leukocytosis, and elevated lipase consistent with acute pancreatitis. CT of the abdomen andpelvis with contrast medium showed multiple peripancreatic fluid collections (PFC) around the pancreatic head. EUS showed a large PFC in the head region compressing the distal common bile duct (Fig. 1) and a pancreatic duct leak in the neck region. Because the PFC was causing obstructive jaundice, it was aspirated, revealing hemorrhagic fluid. ERCP was then performed to evaluate the pancreatic duct. A leak from a side branch in the head region was demonstrated on pancreatogram, which was bridged with a 4F 10-cm stent (Video 1, available online at www.giejournal.org). The patient also underwent jejunal feeding for 4 weeks through a nasojejunal tube, with resultant clinical improvement and resolution of the PFC on follow-up CT at 30 days. The risk of acute pancreatitis after EUS-FNA of pancreatic lesions is highest with SB-IPMN at 8%. Despite the lack of data, the use of indomethacin before EUS-FNA for pancreatitis prophylaxis can be considered in high-risk patients.

Risk of pancreatic cancer in patients with pancreatic cyst

Certain pancreatic cysts (mucinous cystic neoplasm and side branch intraductal papillary mucinous neoplasm [IPMN]) have malignant potential and require surveillance. However, whether patients with pancreatic cysts have a higher long-term risk of pancreatic cancer (PaCa) has still not been established. This was a retrospective study of Veterans Administration patients. Patients noted to have pancreatic cysts on CT/magnetic resonance imaging (n= 1050) were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients aged<15 years (n= 425), patients with<1 year of follow-up (n=13,259), and patients diagnosed to have PaCa within 1 year of identification of a pancreatic cyst (n=102) or within 1 year of follow-up in the remaining patients in the database (n= 200) were excluded. Patients with pancreatic cystic lesions (group A, n= 755) and the remaining patients in the database without cysts (group B, n= 520,215) were followed from 1998 to2007. During the study period, in group A and B PaCa was diagnosed in 17 and 1206 patients, respectively, and the incidence rate of PaCa was 5.08 and .32 per 1000 patient-years, respectively. The hazard ratio of PaCa in all patients with cysts was 19.64 (95% CI, 12.12-31.82; P< .0001) when compared with the rest of the patients without cysts. In the subset of patients with cysts, without a history of acute or chronic pancreatitis (n=241), the hazard ratio of PaCa (n= 5) was 18.80 (95% CI, 7.80-45.31; P< .0001). Patients with pancreatic cysts have a significantly higher overall risk of PaCa. The etiologic distribution of cysts in our study patients is not available. Patients with mucinous cystic neoplasm and side branch IPMN are likely to have a higher risk of PaCa than our estimation of risk based on all etiologies.

Prevalence and Characteristics of Pancreatic Cystic Lesions in Patients With Cirrhosis

Introduction: little is known about the prevalence and characteristics of pancreatic cystic lesions among patients with cirrhosis. Many cirrhotic patients undergo transplant evaluation and the presence of potential neoplastic lesions in the pancreas warrants further investigation and follow up. Methods: after obtaining IRB approval, we performed a Natural Language Processing search of high quality imaging studies (CT scan, MRI/MRCP and EUS) of patients with documented liver cirrhosis seen in our institution between January 2008 and December 2014. Keywords searched within reports were: cyst, cystic, pseudocyst, IPMN, mucinous and lesion within 20 word distance of the word “Pancreas”. Results: 2605 individual patients with cirrhosis were identified. The prevalence of any cystic lesion in the pancreas was 4.9% (95% CI: 3.8%-5.6). Mean age was 59 year. Cysts were classified as potential neoplastic (mainly mucinous) in 26.7% (95% CI: 19.8-35.1), indeterminate in 11% (95% CI: 6.6-17.8) and pseudocyst/ simple in 62.3 (95%CI: 53.5-70.8%). Cysts were multiple in 19.7% of patients. All potentially neoplastic cysts were considered “low risk” for progression with no worrisome features and consisted mainly of side branch intraductal papillary mucinous neoplasm (82.4%). None of the potentially neoplastic cysts was >30mm in maximum dimension compared to 60.8% of pseudocysts (p Conclusion: The prevalence of pancreatic cystic lesions in patients with cirrhosis is close to 5%. Cyst size and underlying cirrhosis etiology are associated with cyst type with larger cysts and alcoholic cirrhosis are less likely to be neoplastic. A substantial number of pancreatic cystic lesions in cirrhotic patients are potentially low risk neoplastic cysts with side branch IPMN constituting the majority of it.

Low CEA Cystic Pancreatic Tumors: A Tail of Two Cysts

Background: Cystic pancreatic tumors (CPT) have variable malignant potential and are increasingly recognized. Generally, cross-sectional imaging cannot definitely differentiate mucinous from non-mucinous cysts. Endoscopic ultrasound (EUS) with fine needle aspiration (EUS-FNA) is used to evaluate morphologic appearance and fluid. Fluid analysis can help differentiate CPT. In this case series we will review two cases of low carcinoembryonic antigen (CEA) pancreatic tail CPTs with similar preoperative diagnostic evaluation, but differing final diagnoses. Cases: 1) A 71 year old asymptomatic male was found to have an incidental pancreatic tail cyst on imaging. EUS showed an anechoic, lobulated pancreatic tail cyst (4.2 x 2.8 cm) communicating with a small side branch without septation or nodules. FNA yielded viscous clear fluid with cytology negative for malignancy, amylase 5420 IU/L and CEA 99 ng/mL. Surveillance EUS-FNA fluid was inadequate for cytology, however DNA showed KRAS mutation. Robotic distal pancreatectomy showed a pancreatic tail side-branch IPMN (4.3 x 3.0 x 2.4 cm) with low grade intraepithelial dysplasia. 2) A 51 year old female presented with abdominal pain and hematuria. CT scan to rule out nephrolithiasis incidentally showed a cystic lesion of the distal pancreas confirmed with MRI. EUS revealed a pancreatic tail cyst (2.1 x 1.9 cm) with numerous 1mm septations and large pockets within the cyst. FNA yielded thin fluid with cytology negative for malignancy, amylase 44 IU/L and CEA 4.4 ng/mL. Robotic distal pancreatectomy showed a 1.5 x 1.4 x 1.2 cm well differentiated cystic pancreatic neuroendocrine tumor (cPanNET). Discussion: CPT may be malignant and require evaluation prior to resection. EUS appearance can be diagnostic, and cytology has low sensitivity for diagnosing malignancy. A CEA concentration cut-off of 192 ng/mL helps differentiate mucinous from nonmucinous (sensitivity 73%, specificity 84%). Fluid KRAS mutations are associated with mucinous cysts and the development of malignancy. Our IPMN patient had uncharacteristic low CEA, but expected DNA KRAS mutation and high amylase. cPanNETs have fluid findings similar to serous cystadenocarcinomas and presents a diagnostic challenge. Our patient's surgery was necessitated by young age, septations, and the need for long-term follow-up. In this case series we reviewed the diagnostic course of pancreatic tail cysts with low CEA found to be an IPMN and a cPanNET.

Laparoscopic Hand-Assisted Parenchymal-Sparing Resections for Presumed Side-Branch Intraductal Papillary Mucinous Neoplasms.

The diagnosis of side-branch intraductal papillary mucinous neoplasms (IMPNs) is increasingly more common, but their appropriate management is still evolving. We recently began performing laparoscopic hand-assisted enucleation or duodenal-sparing pancreatic head resection for these lesions with vigilant postoperative imaging. Seventeen patients with pancreatic cystic lesions were included in this single-center retrospective review from January 1, 2008 to March 30, 2013. Indication for surgical intervention was growth in size of the cyst, symptoms, cyst size >3 cm, and/or presence of a mural nodule. Twelve patients underwent laparoscopic hand-assisted enucleation, and 5 patients underwent laparoscopic hand-assisted pancreatic head resection. The mean age of patients was 64 years old. The most common presenting symptom was abdominal pain. The indication for surgical intervention was growth in the cyst or symptoms in the majority of patients. Fourteen lesions were in the head/uncinate, two were in the pancreatic body, and one was in the tail. Final pathology was consistent with side-branch IPMN in 13 patients (1 with focal adenocarcinoma). Three patients had serous cysts, and 1 had a mucinous cyst. Three patients developed pancreatic leaks, which were controlled with intraoperative placed drains, whereas 1 patient required additional drain placement. Median time from surgery to latest follow-up imaging is over 2 years. No patients have developed recurrent cysts or adenocarcinoma. Duodenal-sparing pancreatic head resection or pancreatic enucleation for patients with presumed side-branch IPMN is a safe and efficacious option, in terms of both operative outcomes and postoperative recurrence risk.

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.

Cyst Features and Risk of Malignancy in Intraductal Papillary Mucinous Neoplasms of the Pancreas: Imaging and Pathology

Background: Intraductal papillary mucinous neoplasms (IPMNs) display diverse macroscopic, histological, and immunohistochemical characteristics with typical morphological appearance in magnetic resonance imaging. Depending on those, IPMNs may show progression into invasive carcinomas with variable frequency. Overall, IPMN-associated invasive carcinomas are found in about 30% of all IPMNs, revealing phenotpyes comparable with conventional ductal adenocarcinomas or mucinous (colloid) carcinomas of the pancreas. In Sendai-negative side-branch IPMNs, however, the annual risk of the development of invasive cancer is 2%; thus, risk stratification with regard to imaging and preoperative biomarkers and cytology is mandatory. Methods and Results: The present study addresses the radiological and interventional preoperative measures including histological features to determine the risk of malignancy and the prognosis of IPMNs. Conclusion: While preoperative imaging largely relies on the detection of macroscopic features of IPMNs, which are associated with a divergent risk of malignant behavior, in resected specimens the determination of the grade of dysplasia and the detection of an invasive component are the most important features to estimate the prognosis of IPMNs.

High risk of acute pancreatitis after endoscopic ultrasound-guided fine needle aspiration of side branch intraductal papillary mucinous neoplasms.

Background and Objectives:Data on the risk of acute pancreatitis following endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of pancreatic cystic lesions are limited. The aim of our study was to evaluate the frequency of acute pancreatitis after EUS-FNA of pancreatic cysts and solid lesions, and determine whether there was a difference in pancreatitis risk in patients with side branch intraductal papillary mucinous neoplasms (SB-IPMN).Patients and Methods:A retrospective review of patients who underwent EUS-FNA of pancreatic cysts and solid lesions was performed. The primary outcome measure was development of acute pancreatitis after EUS-FNA. Factors associated with acute pancreatitis were examined by statistical analysis to determine independent predictors of acute pancreatitis. Statistical significance was determined at a P ≤ 0.05.Results:We identified 186 patients with pancreatic cystic lesions and 557 with solid lesions in which EUS-FNA was performed. The median size of the cysts was 19 mm (range: 10-66 mm). There were 37 IPMNs, 33 mucinous cystic neoplasms, 58 serous cysts and 46 pseudocysts and 12 solid-cystic ductal carcinomas. The majority of patients (75%) with solid lesions were diagnosed with adenocarcinoma. Patients with pancreatic cysts had a statistically greater frequency of developing pancreatitis after EUS-FNA when compared to those with solid lesions (2.6% vs. 0.36% respectively; P = 0.13). In patients with cysts, there were no statistically significant differences between the two groups (with and without pancreatitis) with regard to a cyst location, size of the cyst, and number of needle passes or trainee involvement. Patients with SB-IPMN had a statistically higher frequency of pancreatitis after EUS-FNA compared to those with other cyst types (8% vs. 1.3% respectively; odds ratio = 6.4, 95% confidence intervals = 1.0-40.3, P = 0.05).Discussion:Patients with SB-IPMN are at a higher risk of developing acute pancreatitis after a EUS-FNA. Alternative means of diagnosis such as magnetic resonance cholangiopancreatogram might be necessary to avoid risk of EUS-FNA.

Intraductal papillary mucinous neoplasm causing recurrent acute pancreatitis, necrotizing pancreatitis, and multifocal adenocarcinoma

A 58-year-old woman presented for evaluation of recurrent acute pancreatitis after routine etiologies were excluded. Initial EUS revealed a small (1.0 × 0.7 cm) cystic lesion in the uncinate process of the pancreas consistent with side-branch intraductal papillary mucinous neoplasm (bIPMN). Fifteen months later, the patient developed another episode of acute pancreatitis, and a repeat magnetic resonance imaging (MRI) study showed a stable IPMN (A). Unfortunately, 5 months later the patient developed necrotizing pancreatitis involving most of the pancreas and requiring prolonged pancreatic rest with nasojejunal tube feeding and ultimately endoscopic cystgastrostomy for walled-off pancreatic necrosis (B).

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

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

Tu1632 High Visceral Fat Area Is Association With Postoperative Complications in Patients With Crohn's Disease Following Primary Surgery

nectomy, and the remainder had either distal pancreatectomy (36%) or central pancreatectomy (2%). Pathologic evaluation identified 28 branch-duct lesions and 54 main-duct lesions, of which 38 had concurrent branch-duct lesions; duct of origin data was unavailable for 2 specimens. Of the 82 patients where the duct was specified, 33 had associated invasive (n= 28) or in-situ (n=5) carcinoma. There was no correlation between branch-duct origin and invasive carcinoma (main-duct 19 of 54, branch-duct 9 of 28, p=0.78). Multivariate analysis including tumor size did not influence this outcome (OR 1.14, CI 0.4-3.3). Malignant tumor size did not significantly differ by duct of origin (main-duct 3.3cm, branch-duct 3cm, p= 0.2). Furthermore, 2 of 9 malignant branch duct lesions were <2cm in size on pre-operative imaging. Of the 6 patients with branch duct lesions ≥3cm on pre-operative imaging, only 50% harbored invasive malignancy. The presence of symptoms preoperatively was significantly associated with malignancy (51% vs. 22%, p=0.01). Weight loss or jaundice on initial presentation was associated with a subsequent diagnosis of malignancy among patients with branch-duct lesions (both p<0.05). Of the 28 patients with invasive carcinoma, branch-duct lesions were significantly associated with the presence of positive lymph nodes, perineural invasion, and lymphovascular invasion (all p<0.05). Conclusions: Our data suggests that branch-duct lesions are as equally likely to be associated with invasive malignancy as main duct lesions, and may demonstrate more aggressive characteristics when invasion occurs. Themalignant potential of IPMN remains clinically elusive based on current clinical strategies, particularly in regards to invasive characteristics of side-branch IPMN. Therefore, surgical resection is recommended for all IPMN lesions in order to reliably assess for concurrent malignancy.

Comparison of the Sendai and Fukuoka Consensus Guidelines for the Management of Mucinous Cystic Lesions of the Pancreas: Are We Making Progress?

Cystic lesions of the pancreas (CLP) are increasingly being found incidentally, due largely to the frequency of three-dimensional (3D) abdominal imaging. The algorithm of resecting all solid pancreatic lesions does not apply to all cystic pancreatic lesions; observation is undoubtedly the most appropriate management for most pancreatic cysts. The series of 317 patients with CLPs reported by Goh et al. in this issue of Annals of Surgical Oncology addresses the core of these diagnostic dilemmas—which criteria should be applied to CLPs as clinicians decide which lesions warrant pancreatic resection? The authors should be recognized for their large study size, systematic review, and thorough application of two widely utilized classification systems: the 2006 Sendai Consensus Guidelines (SCG) and the revised Sendai criteria, also referred to as the Fukuoka Consensus Guidelines (FCG). This comparison is critical as our understanding of CLPs evolves. The 2006 SCG were the first multidisciplinary, standardized recommendations for clinicians counseling patients on the optimal management of their pancreatic cysts, specifically designed to risk-stratify patients with intraductal papillary mucinous neoplasms (IPMNs) or mucinous cystic neoplasms (MCN). Based on these guidelines, all main duct and mixed-type IPMNs, and all MCN should be resected for a patient of appropriate operative risk. However, the Sendai criteria most prominently clarified our understanding of which side-branch (SB) IPMNs required operative intervention. An SB-IPMN associated with high-risk features such as the presence of an intracystic mural nodule, associated main duct dilation of 10 mm, and size greater than 3 cm were considered to be of sufficient risk to warrant resection. For SB-IPMNs that did not meet these criteria, observation at specific intervals dictated by cyst size was considered safe. Following the publication of these guidelines, the risk of dysplasia and malignancy developing in cysts less than 3 cm in size began to be more closely evaluated. In a report from the Moffitt Cancer Center, 105 patients with CLPs underwent definitive surgical therapy. The authors found that in cysts\3 cm in size, the rate of malignancy on final pathology was 34 %, and concluded that this rate of invasion was prohibitively high to recommend surveillance. At the same time, a study by Fritz et al. concurred with the Moffitt group. In this investigation, from a population of 123 resected SBIPMNs, 69 were declared ‘Sendai negative’ (fulfilling none of the high-risk features outlined in the 2006 guidelines), and 17 (25 %) were found to have either high-grade dysplasia (HGD) or invasive ductal carcinoma within the specimen. The authors concluded that a size cutoff of 3 cm was too liberal for safe observation in patients with SB-IPMNs. However, these studies have significant limitations. In neither of these reports are other characteristics of the IPMNs comprehensively stated—how many contained mural nodules, were cytologically positive for malignancy prior to resection, or grew over time. Any one of these features of a SB-IPMN increase the risk of that lesion harboring malignancy, and without clearly understanding the true numerators and denominators in these investigations, accurately estimating the risk of malignancy is not possible—we do not know how many lesions were truly ‘Sendai negative’. In particular, the study from Moffit was unique in that the authors utilized endoscopic ultrasound (EUS) to evaluate the patients in their series, which implies that only cysts with high-risk features were being resected. Society of Surgical Oncology 2014

Secretin-enhanced MR Cholangiopancreatography: Spectrum of Findings

Magnetic resonance cholangiopancreatography (MRCP) is the most effective, safe, noninvasive magnetic resonance (MR) imaging technique for the evaluation of the pancreaticobiliary ductal system. The MRCP imaging technique has substantially improved during the past 2 decades and is based mainly on the acquisition of heavily T2-weighted MR images, with variants of fast spin-echo sequences. MRCP can also be performed by utilizing the hormone secretin, which stimulates a normal pancreas to secrete a significant amount of fluid while transiently increasing the tone of the sphincter of Oddi. The transient increase in the diameter of the pancreatic duct improves the depiction of the ductal anatomy, which can be useful in patients in whom detailed evaluation of the pancreatic duct is most desired because of a suspicion of pancreatic disease. Improved depiction of the ductal anatomy can be important in (a) the differentiation of side-branch intraductal papillary mucinous neoplasms from other cystic neoplasms and (b) the diagnosis and classification of chronic pancreatitis, the disconnected pancreatic duct syndrome, and ductal anomalies such as anomalous pancreaticobiliary junction and pancreas divisum. In patients examined after pancreatectomy, stimulation with secretin can give information about the patency of the pancreaticoenteric anastomosis. Duodenal filling during the secretin-enhanced phase of the MRCP examination can be used to estimate the excretory reserve of the pancreas. Secretin is well tolerated, and complications are rarely seen. Secretin-enhanced MRCP is most useful in (a) the evaluation of acute and chronic pancreatitis, congenital variants of the pancreaticoduodenal junction, and intraductal papillary mucinous neoplasms and (b) follow-up of patients after pancreatectomy.

Teres Hepatis Ligament Flap Plasty to Prevent Pancreatic Fistula after Tumor Enucleation

Due to the rapid technical progresswith development of high quality imaging tools, incidental diagnosis of small pancreatic lesionsdincluding cystic and solid pathologiesdhas significantly increased in recent years. Besides solid tumors (eg, small neuroendocrine tumors), especially small cystic lesions (eg, side-branch intraductal papillary mucinous neoplasms) bear a relevant risk of malignant transformation. Therefore, surgical management is required for a considerable proportion of these findings. Because these often premalignant lesions do not necessarily require radical oncologic resection, parenchyma-sparing resections have been accepted as surgical standards, among them tumor enucleation (TE) for lesions not exceeding a diameter of 2 cm and lacking signs of malignancy. These techniques offer maximum pancreatic tissue preservation to avoid exocrine and endocrine insufficiencies, which are observed in a considerable number of patients after standard procedures such as pancreaticoduodenectomy or distal pancreatectomy. Postoperative pancreatic fistula (POPF) has been reported as the most frequent complication after TE, with a reported rate between 18% and 50%. Although POPFs after TE are mainly uncomplicated (mostly International Study Group on Pancreatic Fistula [ISGPF] grade A), they remain an unsolved and potentially long-lasting clinical problem. The versatility of the teres hepatis ligament and its use as a surgical cover structure has been described in various procedures, including filling of liver defects after hydatid cysts resection in order to prevent bile leakage, covering the gastroduodenal artery stump during pancreaticoduodenectomy, and covering the resection margin after distal pancreatectomy to prevent leakage. To our knowledge, there have been no reports on teres hepatis

Cyst fluid SPINK1 may help to differentiate benign and potentially malignant cystic pancreatic lesions

ObjectiveDifferential diagnosis between benign and potentially malignant cystic pancreatic lesions may be difficult. Previously we have compared cyst fluid serine protease inhibitor Kazal type I (SPINK1) with some traditionally used tumour markers (amylase, CEA, Ca19-9) and found that it may be a new promising maker in the differential diagnosis of cystic pancreatic lesions. In the present study, we focused on cyst fluid SPINK1 levels in benign and potentially malignant cystic pancreatic lesions. DesignSixty-one patients operated on for cystic pancreatic lesion in Tampere University Hospital, Finland and in Verona University Hospital, Italy, were included. Cyst fluid was aspirated during surgery, stored at −70 °C, and analysed with immunofluorometric assay for SPINK1. The final diagnosis was acute pancreatitis with fluid collection (Acute FC) in 4 patients, chronic pseudocyst (PS) in 17 patients, serous cystadenoma (SCA) in 7 patients, mucinous cystadenoma (MCA) in 21 patients and intraductal papillary-mucinous neoplasm (IPMN) in 12 patients (9 main/mixed duct type and 3 branch duct type). ResultsThe acute FC patients had high SPINK1 levels. Among chronic cysts, SPINK1 levels were significantly higher in patients with potentially malignant cysts (main/mixed duct IPMN and MCA) than with benign cysts (side branch IPMN and SCA), (median and range, [480 (13–3602) vs. 18 (0.1–278) μg/L]; p < 0.0001). In the subcohort of 24 patients with <3 cm chronic cyst, cyst fluid SPINK 1 levels were significantly lower in SCA or side branch IPMN (3 [2–116] μg/L) than in main duct IPMN or MCA (638 [66–3602] μg/L; p = 0.018). The best sensitivity and specificity to differentiate any size MCA or main/mixed type IPMN from SCA or side branch IPMN were 85% and 84% (AUC 0.94; cut-off value 118 μg/L). The best sensitivity and specificity to differentiate <3 cm MCA or main duct IPMN from SCA or side branch IPMN were 93% and 89% (AUC 0.98; cut-off value 146 μg/L). ConclusionsCyst fluid SPINK1 may be a possible marker in the differential diagnosis of benign and potentially malignant cystic pancreatic lesions.