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Berevoescu N, Scăunașu R, Berevoescu M, Croitoru A. Mucinous cystadenoma of the pancreas associated with pregnancy. Case report and review of the literature. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2018. [DOI: 10.25083/2559.5555/3.2/88.94] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective. We present a rare pathology with uncommon onset. Background. Mucinous cystic pancreatic neoplasms (MCNs) are rare tumors, which generally occur in the fifth and sixth decades of women. Although some tumours are frankly malignant, all are in fact considered to be potentially malignant. Case report. We present the case of a 30-year-old patient, with a 16/11 cm tumor located in the pancreas body, which was diagnosed 8 months after birth. The preoperative assessment of the pancreatic lesion suggested the diagnosis of mucosal cyst neoplasm, without being able to determine its benign or malignant nature. Central pancreatectomy was performed with a good postoperative evolution. Histopathologic result was represented by mucinous pancreatic chistadenoma. Two years after surgical intervention, the patient presented no signs of recurrence or pancreatic (exocrine or endocrine) secretion deficiency. Conclusions. Preoperative imaging evaluation could be suggestive for mucinous cystic tumour, but this cannot specify however the nature of the tumor. The postpartum occurrence could establish a possible relationship between hormonal levels encountered during pregnancy and the development of this tumor, taking into considerations the ovarian-type stroma and the presence of hormone (estrogen and progesterone) receptors in this neoplasm. Central pancreatectomy without anastomosis preserves the functions of pancreas, and also decreases morbidity.
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52
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Kim JY, Hong SM. Precursor Lesions of Pancreatic Cancer. Oncol Res Treat 2018; 41:603-610. [DOI: 10.1159/000493554] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 09/07/2018] [Indexed: 12/18/2022]
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53
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Pancreatic Cystic Lesions: Pathogenesis and Malignant Potential. Diseases 2018; 6:diseases6020050. [PMID: 29899320 PMCID: PMC6023528 DOI: 10.3390/diseases6020050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/06/2018] [Accepted: 06/07/2018] [Indexed: 01/17/2023] Open
Abstract
Pancreatic cancer remains one of the most lethal cancers despite extensive research. Further understanding of precursor lesions may enhance the ability to treat and prevent pancreatic cancer. Pancreatic cystic lesions (PCLs) with malignant potential include: mucinous PCLs (intraductal papillary mucinous neoplasms and mucinous cystic neoplasm), solid pseudopapillary tumors and cystic neuroendocrine tumors. This review summarizes the latest literature describing what is known about the pathogenesis and malignant potential of these PCLs, including unique epidemiological, radiological, histological, genetic and molecular characteristics.
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54
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Hui L, Rashid A, Foo WC, Katz MH, Chatterjee D, Wang H, Fleming JB, Tamm EP, Wang H. Significance of T1a and T1b Carcinoma Arising in Mucinous Cystic Neoplasm of Pancreas. Am J Surg Pathol 2018; 42:578-586. [PMID: 29462092 PMCID: PMC5893396 DOI: 10.1097/pas.0000000000001040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Mucinous cystic neoplasm (MCN) of pancreas is one of the precursor lesions of pancreatic ductal adenocarcinoma. The 5-year disease-specific survival for noninvasive MCNs was 100% and 20% to 60% for those with pancreatic ductal adenocarcinoma arising in a MCN. However, the significance of T1a (≤0.5 cm) and T1b (>0.5 and <1.0 cm) carcinoma arising in MCN as defined by the upcoming American Joint Committee on Cancer, eighth edition is unclear. In this study, we examined 3 cases of MCN with T1a or T1b carcinoma and compared their clinicopathologic characteristics and survival to 46 cases of MCN with low-grade dysplasia (MCN-LGD), 7 cases of MCN with high-grade dysplasia (MCN-HGD), and 7 cases of MCN with advanced invasive carcinoma (T2 or higher T stage). The tumors from all 3 cases were submitted in their entirety in 123, 296, and 200 blocks, respectively. All 3 patients were alive with no recurrence during the follow-up of 20.0, 113.8, and 137.2 months, respectively. Similarly, none of the patients who had MCN with either LGD or HGD had recurrence or died of disease. In contrast, 5 of 7 patients who had MCN with advanced invasive carcinoma had recurrence and later died of disease with a median survival of 22.9 months (P<0.001). Our study showed that MCN with T1a and T1b carcinoma had an excellent prognosis similar to MCNs with LGD or HGD after complete tumor sampling for histologic examination. Our results along with the previous studies suggest that close follow-up, rather than aggressive systemic therapy, may be a better approach for these patients.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Biopsy
- Carcinoma, Pancreatic Ductal/mortality
- Carcinoma, Pancreatic Ductal/pathology
- Carcinoma, Pancreatic Ductal/surgery
- Databases, Factual
- Female
- Humans
- Male
- Middle Aged
- Neoplasm Grading
- Neoplasm Staging
- Neoplasms, Cystic, Mucinous, and Serous/mortality
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/surgery
- Pancreatectomy
- Pancreatic Neoplasms/mortality
- Pancreatic Neoplasms/pathology
- Pancreatic Neoplasms/surgery
- Pancreaticoduodenectomy
- Predictive Value of Tests
- Risk Factors
- Time Factors
- Tomography, X-Ray Computed
- Treatment Outcome
- Tumor Burden
- Young Adult
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Affiliation(s)
| | | | | | | | | | - Hua Wang
- Gastrointestinal Medical Oncology
| | | | - Eric P Tamm
- Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, TX
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55
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Abstract
Pancreatic cysts are extremely common, and are identified in between 2% to 13% on abdominal imaging studies. Most pancreatic cysts are pseudocysts, serous cystic neoplasms, mucinous cystic neoplasms, or intraductal papillary mucinous neoplasms. The management of pancreatic cysts depends on whether a cyst is benign, has malignant potential, or harbors high-grade dysplasia or invasive carcinoma. The diagnosis of pancreatic cysts, and assessment of risk of malignant transformation, incorporates clinical history, computed tomography (CT), magnetic resonance imaging (MRI), endoscopic ultrasound, and fine-needle aspiration of cyst fluid. This article reviews the cyst fluid markers that are currently used, as well as promising markers under development.
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Affiliation(s)
- Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower, Baltimore, MD 21287, USA
| | - Anne Marie Lennon
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Sheikh Zayed Tower, Room 7125JB3, Baltimore, MD 21287, USA.
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56
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Postlewait LM, Ethun CG, Mcinnis MR, Merchant N, Parikh A, Idrees K, Isom CA, Hawkins W, Fields RC, Strand M, Weber SM, Cho CS, Salem A, Martin RC, Scoggins C, Bentrem D, Kim HJ, Carr J, Ahmad S, Abbott D, Wilson GC, Kooby DA, Maithel SK. The Hand-Assisted Laparoscopic Approach to Resection of Pancreatic Mucinous Cystic Neoplasms: An Underused Technique?. Am Surg 2018. [DOI: 10.1177/000313481808400123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pancreatic mucinous cystic neoplasms (MCNs) are rare tumors typically of the distal pancreas that harbor malignant potential. Although resection is recommended, data are limited on optimal operative approaches to distal pancreatectomy for MCN. MCN resections (2000–2014; eight institutions) were included. Outcomes of minimally invasive and open MCN resections were compared. A total of 289 patients underwent distal pancreatectomy for MCN: 136(47%) minimally invasive and 153(53%) open. Minimally invasive procedures were associated with smaller MCN size (3.9 vs 6.8 cm; P = 0.001), lower operative blood loss (192 vs 392 mL; P = 0.001), and shorter hospital stay(5 vs 7 days; P = 0.001) compared with open. Despite higher American Society of Anesthesiologists class, hand-assisted (n = 46) had similar advantages as laparoscopic/robotic (n = 76). When comparing hand-assisted to open, although MCN size was slightly smaller (4.1 vs 6.8 cm; P = 0.001), specimen length, operative time, and nodal yield were identical. Similar to laparoscopic/robotic, hand-assisted had lower operative blood loss (161 vs 392 mL; P = 0.001) and shorter hospital stay (5 vs 7 days; P = 0.03) compared with open, without increased complications. Hand-assisted laparoscopic technique is a useful approach for MCN resection because specimen length, lymph node yield, operative time, and complication profiles are similar to open procedures, but it still offers the advantages of a minimally invasive approach. Hand-assisted laparoscopy should be considered as an alternative to open technique or as a successive step before converting from total laparoscopic to open distal pancreatectomy for MCN.
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Affiliation(s)
- Lauren M. Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Cecilia G. Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mia R. Mcinnis
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Nipun Merchant
- Division of Surgical Oncology, Department of Surgery, University of Miami, Miami, Florida
| | - Alexander Parikh
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chelsea A. Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William Hawkins
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ryan C. Fields
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew Strand
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Sharon M. Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Clifford S. Cho
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Robert C.G. Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Charles Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - David Bentrem
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hong J. Kim
- Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Jacquelyn Carr
- Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Syed Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati Cancer Institute, Cincinnati, Ohio
| | - Daniel Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Gregory C. Wilson
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati Cancer Institute, Cincinnati, Ohio
| | - David A. Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K. Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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57
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Hepatobiliary Mucinous Cystic Neoplasms With Ovarian Type Stroma (So-Called “Hepatobiliary Cystadenoma/Cystadenocarcinoma”). Am J Surg Pathol 2018; 42:95-102. [DOI: 10.1097/pas.0000000000000963] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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58
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Pittman ME, Rao R, Hruban RH. Classification, Morphology, Molecular Pathogenesis, and Outcome of Premalignant Lesions of the Pancreas. Arch Pathol Lab Med 2017; 141:1606-1614. [PMID: 29189063 DOI: 10.5858/arpa.2016-0426-ra] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT - Invasive pancreatic ductal adenocarcinoma has a greater than 90% mortality rate at 5 years. Understanding noninvasive, curable precursor lesions gives us the best hope for reducing mortality from pancreatic ductal adenocarcinoma. The 3 pancreatic precursor lesions that have been well studied include intraductal papillary mucinous neoplasm, mucinous cystic neoplasm, and pancreatic intraepithelial neoplasia. OBJECTIVE - To give an update on the latest clinical, molecular, and pathologic advances in intraductal papillary mucinous neoplasm, mucinous cystic neoplasm, and pancreatic intraepithelial neoplasia for the general surgical pathologist. DATA SOURCES - The current literature was analyzed and the authors' experiences with institutional and consult material were incorporated. CONCLUSIONS - Our understanding of the molecular alterations that lead from pancreatic precursor lesion to invasive carcinoma continues to evolve. These advances aid clinicians in their treatment decisions and researchers in their search for actionable, druggable targets.
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59
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Tamura S, Yamamoto H, Ushida S, Suzuki K. Mucinous cystic neoplasms in male patients: two cases. Rare Tumors 2017; 9:7096. [PMID: 29081929 PMCID: PMC5643879 DOI: 10.4081/rt.2017.7096] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/24/2017] [Accepted: 08/17/2017] [Indexed: 11/23/2022] Open
Abstract
Mucinous cystic neoplasms (MCNs) of the pancreas in male patients are very rare. Though few cases of MCNs in male patients have been reported, it is difficult to reveal them preoperatively. The first patient was a 50-year-old man and was incidentally found to have a cystic mass of 51 mm in the tail of the pancreas. We performed a distal pancreatectomy. The second patient was a 73-year-old man, incidentally found to have a cystic mass of 25 mm in diameter in the tail of the pancreas and a carcinoma of the bile duct. We performed a subtotal stomachpreserving pancreaticoduodenectomy and distal pancreatectomy. In both cases, the cystic lesion was diagnosed pathologically as MCNs. Since MCNs have the risk of malignancy, a resection is recommended. Cases of MCNs in male patients exhibit features that are similar to MCNs in women. We should recognize that MCNs of the pancreas in male patients exists.
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Affiliation(s)
| | | | | | - Kazufumi Suzuki
- Department of Gastrointestinal Surgery, Seirei Hamamatsu General Hospital, Shizuoka, Japan
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60
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Ivry SL, Sharib JM, Dominguez DA, Roy N, Hatcher SE, Yip-Schneider MT, Schmidt CM, Brand RE, Park WG, Hebrok M, Kim GE, O'Donoghue AJ, Kirkwood KS, Craik CS. Global Protease Activity Profiling Provides Differential Diagnosis of Pancreatic Cysts. Clin Cancer Res 2017; 23:4865-4874. [PMID: 28424202 PMCID: PMC5712228 DOI: 10.1158/1078-0432.ccr-16-2987] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 02/23/2017] [Accepted: 04/14/2017] [Indexed: 12/18/2022]
Abstract
Purpose: Pancreatic cysts are estimated to be present in 2%-3% of the adult population. Unfortunately, current diagnostics do not accurately distinguish benign cysts from those that can progress into invasive cancer. Misregulated pericellular proteolysis is a hallmark of malignancy, and therefore, we used a global approach to discover protease activities that differentiate benign nonmucinous cysts from premalignant mucinous cysts.Experimental Design: We employed an unbiased and global protease profiling approach to discover protease activities in 23 cyst fluid samples. The distinguishing activities of select proteases was confirmed in 110 samples using specific fluorogenic substrates and required less than 5 μL of cyst fluid.Results: We determined that the activities of the aspartyl proteases gastricsin and cathepsin E are highly increased in fluid from mucinous cysts. IHC analysis revealed that gastricsin expression was associated with regions of low-grade dysplasia, whereas cathepsin E expression was independent of dysplasia grade. Gastricsin activity differentiated mucinous from nonmucinous cysts with a specificity of 100% and a sensitivity of 93%, whereas cathepsin E activity was 92% specific and 70% sensitive. Gastricsin significantly outperformed the most widely used molecular biomarker, carcinoembryonic antigen (CEA), which demonstrated 94% specificity and 65% sensitivity. Combined analysis of gastricsin and CEA resulted in a near perfect classifier with 100% specificity and 98% sensitivity.Conclusions: Quantitation of gastricsin and cathepsin E activities accurately distinguished mucinous from nonmucinous pancreatic cysts and has the potential to replace current diagnostics for analysis of these highly prevalent lesions. Clin Cancer Res; 23(16); 4865-74. ©2017 AACR.
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MESH Headings
- Animals
- Biomarkers, Tumor/metabolism
- Carcinoembryonic Antigen/metabolism
- Cathepsin E/metabolism
- Cyst Fluid/enzymology
- Diagnosis, Differential
- Fluorescent Dyes/metabolism
- Humans
- Mice, Knockout
- Mice, Transgenic
- Neoplasms, Cystic, Mucinous, and Serous/diagnosis
- Neoplasms, Cystic, Mucinous, and Serous/enzymology
- Pancreatic Cyst/diagnosis
- Pancreatic Cyst/enzymology
- Pancreatic Neoplasms/diagnosis
- Pancreatic Neoplasms/enzymology
- Pancreatic Pseudocyst/diagnosis
- Pancreatic Pseudocyst/enzymology
- Pepsin A/metabolism
- Peptide Hydrolases/metabolism
- Retrospective Studies
- Sensitivity and Specificity
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Affiliation(s)
- Sam L Ivry
- Department of Pharmaceutical Chemistry, University of California, San Francisco, San Francisco, California
- Pharmaceutical Sciences and Pharmacogenomics Graduate Program, University of California, San Francisco, San Francisco, California
| | - Jeremy M Sharib
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Dana A Dominguez
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Nilotpal Roy
- Diabetes Center, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Stacy E Hatcher
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | | | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Randall E Brand
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Walter G Park
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Matthias Hebrok
- Diabetes Center, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Grace E Kim
- Department of Pathology, University of California, San Francisco, San Francisco, California
| | - Anthony J O'Donoghue
- Skaggs School of Pharmacy and Pharmaceutical Chemistry, University of California, San Diego, La Jolla, California
| | - Kimberly S Kirkwood
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Charles S Craik
- Department of Pharmaceutical Chemistry, University of California, San Francisco, San Francisco, California.
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61
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Nonmucinous Biliary Epithelium Is a Frequent Finding and Is Often the Predominant Epithelial Type in Mucinous Cystic Neoplasms of the Pancreas and Liver. Am J Surg Pathol 2017; 41:116-120. [PMID: 27673548 DOI: 10.1097/pas.0000000000000745] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Mucinous cystic neoplasms (MCNs) can occur in the pancreas and liver. Classically, these cystic lesions are lined by columnar mucinous epithelium with underlying ovarian-type stroma. It has been proposed that cysts with ovarian-type stroma and nonmucinous epithelium be considered separate entities in both the pancreas and liver. Using a series of 104 pancreatic and 32 hepatic cases, we aimed to further characterize the epithelium present in MCNs. Mucinous epithelium was defined as pancreatic intraepithelial neoplasia-like columnar cells with pale pink/clear apical mucin. Epithelial cells ranging from flat to cuboidal to short columnar without obvious mucin or goblet cells were classified as nonmucinous/biliary epithelium. A mixture (at least 5%) of mucinous and nonmucinous/biliary epithelium was noted in 81%. Almost half (47%) of the cases had abundant (>50%) nonmucinous/biliary epithelium. Of the 71 cases with ≤50% nonmucinous/biliary epithelium, 8 cases demonstrated high-grade dysplasia (7 pancreas, 1 liver) and 14 demonstrated invasive adenocarcinoma (11 pancreas, 3 liver). Conversely, of the 58 cases with >50% nonmucinous/biliary epithelium, not a single case of high-grade dysplasia (P=0.007) or invasive carcinoma (P<0.001) was identified. In summary, nonmucinous/biliary epithelium frequently occurs in MCNs of the pancreas and liver. As mucinous and nonmucinous/biliary epithelia often occur together, there does not appear to be enough evidence to regard cases with predominantly nonmucinous/biliary epithelium as separate entities. Our findings suggest that mucinous change is a "progression" phenomenon in MCNs of the pancreas and liver, and only when abundant mucinous epithelium is present is there a risk of progression to malignancy.
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62
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Paniccia A, Torphy R, Devaraj K, Schulick RD. Anaplastic Pancreatic Carcinoma Arising Within a Mucinous Cystic Neoplasm of the Pancreas: A Case Report and a Brief Review of the Literature. J Pancreat Cancer 2017; 3:40-45. [PMID: 30631840 PMCID: PMC5933473 DOI: 10.1089/pancan.2017.0004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background: Anaplastic pancreatic carcinomas (APCs) are among the least frequently encountered pancreatic malignancies, ranging from 0.5% to 7% of all nonendocrine pancreatic malignancies. Furthermore, few cases of APCs have been described arising within a pancreatic mucinous cystic neoplasm (MCN). Case Presentation: A 36-year-old female presented with left upper quadrant pain and a 10 × 8 cm complex cystic mass in the pancreatic tail. Fine needle aspiration of the cyst showed papillary clusters of cells with mild cytological atypia, cyst fluid carcinoembryonic antigen >4000 ng/mL, and amylase of 25 U/L. After an open distal pancreatectomy and splenectomy, the specimen revealed an MCN with multifocal microscopic foci of invasive well-differentiated adenocarcinoma. After additional sampling, foci of undifferentiated malignancy-morphologically resembling sarcomas but with immunohistochemical staining consistent with anaplastic carcinoma-were identified. The patient had an uneventful recovery and is currently undergoing a regimen of gemcitabine-based adjuvant chemotherapy; she remains disease-free at 5 months after initial diagnosis. Conclusions: In this study, we describe a rare case of APC originating from a large pancreatic MCN lesion. This case underlines the importance of scrupulous pathological evaluation of the entire MCN epithelium and adds to the limited world literature of APC originating from pancreatic MCN lesions.
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Affiliation(s)
- Alessandro Paniccia
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Robert Torphy
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kalpana Devaraj
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Richard D Schulick
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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63
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64
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Postlewait LM, Ethun CG, McInnis MR, Merchant N, Parikh A, Idrees K, Isom CA, Hawkins W, Fields RC, Strand M, Weber SM, Cho CS, Salem A, Martin RCG, Scoggins C, Bentrem D, Kim HJ, Carr J, Ahmad S, Abbott DE, Wilson GC, Kooby DA, Maithel SK. Association of Preoperative Risk Factors With Malignancy in Pancreatic Mucinous Cystic Neoplasms: A Multicenter Study. JAMA Surg 2017; 152:19-25. [PMID: 27760255 DOI: 10.1001/jamasurg.2016.3598] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance Pancreatic mucinous cystic neoplasms (MCNs) harbor malignant potential, and current guidelines recommend resection. However, data are limited on preoperative risk factors for malignancy (adenocarcinoma or high-grade dysplasia) occurring in the setting of an MCN. Objectives To examine the preoperative risk factors for malignancy in resected MCNs and to assess outcomes of MCN-associated adenocarcinoma. Design, Setting, and Participants Patients who underwent pancreatic resection of MCNs at the 8 academic centers of the Central Pancreas Consortium from January 1, 2000, through December 31, 2014, were retrospectively identified. Preoperative factors of patients with and without malignant tumors were compared. Survival analyses were conducted for patients with adenocarcinoma. Main Outcomes and Measures Binary logistic regression models were used to determine the association of preoperative factors with the presence of MCN-associated malignancy. Results A total of 1667 patients underwent resection of pancreatic cystic lesions, and 349 (20.9%) had an MCN (310 women [88.8%]; mean (SD) age, 53.3 [14.7] years). Male sex (odds ratio [OR], 3.72; 95% CI, 1.21-11.44; P = .02), pancreatic head and neck location (OR, 3.93; 95% CI, 1.43-10.81; P = .01), increased radiographic size of the MCN (OR, 1.17; 95% CI, 1.08-1.27; P < .001), presence of a solid component or mural nodule (OR, 4.54; 95% CI, 1.95-10.57; P < .001), and duct dilation (OR, 4.17; 95% CI, 1.63-10.64; P = .003) were independently associated with malignancy. Malignancy was not associated with presence of radiographic septations or preoperative cyst fluid analysis (carcinoembryonic antigen, amylase, or mucin presence). The median serum CA19-9 level for patients with malignant neoplasms was 210 vs 15 U/mL for those without (P = .001). In the 44 patients with adenocarcinoma, 41 (93.2%) had lymph nodes harvested, with nodal metastases in only 14 (34.1%). Median follow-up for patients with adenocarcinoma was 27 months. Adenocarcinoma recurred in 11 patients (25%), with a 64% recurrence-free survival and 59% overall survival at 3 years. Conclusions and Relevance Adenocarcinoma or high-grade dysplasia is present in 14.9% of resected pancreatic MCNs for which risks include male sex, pancreatic head and neck location, larger MCN, solid component or mural nodule, and duct dilation. Mucinous cystic neoplasm-associated adenocarcinoma appears to have decreased nodal involvement at the time of resection and increased survival compared with typical pancreatic ductal adenocarcinoma. Indications for resection of MCNs should be revisited.
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Affiliation(s)
- Lauren M Postlewait
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia
| | - Cecilia G Ethun
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia
| | - Mia R McInnis
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia
| | - Nipun Merchant
- Division of Surgical Oncology, Department of Surgery, University of Miami, Miami, Florida
| | - Alexander Parikh
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kamran Idrees
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chelsea A Isom
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William Hawkins
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Ryan C Fields
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Matthew Strand
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Sharon M Weber
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Clifford S Cho
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Ahmed Salem
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Charles Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - David Bentrem
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hong J Kim
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill
| | - Jacquelyn Carr
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill
| | - Syed Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati Cancer Institute, Cincinnati, Ohio
| | - Daniel E Abbott
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati Cancer Institute, Cincinnati, Ohio
| | - Gregory C Wilson
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati Cancer Institute, Cincinnati, Ohio
| | - David A Kooby
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Winship Cancer Institute, Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, Georgia
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Kim SJ, An S, Lee JH, Kim JY, Song KB, Hwang DW, Kim SC, Yu E, Hong SM. Loss of Progesterone Receptor Expression Is an Early Tumorigenesis Event Associated with Tumor Progression and Shorter Survival in Pancreatic Neuroendocrine Tumor Patients. J Pathol Transl Med 2017; 51:388-395. [PMID: 28597868 PMCID: PMC5525038 DOI: 10.4132/jptm.2017.03.19] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 02/21/2017] [Accepted: 03/19/2017] [Indexed: 12/12/2022] Open
Abstract
Background Pancreatic neuroendocrine tumors (PanNETs) are the second most common pancreatic neoplasms and there is no well-elucidated biomarker to stratify their detection and prognosis. Previous studies have reported that progesterone receptor (PR) expression status was associated with poorer survival in PanNET patients. Methods To validate previous studies, PR protein expression was assessed in 21 neuroendocrine microadenomas and 277 PanNETs and compared with clinicopathologic factors including patient survival. Results PR expression was gradually decreased from normal islets (49/49 cases, 100%) to neuroendocrine microadenoma (14/21, 66.6%) to PanNETs (60/277, 21.3%; p < .001). PanNETs with loss of PR expression were associated with increased tumor size (p < .001), World Health Organization grade (p = .001), pT classification (p < .001), perineural invasion (p = .028), lymph node metastasis (p = .004), activation of alternative lengthening of telomeres (p = .005), other peptide hormonal expression (p < .001) and ATRX/DAXX expression (p = .015). PanNET patients with loss of PR expression (5-year survival rate, 64.1%) had significantly poorer recurrence-free survival outcomes than those with intact PR expression (90%) by univariate (p = .012) but not multivariate analyses. Similarly, PanNET patients with PR expression loss (5-year survival rate, 76%) had significantly poorer overall survival by univariate (p = .015) but not multivariate analyses. Conclusions Loss of PR expression was noted in neuroendocrine microadenomas and was observed in the majority of PanNETs. This was associated with increased grade, tumor size, and advanced pT and pN classification; and was correlated with decreased patient survival time by univariate but not multivariate analyses. Loss of PR expression can provide additional information on shorter disease-free survival in PanNET patients.
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Affiliation(s)
- Sung Joo Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Soyeon An
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo Young Kim
- Department of Pathology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Ki-Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eunsil Yu
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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66
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Paniccia A, Torphy R, Devaraj K, Schulick RD. Anaplastic Pancreatic Carcinoma Arising Within a Mucinous Cystic Neoplasm of the Pancreas: A Case Report and a Brief Review of the Literature. J Pancreat Cancer 2017. [DOI: 10.1089/crpc.2017.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Alessandro Paniccia
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Robert Torphy
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kalpana Devaraj
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Richard D. Schulick
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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67
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Reid MD, Muraki T, HooKim K, Memis B, Graham RP, Allende D, Shi J, Schaeffer DF, Singh R, Basturk O, Adsay V. Cytologic features and clinical implications of undifferentiated carcinoma with osteoclastic giant cells of the pancreas: An analysis of 15 cases. Cancer Cytopathol 2017; 125:563-575. [DOI: 10.1002/cncy.21859] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 01/13/2017] [Accepted: 02/21/2017] [Indexed: 12/27/2022]
Affiliation(s)
- Michelle D. Reid
- Department of Pathology; Emory University Hospital; Atlanta Georgia
| | - Takashi Muraki
- Department of Pathology; Emory University Hospital; Atlanta Georgia
| | - Kim HooKim
- Department of Pathology; Thomas Jefferson University; Philadelphia Pennsylvania
| | - Bahar Memis
- Department of Pathology; Emory University Hospital; Atlanta Georgia
| | | | | | - Jiaqi Shi
- Department of Pathology; University of Michigan; Ann Arbor Michigan
| | - David F. Schaeffer
- Department of Pathology; Vancouver General Hospital; Vancouver British Columbia Canada
| | - Remmi Singh
- Department of Pathology; Northside Hospital; Atlanta Georgia
| | - Olca Basturk
- Department of Pathology; Memorial Sloan-Kettering Cancer Center; New York New York
| | - Volkan Adsay
- Department of Pathology; Emory University Hospital; Atlanta Georgia
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68
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Mixed epithelial and stromal tumor of the middle ear. Hum Pathol 2017; 61:199-204. [DOI: 10.1016/j.humpath.2016.09.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 09/01/2016] [Accepted: 09/23/2016] [Indexed: 12/16/2022]
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69
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Greer JB, Ferrone CR. Spectrum and Classification of Cystic Neoplasms of the Pancreas. Surg Oncol Clin N Am 2016; 25:339-50. [PMID: 27013368 DOI: 10.1016/j.soc.2015.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
As patients are living longer and axial imaging is more widespread, increasing numbers of cystic neoplasms of the pancreas are found. Intraductal papillary mucinous neoplasms and mucinous cystic neoplasms are the most common. The revised Sendai guidelines provide a safe algorithm for expectant management of certain cystic neoplasms; however, studies are ongoing to identify further subgroups that can be treated nonoperatively. For those patients with high-risk clinical features or symptoms, surgical resection can be performed safely at high-volume pancreatic centers. Accurate diagnosis is critical for accurate decision making.
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Affiliation(s)
- Jonathan B Greer
- General Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, GRB-425, Boston, MA 02114, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA 02114, USA.
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70
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Scourtas A, Dudley JC, Brugge WR, Kadayifci A, Mino-Kenudson M, Pitman MB. Preoperative characteristics and cytological features of 136 histologically confirmed pancreatic mucinous cystic neoplasms. Cancer Cytopathol 2016; 125:169-177. [PMID: 27926784 DOI: 10.1002/cncy.21806] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/11/2016] [Accepted: 11/10/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND Mucinous cystic neoplasms (MCNs) of the pancreas present a management conundrum. The majority are benign but all are resected due to their malignant potential. Recent studies have recommended nonsurgical management. In the current study, the authors analyzed the preoperative imaging, cytology, and cyst fluid characteristics of 136 histologically confirmed MCNs to assess predictors of a high-risk (HR) cyst for surgical triage. METHODS MCNs resected at the Massachusetts General Hospital between 1990 and 2014 formed the study cohort. Patient demographics, cyst size, and mural nodules (MNs) by endoscopic ultrasound, cytology, and cyst fluid carcinoembryonic antigen and amylase levels were correlated with histological grade. A HR cyst was defined as high-grade dysplasia or invasive carcinoma on histology. Performance characteristics were assessed for each parameter, with a cyst size ≥3 cm or a MN on imaging and malignant cytology considered to be "true-positive" results for predicting malignancy. RESULTS Only 15 of the 136 cysts had HR histology (11%). On average, patients with HR cysts were older than those with low-risk cysts (55 years vs 49 years, respectively). High-grade cytology was the most accurate predictor of malignancy (95%) followed by MN and cyst size together (88%) and MN alone (83%). The average carcinoembryonic antigen level (in ng/mL) increased with the grade of dysplasia but the ranges overlapped between low risk and HR cysts. CONCLUSIONS To the authors' knowledge, the current study is the largest series to date analyzing the cytological features of histologically confirmed MCN. Cytology is insensitive but very specific for detecting a HR MCN and outperformed imaging for the detection of HR MCN. Endoscopic ultrasound-guided fine-needle aspiration and cytology should be performed on any clinically suspected MCN that is being considered for conservative management. Cancer Cytopathol 2017;125:169-177. © 2016 American Cancer Society.
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Affiliation(s)
- Aristana Scourtas
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan C Dudley
- Department of Pathology, Stanford University Medical Center, Palo Alto, California
| | - William R Brugge
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Abdurrahman Kadayifci
- Division of Gastroenterology, Gaziantep University School of Medicine, Gaziantep, Turkey
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
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Abstract
To better understand pancreatic ductal adenocarcinoma (PDAC) and improve its prognosis, it is essential to understand its origins. This article describes the pathology of the 3 well-established pancreatic cancer precursor lesions: pancreatic intraepithelial neoplasia, intraductal papillary mucinous neoplasm, and mucinous cystic neoplasm. Each of these precursor lesions has unique clinical findings, gross and microscopic features, and molecular aberrations. This article focuses on histopathologic diagnostic criteria and reporting guidelines. The genetics of these lesions are briefly discussed. Early detection and adequate treatment of pancreatic cancer precursor lesions has the potential to prevent pancreatic cancer and improve the prognosis of PDAC.
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Affiliation(s)
- Michaël Noë
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
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72
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Muraki T, Reid MD, Basturk O, Jang KT, Bedolla G, Bagci P, Mittal P, Memis B, Katabi N, Bandyopadhyay S, Sarmiento JM, Krasinskas A, Klimstra DS, Adsay V. Undifferentiated Carcinoma With Osteoclastic Giant Cells of the Pancreas: Clinicopathologic Analysis of 38 Cases Highlights a More Protracted Clinical Course Than Currently Appreciated. Am J Surg Pathol 2016; 40:1203-16. [PMID: 27508975 PMCID: PMC4987218 DOI: 10.1097/pas.0000000000000689] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Undifferentiated carcinomas with osteoclastic giant cells of the pancreas (OGC) are rare tumors. The current impression in the literature is that they are highly aggressive tumors similar in prognosis to ductal adenocarcinomas. In this study, the clinicopathologic characteristics of 38 resected OGCs were investigated and contrasted with 725 resected pancreatic ductal adenocarcinomas without osteoclastic cells (PDCs). The frequency among systematically reviewed pancreatic cancers was 1.4%. OGCs showed a slight female predominance (62.9%, vs. 51.4% in PDCs). The mean age was 57.9 years (vs. 65.0). The mean size of invasive cancer was 5.3 cm (vs. 3.2). They were characterized by nodular, pushing-border growth, and 8 arose in tumoral intraepithelial neoplasms (4 in mucinous cystic neoplasms, 4 in intraductal papillary mucinous neoplasms type lesions), and 23 (61%) also showed prominent intraductal/intracystic growth. Twenty-nine (76%) had an invasive ductal/tubular adenocarcinoma component. Osteoid was seen in 12. Despite their larger size, perineural invasion and nodal metastasis were uncommon (31.6% and 22.6%, vs. 85.5% and 64.0%, respectively). Immunohistochemistry performed on 24 cases revealed that osteoclastic cells expressed the histiocytic marker CD68, and background spindle cells and pleomorphic/giant carcinoma cells often showed p53 and often lacked cytokeratin. Survival of OGCs was significantly better than that of PDCs (5 yr, 59.1% vs. 15.7%, respectively, P=0.0009). In conclusion, pancreatic OGCs present with larger tumor size and in slightly younger patients than PDC, 21% arise in mucinous cystic neoplasms/intraductal papillary mucinous neoplasms, and 61% show intraductal/intracystic polypoid growth. OGCs have a significantly better prognosis than is currently believed in the literature.
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Affiliation(s)
- Takashi Muraki
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, GA, USA
| | - Michelle D. Reid
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, GA, USA
| | - Olca Basturk
- Department of Pathology, Memorial Sloan Kettering Cancer Center, NY, USA
| | - Kee-Taek Jang
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gabriela Bedolla
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, GA, USA
| | - Pelin Bagci
- Department of Pathology, Marmara University, Istanbul, Turkey
| | - Pardeep Mittal
- Department of Radiology, Emory University School of Medicine, GA, USA
| | - Bahar Memis
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, GA, USA
| | - Nora Katabi
- Department of Pathology, Memorial Sloan Kettering Cancer Center, NY, USA
| | | | | | - Alyssa Krasinskas
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, GA, USA
| | - David S. Klimstra
- Department of Pathology, Memorial Sloan Kettering Cancer Center, NY, USA
| | - Volkan Adsay
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, GA, USA
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73
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Jang KT, Ahn S. Tumoral Versus Flat Intraepithelial Neoplasia of Pancreatobiliary Tract, Gallbladder, and Ampulla of Vater. Arch Pathol Lab Med 2016; 140:429-36. [DOI: 10.5858/arpa.2015-0319-ra] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—The identification of a precursor lesion is important to understanding the histopathologic and genetic alterations in carcinogenesis. There are a plethora of terminologies that describe precursor lesions of the pancreatobiliary tract, ampulla of Vater, and gallbladder. The current terminologies for precursor lesions may make it difficult to understand the tumor biology. Here, we propose the concept of tumoral and flat intraepithelial neoplasia to improve our understanding of precursor lesions of many epithelial organs, including the pancreatobiliary tract, ampulla of Vater, and gallbladder.
Objective.—To understand the dichotomous pattern of tumoral and flat intraepithelial neoplasia in carcinogenesis of pancreatobiliary tract, ampulla of Vater, and gallbladder.
Data Sources.—Review of relevant literatures indexed in PubMed.
Conclusions.—Tumoral intraepithelial neoplasia presents as an intraluminal or intraductal, mass-forming, polypoid lesion or a macroscopic, visible, cystic lesion without intracystic papillae. Microscopically, tumoral intraepithelial neoplasia shows various proportions of papillary and tubular architecture, often with a mixed pattern, such as papillary, tubular, and papillary-tubular. The malignant potential depends on the degree of dysplasia and the cell phenotype of the epithelium. Flat intraepithelial neoplasia presents as a flat or superficial, spreading, mucosal lesion that is frequently accompanied by an invasive carcinoma. Tumoral and flat intraepithelial neoplasias are not homogeneous entities and may exhibit histopathologic spectrum changes and different genetic profiles. Although intraepithelial neoplasia showed a dichotomous pattern in the tumoral versus flat types, they can coexist. Tumoral and flat intraepithelial neoplasia can be interpreted as part of a spectrum of changes in the carcinogenesis pathway of each organ.
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Affiliation(s)
| | - Sangjeong Ahn
- From the Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (Dr Jang); and the Department of Pathology, Pusan National University Hospital and the Pusan National University School of Medicine, and the Biomedical Research Institute, Pusan National University Hospital, Pusan, Korea (Dr Ahn)
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74
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Adsay V, Mino-Kenudson M, Furukawa T, Basturk O, Zamboni G, Marchegiani G, Bassi C, Salvia R, Malleo G, Paiella S, Wolfgang CL, Matthaei H, Offerhaus GJ, Adham M, Bruno MJ, Reid M, Krasinskas A, Klöppel G, Ohike N, Tajiri T, Jang KT, Roa JC, Allen P, Castillo CFD, Jang JY, Klimstra DS, Hruban RH. Pathologic Evaluation and Reporting of Intraductal Papillary Mucinous Neoplasms of the Pancreas and Other Tumoral Intraepithelial Neoplasms of Pancreatobiliary Tract: Recommendations of Verona Consensus Meeting. Ann Surg 2016; 263:162-77. [PMID: 25775066 PMCID: PMC4568174 DOI: 10.1097/sla.0000000000001173] [Citation(s) in RCA: 167] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND There are no established guidelines for pathologic diagnosis/reporting of intraductal papillary mucinous neoplasms (IPMNs). DESIGN An international multidisciplinary group, brought together by the Verona Pancreas Group in Italy-2013, was tasked to devise recommendations. RESULTS (1) Crucial to rule out invasive carcinoma with extensive (if not complete) sampling. (2) Invasive component is to be documented in a full synoptic report including its size, type, grade, and stage. (3) The term "minimally invasive" should be avoided; instead, invasion size with stage and substaging of T1 (1a, b, c; ≤ 0.5, > 0.5-≤ 1, > 1 cm) is to be documented. (4) Largest diameter of the invasion, not the distance from the nearest duct, is to be used. (5) A category of "indeterminate/(suspicious) for invasion" is acceptable for rare cases. (6) The term "malignant" IPMN should be avoided. (7) The highest grade of dysplasia in the non-invasive component is to be documented separately. (8) Lesion size is to be correlated with imaging findings in cysts with rupture. (9) The main duct diameter and, if possible, its involvement are to be documented; however, it is not required to provide main versus branch duct classification in the resected tumor. (10) Subtyping as gastric/intestinal/pancreatobiliary/oncocytic/mixed is of value. (11) Frozen section is to be performed highly selectively, with appreciation of its shortcomings. (12) These principles also apply to other similar tumoral intraepithelial neoplasms (mucinous cystic neoplasms, intra-ampullary, and intra-biliary/cholecystic). CONCLUSIONS These recommendations will ensure proper communication of salient tumor characteristics to the management teams, accurate comparison of data between analyses, and development of more effective management algorithms.
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Affiliation(s)
- Volkan Adsay
- Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Toru Furukawa
- Department of Pathology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Olca Basturk
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | - Claudio Bassi
- Department of Surgery, University of Verona, Verona, Italy
| | - Roberto Salvia
- Department of Surgery, University of Verona, Verona, Italy
| | | | | | - Christopher L. Wolfgang
- Department of Surgery, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Hanno Matthaei
- Department of Surgery, University of Bonn, Bonn, Germany
| | - G. Johan Offerhaus
- Department of Pathology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Mustapha Adham
- Department of Surgery, Edouard Herriot Hospital, HCL, Lyon, France
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Michelle Reid
- Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Alyssa Krasinskas
- Department of Pathology, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA, USA
| | - Günter Klöppel
- Department of Pathology, Technical University, München, Germany
| | - Nobuyuki Ohike
- Department of Pathology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Takuma Tajiri
- Department of Pathology, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Kee-Taek Jang
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Juan Carlos Roa
- Department of Pathology, Pontificia Universidad Católica de Chile, Chile
| | - Peter Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
| | - David S. Klimstra
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Ralph H. Hruban
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, USA
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