Intraoperative pancreatoscopy with the ultrathin pancreatoscope for mucin-producing tumors of the pancreas

The Role of Intraoperative Pancreatoscopy in the Surgical Management of Intraductal Papillary Mucinous Neoplasms: A Scoping Review

OBJECTIVES

Most patients with intraductal papillary mucinous neoplasms (IPMNs) are diagnosed with a solitary lesion; however, the presence of skip lesions, not appreciable on imaging, has been described. Postoperatively, these missed lesions can continue to grow and potentially become cancerous. Intraoperative pancreatoscopy (IOP) may facilitate detection of such skip lesions in the remnant gland. The aim of this scoping review was to appraise the evidence on the role of IOP in the surgical management of IPMNs.

MATERIALS AND METHODS

Studies reporting on the use of IOP during IPMN surgery were identified through searches of the PubMed, Embase, and Scopus databases. Data extracted included IOP findings, surgical plan modifications, and patient outcomes. The primary outcome of interest was the utility of IOP in surgical decision making.

RESULTS

Ten studies reporting on the use of IOP for IPMNs were identified, representing 147 patients. A total of 46 skip lesions were identified by IOP. Overall, surgical plans were altered in 37% of patients who underwent IOP. No IOP-related complications were reported.

CONCLUSIONS

The current literature suggests a potential role of integration of IOP into the management of patients with IPMNs. This tool is safe and feasible and can result in changes in surgical decision making.

The role of intraoperative pancreatoscopy in the surgical management of intraductal papillary mucinous neoplasms of the pancreas: a systematic scoping review

BACKGROUND

The type and the extent of surgery is still debatable for intraductal papillary mucinous neoplasm (IPMN). Intraoperative pancreatoscopy (IOP) allows the visualization of the main pancreatic duct (MPD) in its entire length and could help determine the extent of MPD involvement and the type and extent of pancreatic resection. However, current guidelines do not advise its routine use as there is a lack of evidence supporting its safety and feasibility. The present study aims to perform a scoping review of published evidence on the safety and feasibility of IOP in IPMN surgical management.

METHODS

We systematically searched PubMed, Cochrane, Medline and EMbase to identify studies reporting the use of IOP in IPMN surgical management. The research was completed in June 2023. Data extracted included patient selection criteria, demographics, safety of the procedure, intraoperative findings, impact on surgical strategy, histology results and postoperative outcomes.

RESULTS

Four retrospective and one prospective study were included in this scoping review. A total of 142 patients had IOP. The selection criteria for inclusion were heterogenous, with one out of five studies including branch duct (BD), main duct (MD) and mixed type IPMN. Indications for IOP and surgical resection were only reported in two studies. A median of seven outcomes (range 5-8) was described, including the type of surgical resection, additional lesions and change of surgical plan, and complications after IOP. IOP showed additional lesions in 48 patients (34%) and a change of surgical plan in 48(34%). No IOP-related complications were reported.

CONCLUSIONS

This scoping review suggests IOP is safe and identifies additional lesions impacting the surgical strategy for IPMN. However, the included studies were small and heterogeneous regarding IPMN definition and indications for surgery and IOP. There is a need for a large multi-centre prospective study to determine the role of IOP and its impact on surgical strategy for IPMN.

Systematic review of challenging issues in pathology of intraductal papillary mucinous neoplasms

BACKGROUND

Intraductal papillary mucinous neoplasms (IPMNs) are a cystic precursor to pancreatic cancer. IPMNs deemed clinically to be at high-risk for malignant progression are frequently treated with surgical resection, and pathological examination of the pancreatectomy specimen is a key component of the clinical care of IPMN patients.

METHODS

Systematic literature reviews were conducted around eight topics of clinical relevance in the examination of pathological specimens in patients undergoing resection of IPMN.

RESULTS

This review provides updated perspectives on morphological subtyping of IPMNs, classification of intraductal oncocytic papillary neoplasms, nomenclature for high-grade dysplasia, assessment of T stage, distinction of carcinoma associated or concomitant with IPMN, role of molecular assessment of IPMN tissue, role of intraoperative assessment by frozen section, and preoperative evaluation of cyst fluid cytology.

CONCLUSIONS

This analysis provides the foundation for data-driven approaches to several challenging issues in the pathology of IPMNs.

The role of pancreatoscopy in the diagnostic work-up of intraductal papillary mucinous neoplasms: a systematic review and meta-analysis

BACKGROUND

Confirming the diagnosis, invasiveness, and disease extent of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas is challenging. The aim of this study was to summarize the literature on the efficacy and safety of peroral pancreatoscopy (POP) in the diagnosis of IPMN, including the impact of pre- and intraoperative POP on the management of IPMN.

METHODS

The EMBASE, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar databases were systematically searched for articles. Eligible articles investigated cohorts of patients who underwent POP for (suspected) IPMN.

RESULTS

25 articles were identified and included in this review; with 22 of these reporting on the diagnostic yield of POP in IPMN and 11 reporting on the effect of pre- or intraoperative POP on clinical decision-making. Cannulation and observation rates, and overall diagnostic accuracy were high across all studies. Frequently reported visual characteristics of IPMN were intraductal fish-egg-like lesions, hypervascularity, and granular mucosa. Overall, the adverse event rate was 12 %, primarily consisting of post-endoscopic retrograde cholangiopancreatography pancreatitis, with a pooled rate of 10 %, mostly of mild severity. Regarding the impact of POP on clinical decision-making, POP findings altered the surgical approach in 13 %-62 % of patients.

CONCLUSION

POP is technically successful in the vast majority of patients with (suspected) IPMN, has a consistently high diagnostic accuracy, but an adverse event rate of 12 %. Data on intraoperative pancreatoscopy are scarce, but small studies suggest its use can alter surgical management. Future studies are needed to better define the role of POP in the diagnostic work-up of IPMN.

Determination of the Length of Pancreatic Ductotomy by Pancreaticoscopy During Frey's Procedure for Chronic Pancreatitis

Objective

To study the impact of pancreaticoscopy during Frey's procedure for treating chronic pancreatitis (CP).

Background

Excision of the central part of the head of the pancreas along with longitudinal pancreaticotomy (Frey's procedure) is widely performed for the treatment of CP. However, there is no reliable method to determine the necessary length of longitudinal pancreaticotomy during surgery for CP.

Methods

Thirty-five consecutive patients with CP were scheduled for Frey's procedure with intraoperative pancreaticoscopy. The length of the longitudinal pancreaticotomy was tailored by pancreaticoscopy in the following manner: (1) it did not extend beyond the neck in case of a uniformly dilated main duct with patent branch duct confluences and a clear lumen; (2) in case of an obstructed main duct or branch duct confluence of any cause, the main duct was opened to include the most distal obstruction.

Results

All patients underwent Frey's procedure and intraoperative pancreaticoscopy. Based on the pancreaticoscopy findings, pancreaticotomy over the body of the gland was not necessary in 34% of the patients. A short (4-6 cm) ductotomy extension over the pancreatic body was required in 14% of the patients. Full-length pancreaticotomy was required in 52% of the patients. The median operative time was 145 minutes, and the median blood loss was 70 mL. Four patients (11.4%) experienced postoperative complications. There were no 90-day postoperative mortality or hospital readmission rates. At the median follow-up of 19 months, 31 patients (88.5%) had no pain attacks requiring medication.

Conclusions

Intraoperative pancreaticoscopy helps to determine the length of longitudinal pancreaticotomy and reduce pancreatic trauma during Frey's procedure for treating CP.

Indications to total pancreatectomy for positive neck margin after partial pancreatectomy: a review of a slippery ground

The extension of a partial pancreatectomy up to total pancreatectomy because of positive neck margin examined at intraoperative frozen section (IFS) analysis is an accepted procedure in modern pancreatic surgery with good accuracy. The goal of this practice is to improve the rate of radical (R0) resection in malignant tumors, mainly pancreatic ductal adenocarcinoma (PDAC), and to completely resect pre-invasive neoplasms such as intraductal papillary mucinous neoplasms (IPMNs). In the setting of IPMNs there is a consensus for pancreatic re-resection when high-grade dysplasia and invasive cancer are present at the neck margin. The presence of denudation is another indication for further resection in IPMNs. The role of IFS analysis in the management of pancreatic cancer is more debated. The presence of a positive intraoperative transection margin can be considered the surrogate of a biologically aggressive disease associated with a poorer prognosis. There are conflicting data regarding possible advantages of pancreatic re-resection up to total pancreatectomy, and the lack of randomized trials comparing different strategies does not offer a definitive answer. The goal of this review is to provide an up-to-date overview of the role IFS analysis of pancreatic margin and of pancreatic re-resection up to total pancreatectomy considering different pancreatic tumors.

Management Algorithms for Pancreatic Cystic Neoplasms: The Surgeon's Perspective

CONTEXT.—

The detection of pancreatic cystic neoplasms (PCNs) has increased owing to the advancement and widespread use of imaging modalities, resulting in differences between past and current management methods for PCNs, including intraductal papillary mucinous neoplasms (IPMNs). Therefore, clinicians should accurately diagnose and determine appropriate treatment strategies. However, previously published treatment guidelines for IPMNs present different indications for treatment.

OBJECTIVE.—

To review the current status of PCNs, including epidemiologic change, malignancy risk, and factors for treatment, and to provide the optimal management algorithms for PCNs, including IPMNs, from the clinician's point of view.

DATA SOURCES.—

Literature review of published studies and the authors' own work.

CONCLUSIONS.—

The treatment of PCNs relies on the type of cyst that is present or suspected. Serous cystic neoplasms are usually benign, and observation is sufficient. However, surgical treatment is required for mucinous cystic neoplasms, and malignancy risk differs according to lesion size. Solid pseudopapillary neoplasms also require surgery. The detection of small IPMNs has been increasing, and most branch duct-type IPMNs are dormant. However, cysts 3 cm or larger or growing branch duct-type IPMNs must be carefully monitored because of the increasing risk of malignancy. Therefore, surveillance strategies should be different according to the size of the lesions. A tailored approach is needed for selecting surgery or surveillance, considering the malignancy potential of the lesion and patient-associated factors such as operative risks and life expectancy. Nomograms are valuable tools for selecting treatment methods as a customized approach for IPMNs.

Fate of Patients With Intraductal Papillary Mucinous Neoplasms of Pancreas After Resection According to the Pathology and Margin Status: Continuously Increasing Risk of Recurrence Even After Curative Resection Suggesting Necessity of Lifetime Surveillance

OBJECTIVE

This study evaluated the associated factors and prognosis according to pathology and margin after surgical resection of intraductal papillary mucinous neoplasms (IPMN).

BACKGROUND

There is limited information on recurrence patterns according to pathology and margin in IPMN.

METHODS

Total 577 patients who underwent operation for IPMN at a tertiary center were included. Factors associated with recurrence, survival and recurrence outcomes according to pathology and margin were analyzed.

RESULTS

Among 548 patients analyzed, 353 had low-grade dysplasia (LGD); 78, high-grade dysplasia (HGD); and 117, invasive IPMN. Total 50 patients developed recurrences, with four resection margins, eight remnant pancreas, 11 locoregional, and 35 distant recurrences. Invasive IPMN showed worse 5-year cumulative recurrence risk (LGD vs HGD vs invasive: 0.7% vs 4.3% vs 37.6%, p < 0.001) and 5-year survival rate (89.0% vs 84.0% vs 48.4%, p < 0.001). Recurrence risk increased after 5 years, even in LGD and HGD. Malignant margin (HGD and invasive) had worse 5-year cumulative recurrence rate (R0 vs LGD vs malignant: 8.3% vs 5.9% vs 50.6%, p < 0.001) and 5-year survival rate (80.7% vs 83.0% vs 30.8%, p < 0.001). CA19-9 > 37 (p = 0.003), invasive IPMN (p < 0.001), and malignant margin (p = 0.036) were associated with recurrence.

CONCLUSIONS

Invasive IPMN developed more recurrences and had worse survival than LGD or HGD, indicating the need for more efficient postoperative treatment strategies. Patients with LGD and HGD also need regular follow-up for recurrence after 5 years. Malignant margins need additional resection to achieve negative or at least LGD margin.

Role of pancreatoscopy in management of pancreatic disease: A systematic review

BACKGROUND

Per-oral pancreatoscopy (POP) plays a role in the diagnosis and therapy of pancreatic diseases. With recent technological advances, there has been renewed interest in this modality.

AIM

To evaluate the efficacy and safety of POP in management of pancreatic stone disease and pancreatic ductal neoplasia.

METHODS

To determine the safety and efficacy of POP in the management of pancreatic diseases, a systematic search was conducted in MEDLINE, EMBASE and Ovid. Articles in languages other than English and case reports were excluded. All published case series were eligible. Data specific to POP were extracted from studies, which combined cholangiopancreatoscopy. Ten studies were included in the analysis of POP therapy for pancreatic stone disease, and 15 case series satisfied the criteria for inclusion for the role of POP in the management of pancreatic ductal neoplasia. The examined data were subcategorized according to adjunctive modalities, such as direct tissue sampling, cytology, the role of intraoperative POP, intraductal ultrasound (IDUS) and POP combined with image-enhancing technology.

RESULTS

The success rate for complete ductal stone clearance ranged from 37.5%-100%. Factors associated with failure included the presence of strictures, multiple stones and the inability to visualize the target area. Although direct visualization can identify malignant and premalignant conditions, there is significant overlap with benign diseases. Visually-directed biopsies provide a high degree of accuracy, and represent a unique approach for tissue acquisition in patients with ductal abnormalities. Addition of pancreatic fluid cytology increases diagnostic yield for indeterminate lesions. Protrusions larger than 3 mm noted on IDUS are significantly more likely to be associated with malignancy. The rate of adverse events associated with POP ranged from 0%-35%.

CONCLUSION

Current evidence supports wider adoption of pancreatoscopy, as it is safe and effective. Improved patient selection and utilization of novel technologies may further enhance its role in managing pancreatic disease.

Current role of endoscopic pancreatoscopy

PURPOSE OF REVIEW

To provide an overview of the field of pancreatoscopy and to summarize the data informing its clinical utility.

RECENT FINDINGS

Regarding the technological advance of pancreatoscopy, recent studies are the first to report the use of digital, single-operator pancreatoscopy (SpyGlass DS; Boston Scientific, Natick, MA). New data on the use of preoperative pancreatoscopy offer promising results for the potential to optimize treatment of intraductal papillary mucinous neoplasms and to differentiate between benign and malignant pancreatic strictures. Finally, there has been accumulating evidence for the use of pancreatoscopy-guided lithotripsy for the management of painful chronic calcific pancreatitis.

SUMMARY

Endoscopic pancreatoscopy offers the advantage of direct visualization of the pancreatic duct, allowing for optimal macroscopic assessment, targeted tissue acquisition and guided therapies such as lithotripsy of pancreatic duct stones. The data informing some aspects remain limited, but the accumulating literature forms our understanding of the current and future role of pancreatoscopy in the management of pancreatic disease.

European evidence-based guidelines on pancreatic cystic neoplasms

Evidence-based guidelines on the management of pancreatic cystic neoplasms (PCN) are lacking. This guideline is a joint initiative of the European Study Group on Cystic Tumours of the Pancreas, United European Gastroenterology, European Pancreatic Club, European-African Hepato-Pancreato-Biliary Association, European Digestive Surgery, and the European Society of Gastrointestinal Endoscopy. It replaces the 2013 European consensus statement guidelines on PCN. European and non-European experts performed systematic reviews and used GRADE methodology to answer relevant clinical questions on nine topics (biomarkers, radiology, endoscopy, intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystic neoplasm, rare cysts, (neo)adjuvant treatment, and pathology). Recommendations include conservative management, relative and absolute indications for surgery. A conservative approach is recommended for asymptomatic MCN and IPMN measuring <40 mm without an enhancing nodule. Relative indications for surgery in IPMN include a main pancreatic duct (MPD) diameter between 5 and 9.9 mm or a cyst diameter ≥40 mm. Absolute indications for surgery in IPMN, due to the high-risk of malignant transformation, include jaundice, an enhancing mural nodule >5 mm, and MPD diameter >10 mm. Lifelong follow-up of IPMN is recommended in patients who are fit for surgery. The European evidence-based guidelines on PCN aim to improve the diagnosis and management of PCN.

Impact of Intraoperative Pancreatoscopy with Intraductal Biopsies on Surgical Management of Intraductal Papillary Mucinous Neoplasm of the Pancreas

BACKGROUND

Because of its known malignant potential, precise histologic diagnosis of intraductal papillary mucinous neoplasm of the pancreas (IPMN) during intraoperative pancreatoscopy (IOP) is essential for complete surgical resection. The impact of IOP on perioperative IPMN patient management was reviewed over 20 years of practice at Cliniques universitaires Saint-Luc, Brussels, Belgium.

STUDY DESIGN

Among 86 IPMN patients treated by pancreatectomy between 1991 and 2013, 21 patients had a dilated main pancreatic duct enabling IOP and were retrospectively reviewed. The IOP was performed using an ultrathin flexible endoscope and biopsy forceps, and specimens of all suspicious lesions underwent frozen section examination.

RESULTS

Complete IOP with intraductal biopsies was easily and safely performed in 21 patients, revealing 8 occult IPMN lesions. In 5 cases (23.8%), initially planned surgical resection was modified secondary to IOP: 3 for carcinoma in situ and 2 for invasive carcinoma. The postoperative morbidity rate at 3 months was 25.0% (5 of 20); 1 patient died from septic shock postoperatively and was excluded. Median follow-up was 93 months (range 13 to 248 months). Nineteen of 21 patients were still alive and free of disease at last follow-up (90.5%); there was 1 patient with invasive carcinoma at initial pathology (pT3 N1) who died of pulmonary recurrence 21 months after surgery.

CONCLUSIONS

Intraoperative pancreatoscopy of the main pancreatic duct combined with intraductal biopsies plays a significant role in the surgical management of IPMN patients and should be used in all patients presenting a sufficiently dilated main pancreatic duct.

Extent of Surgery and Implications of Transection Margin Status after Resection of IPMNs

Appropriate surgical strategies for management of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are a matter of debate. Preoperative and intraoperative evaluation of malignant potential of IPMN and of patient's comorbidities is of paramount importance to balance potential complications of surgery with tumors' risk of being or becoming malignant; the decision about the extent of pancreatic resection and the eventual total pancreatectomy needs to be determined on individual basis. The analysis of frozen-section margin of pancreas during operation is mandatory. The goal should be the complete resection of IPMN reaching negative margin, although there is still no agreed definition of “negative margin.” Of note, the presence of deepithelization is often wrongly interpreted as absence of neoplasia. Management of resection margin status and stratification of surveillance of the remnant pancreas, based on characteristics of primary tumour, are of crucial importance in the management of IPMNs in order to decrease the risk of tumor recurrence after resection. Although risk of local and distant recurrence for invasive IPMNs is increased even in case of total pancreatectomy, also local recurrence after complete resection of noninvasive IPMNs is not negligible. Therefore, a long-term/life-time follow-up monitoring is of paramount importance to detect eventual recurrences.

Intraoperative pancreatoscopy: a valuable tool for pancreatic surgeons?

Effective treatment of pancreatic pathology relies on both preoperative and intraoperative decision making. Traditionally, the use of preoperative imaging and endoscopic modalities, in combination with intraoperative findings and pathologic evaluation, has guided the surgeons to perform the correct operative procedure. We hypothesize that the intraoperative use of pancreatoscopy (fiberoptic endoscopy of the pancreatic duct) is a valuable adjunct in selected cases to facilitate the performance of the appropriate definitive surgical treatment. We queried our IRB-approved, prospectively maintained the pancreatic surgery database identifying the uses of intraoperative pancreatoscopy in all pancreatic resections at our institution from 2005-2012. Operative notes, pathology reports, and perioperative outcomes were evaluated. During the study period, 1,016 pancreatic resections were performed at our institution. Twenty-three cases during this period included the use of intraoperative pancreatoscopy. Eighteen (78 %) of these operations were performed for presumed main duct intraductal papillary mucinous neoplasm. In five cases (22 %), the surgical resection was extended secondary to the intraoperative pancreatoscopy findings. Appropriate surgical treatment of the pancreatic lesions can be challenging in the face of preoperative imaging limitations. The selective use of intraoperative fiberoptic endoscopy to evaluate the pancreatic duct appears to help to enable the surgeon to better perform the appropriate resection and optimal treatment.

Italian consensus guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms

This report contains clinically oriented guidelines for the diagnostic work-up and follow-up of cystic pancreatic neoplasms in patients fit for treatment. The statements were elaborated by working groups of experts by searching and analysing the literature, and then underwent a consensus process using a modified Delphi procedure. The statements report recommendations regarding the most appropriate use and timing of various imaging techniques and of endoscopic ultrasound, the role of circulating and intracystic markers and the pathologic evaluation for the diagnosis and follow-up of cystic pancreatic neoplasms.

Intraoperative pancreatoscopy with narrow band imaging: a novel method for assessment of resection margins in case of intraductal papillary mucinous neoplasm

BACKGROUND

Intraductal papillary mucinous neoplasm (IPMN) is characterized by intraductal proliferation of neoplastic mucinous cells with a variable extent along the main duct or its branches. The lesion may be continuous or discontinuous. Skip lesions have been described in about 6-19% of cases. Complete resection without leaving behind any skip lesions is important, to such an extent that many groups suggest even total pancreatectomy, a major and morbid surgery.

METHODS

A 40 year-male patient with chronic pancreatitis presented with recent-onset diabetes mellitus and weight loss. Ultrasound and computed tomography (CT) scan showed a cystic lesion in the head and uncinate process of pancreas. Peroral pancreatoscopy showed villous projections with dilated tortuous vessel in the head, suspicious of IPMN. The duct beyond pancreatic head could not be visualized and remained unassessed. At pancreatoduodenectomy, pancreatoscopy with narrow band imaging (NBI) was done using flexible pancreatoscope through the cut end of the duct at the neck to assess the duct in the body and tail.

RESULTS

Pancreatoscopy with NBI showed a normal-looking resection margin and a skip lesion 1 cm beyond it. The revised resection margin confirmed the skip lesion on frozen section and also that the fresh cut margin was negative. The remaining duct in the body and tail was normal on pancreatoscopy. Total clearance of the disease could be achieved without a major procedure such as total pancreatectomy.

CONCLUSIONS

Intraoperative pancreatoscopy, especially with NBI, is a good diagnostic tool for IPMN and also helps in intraoperative decision-making of the resection margins.

Role of frozen section assessment for intraductal papillary and mucinous tumor of the pancreas

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas include a spectrum of dysplasia ranging from minimal mucinous hyperplasia to invasive carcinoma and are extensive tumors that often spread along the ductal tree. Several studies have demonstrated that preoperative imaging is not accurate enough to adapt the extent of pancreatectomy and have suggested routinely using frozen sectioning (FS) to evaluate the completeness of resection and also to check if ductal dilatation is active or passive, in order to avoid an excessive pancreatic resection. Separate main duct and branch duct analysis is needed due to the difference in the natural history of the disease. FS accuracy averages 95%. Eroded epithelium on the main duct, severe ductal inflammation mimicking dysplasia and reactive epithelial changes secondary to obstruction can lead to inappropriate FS results. FS results change the planned extent of resection in up to 30% of cases. The optimal cut-off leading to extend pancreatectomy is not consensual and our standard option is to extend pancreatectomy if FS reveals: (1) at least IPMN adenoma on the main duct; or (2) at least borderline IPMN on branch ducts; or (3) invasive carcinoma. However, the decision to extend resection must be taken after a multidisciplinary discussion since it does not exclusively depend on the FS result but also on age, general condition and expected prognosis after resection. The main limitation of using FS is the existence of discontinuous (“skip”) lesions which account for approximately 10% of IPMN in surgical series and can lead to reoperation in up to 8% of cases.

Natural history of intraductal papillary mucinous neoplasia: How much do we really know?

Information on the natural history of intraductal papillary mucinous neoplasia (IPMN) is currently inadequate due to a lack of carefully orchestrated long-term follow-up on a large cohort of patients with asymptomatic disease. Based on the available data, one can draw the conclusions that main duct IPMN is commonly associated with malignancy and an aggressive operative stance should be taken with resection being offered to most patients who are suitable operative candidates. In contrast, the majority of branch type IPMN with a diameter of less than 3 cm can be safely followed with routine surveillance imaging provided they lack the high-risk covariates of age, symptomatology, nodularity or wall thickness.

Malignant potential of intraductal papillary mucinous neoplasms of the pancreas

An intraductal papillary mucinous neoplasm (IPMN) is now a well-recognized disease entity. In general, the prognosis of IPMN is much more favorable than that of pancreatic ductal adenocarcinoma (PDAC). However, IPMN has a broad biological spectrum and it sometimes progresses, slowly showing neoplastic transformations. International consensus guidelines have been recently proposed for the management of IPMN. While they significantly contribute to appropriate management of IPMN, various issues including the natural history and malignant potential of IPMN are not fully elucidated. This review focuses on the malignant potential, including the postoperative recurrence of IPMN, coincidence of IPMN with PDAC, and extrapancreatic malignancy that may affect the long-term survival of the patients rather than IPMN itself.

Clinical presentation can predict disease course in patients with intraductal papillary mucinous neoplasm of the pancreas

BACKGROUND

Preoperative diagnosis of malignancy within intraductal papillary mucinous neoplasm of the pancreas (IPMN) solely by clinical or radiological findings is not always possible. We sought a correlation between preoperative clinico-radiological findings and outcome.

METHODS

A prospective database of pancreatic resections for IPMN (2002-2008) and a retrospective pathological revision of all pancreatic cancer specimens (1995-2001) were analyzed. The patients were grouped into asymptomatic with preoperative diagnosis of IPMN (group 1), symptomatic with a preoperative diagnosis of IPMN (group 2), and those with a preoperative diagnosis of pancreatic cancer whose specimen revealed a background of IPMN (group 3). The groups were compared for demographics, clinical presentation, pathological findings, and outcome.

RESULTS

Of the 62 patients with IPMN, 19 were in group 1, 23 in group 2, and 20 in group 3. Their median age (range) was 65.6 (46-80), 67 (50-84), and 73.4 (57-86) years, respectively. The clinical presentation for groups 2 and 3 included abdominal pain (56% vs. 32 %), weight loss (8% vs. 52%), obstructive jaundice (4% vs. 57%), pancreatitis (22% and 5%), and new onset of diabetes (14% and 44%). Invasive cancer was found in one patient in group 1 (5.2%), two patients in group 2 (8.7%), and all patients in group 3. IPMN was present in 23 of 217 (10.6%) of all resected pancreatic cancer specimens. Five year survival for patients with invasive disease was 47% and 92% for patients with noninvasive disease (mean follow-up 37.6 months).

CONCLUSIONS

Benign IPMN can usually be differentiated from adenocarcinoma preoperatively. The clinical presentation is highly indicative of disease course.

Cholangiopancreatoscopy: a comprehensive review

Cholangiopancreatoscopy (CP) is a well-established modality for the direct visualization of intrahepatic biliary, extrahepatic biliary, and pancreatic ductal systems. The use of CP in the treatment of difficult biliary stones has become paramount when standard endoscopic retrograde cholangiopancreatography is ineffective. This article describes the available cholangioscopic devices and technical and clinical applications of cholangiopancreatoscopy. The efficacy and limitations of CP, as well as published comparative studies, are briefly reviewed.

Peroral pancreatoscopy in the diagnosis and management of intraductal papillary mucinous neoplasia and indeterminate pancreatic duct pathology

Peroral pancreatoscopy (POP) is an exciting modality for the evaluation of pancreatic diseases. It has proved efficacy in the evaluation of suspected intraductal papillary mucinous neoplasia and allows for a determination of the presence and extent of pancreatic duct involvement. When other imaging modalities are inconclusive, POP seems a useful adjunct in the evaluation of indeterminate pancreatic duct strictures and permits tissue sampling under direct vision. Despite recent advances, refinements in endoscope caliber, tip deflection, and optics are still required for more routine application in pancreatic diseases.

Middle pancreatectomy: safety and long-term results

BACKGROUND

Pancreaticoduodenectomy and distal pancreatectomy for lesions of the neck or body of the pancreas sacrifice a large amount of normal pancreatic tissue. Middle pancreatectomy (MP) is a parenchyma sparing technique that reduces the risk of postoperative endocrine and exocrine insufficiency. This study aims to evaluate the perioperative and long-term results of MP and to clarify whether MP can be performed with outcomes comparable with traditional pancreatectomies.

METHOD

Twenty-six patients who underwent MP for benign or low-grade malignant tumor of the pancreas between 1991 and 2006 at the Department of Surgery II, Nagoya University Graduate School of Medicine, were identified. Their outcomes were compared with 2 separate control groups, 35 left-side pancreatectomies (LSP) and 60 right-side pancreatectomies (RSP).

RESULTS

The mean operating time of the MP group was 295 minutes, which was significantly shorter than that for RSP (P=.0001). The rate of pancreatic fistula formation was higher in the MP group than in the 2 control groups, although the differences did not reach statistical significance. After a mean follow-up of 71 months, postoperative endocrine function was equivalent to the pre-operative values in the MP group, and none of the patients developed diabetes mellitus postoperatively. Only 1 patient in the MP group required enzyme substitution postoperatively for exocrine insufficiency. The MP group was inclined to be superior to the other 2 control groups in terms of postoperative nutritional status.

CONCLUSION

Middle pancreatectomy is a reasonable technique that is indicated for selected patients with benign or low malignant tumors in the neck and body of the pancreas. Middle pancreatectomy seems to result in better preservation of exocrine and endocrine functions as well as in better nutritional status postoperatively.

Comparison between mucinous cystic neoplasm and intraductal papillary mucinous neoplasm of the branch duct type of the pancreas with respect to expression of CD10 and cytokeratin 20

OBJECTIVE

Mucinous cystic neoplasm (MCN) and intraductal papillary mucinous neoplasm of the branch duct type (IPMN-BD) differ in biological and clinical behaviors, but MCN is often misdiagnosed as IPMN-BD. The purpose of this study was to find useful markers for the differential diagnosis of MCN and IPMN-BD.

METHODS

Immunohistochemically, the expression of the 2 types of mucin (MUC) 1 (MUC1/DF3 and MUC1/CORE), MUC2, MUC5AC, MUC6, human gastric mucin (HGM), caudal-related homeobox transcription factor 2 (CDX2), CD10, cytokeratin (CK) 7, and CK20 was examined in 7 cases of MCN and 16 cases of IPMN-BD.

RESULTS

Expression frequencies in MCN and IPMN-BD were 100% versus 44% for MUC1/DF3, 86% versus 31% for MUC1/CORE, 57% versus 19% for MUC2, 86% versus 100% for MUC5AC, 57% versus 88% for MUC6, 86% versus 100% for HGM, 57% versus 0% for CDX2, 71% versus 0% for CD10, 100% versus 69% for CK7, and 86% versus 6% for CK20.

CONCLUSIONS

Mucin 1/DF3, MUC1/CORE, CDX2, CD10, and CK20 were expressed significantly more frequently in MCN than in IPMN-BD. In particular, CD10 and CK20 showed marked differences in immunohistochemical sensitivity and specificity between MCN and IPMN-BD. It is therefore proposed that CD10 and CK20 may be used for the differential diagnosis of MCN and IPMN-BD.

Management of mucin-producing cystic neoplasms of the pancreas

During the last decade small lesions of the pancreas have been increasingly recognized in clinical practice. Among these lesions, mucin-producing cystic neoplasms represent a recently described and unique entity among pancreatic tumors. In 1996, the World Health Organization distinguished two different types of mucinous cystic tumors: intraductal papillary mucinous neoplasms (IPMNs) of the pancreas, which are characterized by mucin production, cystic dilation of the pancreatic ducts, and intrapapillary growth, and mucinous cystic neoplasms (MCNs), which are defined by ovarian-like stroma and in most cases do not communicate with pancreatic ducts. Further, IPMNs can be subdivided into main-duct type, mixed-type, and branch-duct type tumors. Older data did not distinguish among different subsets of cystic neoplasms of the pancreas, and consequently many databases were inconsistent. Histopathologically, both IPMNs and MCNs demonstrate a wide spectrum of cellular atypia ranging from mild mucinous hyperplasia to invasive adenocarcinoma. Because mucinous cystic neoplasms of the pancreas show significant differences in clinical behavior from patient to patient, knowledge of the clinicopathologic characteristics and natural history of specific subtypes of IPMNs and MCNs has become crucial for physicians working in the field of gastroenterology. The present work offers an overview of current and generally accepted clinical guidelines for the diagnosis and treatment of IPMNs and MCNs.

Intraductal biliary and pancreatic endoscopy: An expanding scope of possibility

Intraductal endoscopy describes the use of an endoscope to directly visualize the biliary and pancreatic ducts. For many years, technological challenges have made performing these procedures difficult. The “mother-baby” system and other various miniscopes have been developed, but routine use has been hampered due to complex setup, scope fragility and the time consuming, technically demanding nature of the procedure. Recently, the SpyGlass peroral cholangiopancreatoscopy system has shown early success at providing diagnostic information and therapeutic options. The clinical utility of intraductal endoscopy is broad. It allows better differentiation between benign and malignant processes by allowing direct visualization and targeted sampling of tissue. Therapeutic interventions, such as electrohydraulic lithotripsy (EHL), laser lithotripsy, photodynamic therapy, and argon plasma coagulation (APC), may also be performed as part of intraductal endoscopy. Intraductal endoscopy significantly increases the diagnostic and therapeutic yield of standard endoscopic retrograde cholangiography (ERCP), and as technology progresses, it is likely that its utilization will only increase. In this review of intraductal endoscopy, we describe in detail the various endoscopic platforms and their diagnostic and clinical applications.

Benign pancreatic tumors

The goal of this article is to describe the different types of benign pancreatic neoplasms, methods to distinguish between them, and treatment options. Pancreatic adenocarcinoma is associated with specific neoplastic lesions that are similar in radiographic appearance to some benign lesions. The correct differentiation of these malignant and premalignant lesions from their benign counterpart is paramount to their proper management.

Pancreatoscopy: present and future role

Current imaging modalities do not allow for direct access to the pancreatic duct. Because of this limitation, diagnosis and assessment of pancreatic diseases require radiographic imaging and cytologic analysis. Although many of these techniques have excellent specificity for the detection of pancreatic cancer, they offer no therapeutic capabilities and are relatively poor in early detection of cancer and in differentiating chronic pancreatitis from malignancy, particularly when the conditions coexist. Currently available cholangioscopes are too large to access the pancreatic duct without sphincterotomy or balloon dilation, increasing the risk of instrumentation trauma to the pancreas. Novel, dedicated pancreatoscopes have recently been developed and are under investigation in clinical trials. Preliminary evidence suggests that these new technologies allow for direct visualization of the pancreatic ducts, with the potential for forceps biopsy in suspected malignancy and endotherapy for pancreatic calculi. Future and ongoing clinical trials will better define the utility and roles of these new endoscopy tools.

International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas

Non-inflammatory cystic lesions of the pancreas are increasingly recognized. Two distinct entities have been defined, i.e., intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN). Ovarian-type stroma has been proposed as a requisite to distinguish MCN from IPMN. Some other distinct features to characterize IPMN and MCN have been identified, but there remain ambiguities between the two diseases. In view of the increasing frequency with which these neoplasms are being diagnosed worldwide, it would be helpful for physicians managing patients with cystic neoplasms of the pancreas to have guidelines for the diagnosis and treatment of IPMN and MCN. The proposed guidelines represent a consensus of the working group of the International Association of Pancreatology.

Frozen sectioning of the pancreatic cut surface during resection of intraductal papillary mucinous neoplasms of the pancreas is useful and reliable: a prospective evaluation

OBJECTIVE

To prospectively evaluate the accuracy of frozen sectioning (FS) of the pancreatic transection margin and its influence on surgery during resection of intraductal papillary and mucinous neoplasms (IPMNs).

SUMMARY BACKGROUND DATA

Preoperative assessment of IPMN extension is difficult and transection margin is frequently tumoral on the surgical specimen.

PATIENTS AND METHODS

FS was performed in 127 patients who underwent partial pancreatectomy for IPMN from 1996 to 2004, corresponding to 90 pancreaticoduodenectomies (1-4 successive FS; total = 132), 25 distal pancreatectomies (1-2 FS; total = 27), and 12 medial pancreatectomies (2-4 FS; total = 29). Dysplasia was graded in both main (MD) and branch ducts (BD), and pancreatectomy was extended if FS revealed at least IPMN adenoma on the MD or borderline IPMN on BD (defined as "significant" lesions).

RESULTS

The 188 FS revealed that MD and BD epithelium comprised significant noninvasive lesions in 49 and 13 cases, respectively, and infiltrating carcinoma in 4 other ones. Definitive examination corroborated FS in 176 of 188 cases (94%). Altogether, 54 of 188 (29%) FS comprised significant lesions that resulted in 46 additional resections in 38 patients (30%). Eight patients did not have additional resection because of either high operative risk or preoperative diagnosis of noncurable infiltrating carcinoma. The 134 FS without significant lesions were associated with 7 additional resections mainly because of macroscopic suspicion of another tumor location. Conflicting results between FS and definitive examination resulted in inadequate extent of pancreatectomy in 4 patients (3%).

CONCLUSIONS

Results of FS of the transection margin are confirmed by definitive examination in 94% of cases. According to our protocol, FS changes the extent of resection in 30% of patients and allows adequate resection in 97% of patients.

Role of intraoperative cytology combined with histology in detecting continuous and skip type intraductal cancer existence for intraductal papillary mucinous carcinoma of the pancreas

BACKGROUND

Intraductal papillary mucinous neoplasm (IPMN) is a recently discovered pancreatic tumor that has continuous or discontinuous (skip) lesions. Recent reports suggest a higher frequency of cancer recurrence in the remnant pancreas after surgical resection of IPMN. It is therefore important to precisely detect intraductal cancer extension and skip lesions when resecting IPMN.

METHODS

Both intraoperative histologic examination of the surgical margin and cytologic examination of the pancreatic juice from each pancreatic segment (head, body, or tail) were performed on 43 IPMN patients. In addition to the preoperatively planned resection, 1 or 2 pancreatic segment(s) were additionally resected if the pancreatic juice tested positive in cytology. When a surgical margin was positive but the cytology in the remaining segment was negative, a subsegment (2-cm slice in width) was additionally resected until a negative margin was confirmed.

RESULTS

Twenty-five patients (58%) demonstrated negative results in both histology and cytology obtained from the segment(s) that were not initially intended to be removed. In contrast to the preoperative estimation, 5 patients were found to have a positive surgical margin and negative cytology, 5 patients demonstrated a negative surgical margin and positive cytology, and 8 patients demonstrated a positive surgical margin and positive cytology. Investigations of the resected specimens revealed that 8 patients (19%) had skip lesions in addition to the main lesion. Logistic regression analysis revealed that patients with a dilated main pancreatic duct, or those with cancerous lesions in the main tumors, were at high risk for positive histology and/or cytology.

CONCLUSIONS

Using intraoperative frozen-section histology and pancreatic juice cytology, 18 out of 43 patients in the current study (42%) required additional resection of the pancreas. A necessary and sufficient range of resection should be determined by intraoperative examination.

CT virtual pancreatoscopy: a new method for diagnosing intraductal papillary mucinous neoplasm (IPMN) of the pancreas

BACKGROUND

We sought to validate computed tomographic virtual pancreatoscopy (CT-VP) created by multidetector row CT (MD-CT) in the clinical diagnosis of intraductal papillary mucinous neoplasm (IPMN) of the pancreas.

METHODS

Five cases of pancreatic IPMNs were included in this study. A nasopancreatic drainage tube was inserted and the pancreatic duct was filled with contrast medium, after which an upper abdominal scan was performed by MD-CT. CT-VP and three-dimensional (3D) CT pancreatographic images were created using a workstation and compared with images by conventional diagnostic techniques. All cases were evaluated by endoscopic retrograde pancreatography (ERP) and three cases of main duct type were assessed by intraoperative real pancreatoscopy (RP).

RESULTS

In the main duct cases, papillary projections in the main pancreatic duct and branch orifices were clearly detected by CT-VP. These lesions and structures were confirmed by intraoperative RP, and the CT-VP images were clearer than RP images. In branch cases, a surface-rendering method allowed protruding lesions to be clearly detected in the dilated branches.

CONCLUSION

Compared with conventional ERP or RP, CT-VP and 3D-CT pancreatographic images were finer in quality, and the procedures were less invasive, faster, and less expensive. The potential shown by CT-VP with 3D-CT pancreatography in the clinical diagnosis of pancreatic IPMNs suggests that this approach may replace ERP in the near future.

Accuracy of preoperative imaging methods in a retrospective series of 14 patients with operated intraductal papillary mucinous tumors of the pancreas

Accuracy of preoperative imaging methods for the diagnosis of intraductal papillary mucinous tumor of the pancreas (IPMT) is not well known.

AIMS

To compare diagnostic accuracy of various preoperative imaging methods with pathology data following surgical resection.

PATIENTS AND METHODS

Fourteen consecutive patients underwent pancreatic surgical resection for IPMT between January 1988 and May 2002. Imaging methods included endoscopic retrograde cholangiopancreatography and/or magnetic resonance cholangiopancreatography and/or endoscopic ultrasonography. Results of preoperative morphological examinations were compared with histopathological findings from surgical specimens.

RESULTS

IPMT was located to the pancreatic head or body in 72% of patients and involved the main pancreatic duct (MPD) in 79% of cases Carcinoma was diagnosed in 35% of the cases. Sensitivity of imaging methods varied from 64 to 80% to accurately locate the tumor and from 73 to 80% in distinguishing between types involving the MPD or the accessory ducts. Planned surgical resection based on preoperative imagery correlated with final surgery in 57% of the patients. Histological study of whole pancreas specimens revealed lesions in undilated ducts, and also dilated ducts without histological lesions.

CONCLUSION

The sensitivity of preoperative imaging methods is moderate in defining intraductal extension of IPMT. Duct dilatation is not predictive of histological involvement by tumors and ducts may be pathological without dilatation.

Duodenoscope assisted cholangiopancreatoscopy: a review of clinical applications

Duodenoscope assisted cholangiopancreatoscopy allows direct visualization of the pancreatic duct and bile duct. There are several circumstances where direct ductal visualization might be helpful in clarifying a diagnosis or providing targeted treatment. Duodenoscope assisted cholangiopancreatoscopy is currently employed for a variety of indications including: indeterminate ductal strictures and filling defects, marginal chronic pancreatitis, treatment of large intraductal stones, localization of intraductal papillary mucinous tumors, and localization and treatment of hemobilia. There have however been no randomized controlled trials evaluating the diagnostic or therapeutic functions of duodenoscope assisted cholangiopancreatoscopy. This article reviews recent descriptive studies that attempt to clarify the clinical role of this technology.

Magnetic resonance cholangiopancreatography for postoperative follow-up of intraductal papillary-mucinous tumors of the pancreas

BACKGROUND

After resection of an intraductal papillary-mucinous tumor (IPMT), benign tumors or portions of the resected tumor are sometimes left in place to avoid total pancreatectomy. We evaluated the role of magnetic resonance cholangiopancreatography (MRCP) in postoperative follow-up.

METHODS

Twenty-two patients underwent MRCP 0.5 to 6.5 years after pancreatic resection for IPMT.

RESULTS

Two patients with surgical margin involvement of the main pancreatic duct showed mildly enhanced ductal dilatation due to anastomotic stenosis. In 4 patients with residual IPMT of the branch ducts, postoperative MRCP demonstrated no changes. MRCP revealed new IPMT 1 year after surgery in 1 patient. No patients showed intraductal or intracystic mural nodules postoperatively. In 3 patients with postoperative pancreatitis or recurrent abdominal discomfort, MRCP demonstrated ductal dilatation and poor secretin-stimulated pancreatic secretion into the gastrointestinal tract, which suggested pancreatoenterostomic stenosis.

CONCLUSIONS

MRCP is useful for postoperative follow-up of IPMT, in terms of investigating residual or recurrent IPMT and evaluating postpancreatectomy long-term complications.

Optimal management of the branch duct type intraductal papillary mucinous neoplasms of the pancreas

BACKGROUND

To determine the optimal management of the intraductal papillary mucinous neoplasms (IPMNs) according to the morphologic type based on distinguishing between benign and malignant diseases.

BACKGROUNDS

IPMNs are increasingly recognized clinicopathologic entity. Extended pancreatic resection with radical lymph node dissection has been recommended for treatment.

STUDY

A retrospective clinicopathologic study was carried out of the 57 cases with IPMNs who were treated between 1985 and 2001. Forty-three patients with IPMNs underwent resection, and 14 patients with small IPMNs were observed without resection.

RESULTS

Among the 43 resected IPMNs, 25 were benign and 18 were malignant. Malignant tumors were significantly greater in diameter than benign tumors (52.9 vs. 30.2 mm, P< 0.05). All main duct type tumors with mural nodules were malignant. All branch duct type tumors less than 30 mm in diameter and without mural nodules were benign. Twelve branch duct type IPMNs size less than 30 mm were not resected and have not progressed.

CONCLUSION

These results suggest that the branch duct type IPMNs less than 30 mm and without mural nodules is benign and might be treatable with limited resection or careful observation.

The role of ERCP and pancreatoscopy in cystic and intraductal tumors

ERCP and pancreatoscopy may establish a diagnosis of IPMT and differentiate it from a pseudocyst or cystic neoplasm of the pancreas. These techniques may also assess risk of malignancy, extent of disease, allow tissue sampling, and provide therapeutic intervention.