Villous adenomatosis of duct of Wirsung revealed by wirsungorragie: evolution and surgical management

[Intraductal papillary mucinous tumors of the pancreas]

Reports of intraductal papillary mucinous tumors of the pancreas have become substantially more frequent in the literature in the past several years. This increased prevalence is due, among other things, to improved screening techniques, especially high-resolution spatial imaging. These tumors are characterized by proliferation of the intraductal epithelium, mucin production, and ductal dilatation. They grow slowly. Their potential for malignancy is high (although the precise risk remains difficult to assess), but their prognosis, when identified during the first stage of neoplastic transformation (before invasion), is far better than that of 'pancreatic ductal adenocarcinoma. Early diagnosis allows patients to be treated before carcinomatous degeneration. Specific diagnosis makes it possible to define an appropriate treatment strategy - either surgery or monitoring, especially when only the intralobular ducts are affected. In that case, the risk of malignant degeneration is much lower than with lesions in the pancreatic duct or in combined forms.

Intraductal papillary and mucinous tumors of the pancreas: accuracy of preoperative computed tomography, endoscopic retrograde pancreatography and endoscopic ultrasonography, and long-term outcome in a large surgical series

BACKGROUND

Few data are available on the accuracy of preoperative imaging or on long-term outcome after surgery for intraductal papillary and mucinous tumors of the pancreas. The aims of this study were to assess the following: (1) the accuracy of preoperative computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography for determination of tumor invasion and pancreatic extension as compared with surgical findings; (2) the long-term outcome after surgery.

METHODS

Forty-seven patients who underwent surgery between 1980 and 1995 for pathologically diagnosed intraductal papillary and mucinous tumors were included in this study. The findings of available computed tomography (n = 25), endoscopic retrograde pancreatography (n = 29), and endoscopic ultrasonography (n = 21) were reviewed by experienced clinicians blinded to pathologic diagnosis to assess tumor invasion and pancreatic extension. Pathologic specimens were reviewed by experienced pathologists. Postoperative follow-up data were analyzed.

RESULTS

Histologic features of invasive carcinoma were found in 43% of patients, severe dysplasia in 21%, and mild or moderate dysplasia in 36%. The overall accuracy of computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography in distinguishing between invasive and noninvasive tumors were, respectively, 76%, 79%, and 76%. The overall 3-year disease-free survival rate was 63%, but it was 21% among patients with invasive carcinoma at surgery (p < 0.001).

CONCLUSIONS

This study emphasizes the need for early surgical resection in patients with suspected intraductal papillary and mucinous tumors of the pancreas because of the high frequency of invasive carcinoma and the inadequacy of preoperative imaging for assessing malignancy.

Villous adenoma of the main pancreatic duct: a clue to the pathogenesis of pancreatic malignancy

We describe the case of a 78 year old woman with a severely dysplastic villous adenoma of the duct of Wirsung presenting with abdominal pain, emesis, weight loss, and hyperamylasemia. Abdominal ultrasound, computed tomography, and endoscopic retrograde cholangiopancreatography suggested an intraductal lesion in the head of the pancreas with a dilated distal duct. The patient underwent uncomplicated pancreaticoduodenectomy and has done well. A review of the literature on benign and malignant neoplasms of the main pancreatic duct allows formulation of the typical clinical syndrome, appropriate diagnostic work-up, treatment, and prognosis of patients with these rare lesions. The pancreatic ductal epithelium can present the full spectrum of lesions along the pathogenetic route to malignancy. This is evidence for the presence of an adenoma-to-carcinoma sequence in the pancreas analogous to that which exists in the colon.