[Cystic tumors of the pancreas]. Chirurg. 2010;81:755-768; quiz 769. [PMID: 20694789 DOI: 10.1007/s00104-009-1861-2]

Precursor lesions for sporadic pancreatic cancer: PanIN, IPMN, and MCN

Pancreatic cancer is still a dismal disease. The high mortality rate is mainly caused by the lack of highly sensitive and specific diagnostic tools, and most of the patients are diagnosed in an advanced and incurable stage. Knowledge about precursor lesions for pancreatic cancer has grown significantly over the last decade, and nowadays we know that mainly three lesions (PanIN, and IPMN, MCN) are responsible for the development of pancreatic cancer. The early detection of these lesions is still challenging but provides the chance to cure patients before they might get an invasive pancreatic carcinoma. This paper focuses on PanIN, IPMN, and MCN lesions and reviews the current level of knowledge and clinical measures.

Decision making for pancreatic resection in patients with intraductal papillary mucinous neoplasms

AIM: To identify a practical approach for preoperative decision-making in patients with intraductal papillary mucinous neoplasms (IPMNs) of the pancreas.

METHODS: Between March 1999 and November 2006, the clinical characteristics, pathological data and computed tomography/magnetic resonance imaging (CT/MRI) of 54 IPMNs cases were retrieved and analyzed. The relationships between the above data and decision-making for pancreatic resection were analyzed using SPSS 13.0 software. Univariate analysis of risk factors for malignant or invasive IPMNs was performed with regard to the following variables: carcinoembryonic antigen, carbohydrate antigen 19-9 (CA19-9) and the characteristics from CT/MRI images. Receiver operating characteristic (ROC) curve analysis for pancreatic resection was performed using significant factors from the univariate analysis.

RESULTS: CT/MRI images, including main and mixed duct IPMNs, tumor size > 30 mm or a solid component appearance in the lesion, and preoperative serum CA19-9 > 37 U/mL had good predictive value for determining pancreatic resection (P < 0.05), but with limitations. Combining the above factors (CT/MRI images and CA19-9) improved the accuracy and sensitivity for determining pancreatic resection in IPMNs. Using ROC analysis, the area under the curve reached 0.893 (P < 0.01, 95%CI: 0.763-1.023), with a sensitivity, specificity, positive predictive value and negative predictive value of 95.2%, 83.3%, 95.2% and 83.3%, respectively.

CONCLUSION: Combining preoperative CT/MRI images and CA19-9 level may provide useful information for surgical decision-making in IPMNs.

[New aspects of surgery for pancreatic cancer. Principles, results and evidence]

Ductal adenocarcinoma is the most frequent malignant tumor of the pancreas and total resection of the pancreatic tumor is still the only curative treatment option. Most tumors are located in the pancreatic head, therefore, pylorus-preserving pancreaticoduodenectomy (Whipple PPPD) is the oncological standard procedure. By concentrating pancreatic resections in specialized centers for pancreatic surgery perioperative mortality and morbidity has decreased in recent years. However, pancreatic resections remain complex and difficult operations and pancreatic anastomosis is particular challenging. To achieve complete resection (R0) resection and reconstruction of large venous vessels is often necessary. Resection of arterial vessels is rarely performed and usually does not lead to an R0 resection of the tumor. Currently adjuvant chemotherapy after total tumor resection is standard of care for all tumor stages but neoadjuvant regimes have recently been reported increasingly more often. Advances in translational research has led to a better understanding of tumor biology and new diagnostic options and therapies are expected in the near future.

[Familial pancreatic carcinoma]

Less than 10% of pancreatic ductal adenocarcinomas are based on a hereditary syndrome. In contrast a positive family history for pancreatic cancer raises the individual risk for the development of pancreatic and extrapancreatic malignancies.While 70% of hereditary pancreatic carcinomas can be attributed to the familiar pancreatic cancer syndrome 30% are caused by other hereditary syndromes, e.g., Peutz-Jeghers syndrome or familial adenomatous polyposis. Furthermore, genetically determined pancreatitis (e.g., hereditary pancreatitis or cystic fibrosis) can lead to pancreatic cancer.Up to now conclusive data for routine screening of high risk patients are not available which is due in part to the difficult identification of high risk patients and the problematic classification of detected pancreatic lesions. Therefore, high risk patients should be included in controlled clinical trials for screening. Small pancreatic lesions are not clear indications for surgical resection as false positive results can hamper a clear diagnosis and prophylactic pancreatectomy is not recommended. In the case of a histologically proven carcinoma a prophylactic extension of resection might be reasonable. Prevention of familial pancreatic cancer can be achieved through nicotine abstinence.