IPMN: surgical treatment. Langenbecks Arch Surg. 2013;398:1029-1037. [PMID: 23999775 DOI: 10.1007/s00423-013-1106-1]

No communication between the bile duct and intraductal papillary neoplasm of the bile duct on imaging

As a rare biliary tract tumor, intraductal papillary neoplasm of the bile duct (IPNB) is most common in elderly men and can progress to cholangiocarcinoma- (CCa) if left untreated. It is reported that IPNB usually communicates with the bile duct. As a result, the downstream bile ducts are imaged asymmetrically dilated. However, a case of IPNB that we report here is different. Enhanced MRI revealed a lack of connectivity with the bile duct in this case. Based on this, the purpose of this case study is to suggest that the majority of imaging doctors should widely understand the various imaging manifestations of the disease to avoid misdiagnosis. In addition, although this feature was not indicated by ultrasound in this case, given previous studies and considering the convenience and non-ionizing radiation damage of CEUS, we recommend its use as a screening method for IPNB to improve diagnostic accuracy.

Single-cell omics: a new perspective for early detection of pancreatic cancer?

Pancreatic cancer is one of the most lethal cancers, mostly due to late diagnosis and limited treatment options. Early detection of pancreatic cancer in high-risk populations bears the potential to greatly improve outcomes, but current screening approaches remain of limited value despite recent technological advances. This review explores the possible advantages of liquid biopsies for this application, particularly focusing on circulating tumour cells (CTCs) and their subsequent single-cell omics analysis. Originating from both primary and metastatic tumour sites, CTCs provide important information for diagnosis, prognosis and tailoring of treatment strategies. Notably, CTCs have even been detected in the blood of subjects with pancreatic precursor lesions, suggesting their suitability as a non-invasive tool for the early detection of malignant transformation in the pancreas. As intact cells, CTCs offer comprehensive genomic, transcriptomic, epigenetic and proteomic information that can be explored using rapidly developing techniques for analysing individual cells at the molecular level. Studying CTCs during serial sampling and at single-cell resolution will help to dissect tumour heterogeneity for individual patients and among different patients, providing new insights into cancer evolution during disease progression and in response to treatment. Using CTCs for non-invasive tracking of cancer features, including stemness, metastatic potential and expression of immune targets, provides important and readily accessible molecular insights. Finally, the emerging technology of ex vivo culturing of CTCs could create new opportunities to study the functionality of individual cancers at any stage and develop personalised and more effective treatment approaches for this lethal disease.

Pancreatic cancer in patient with groove pancreatitis: Potential pitfalls in diagnosis

Pancreatic cancer is among the leading causes of cancer death in the United States of America. Early detection and intervention are critical as a large majority of patients have either local or distant metastatic disease at the time of diagnosis. However, groove pancreatitis, a rare form of chronic pancreatitis, presents as a challenge for adequate and efficient differential diagnosis of pancreatic cancer as a result of similar clinical symptoms and imaging features. Furthermore, intraductal papillary mucinous neoplasms and pancreatic intraepithelial neoplasia are 2 of the precursor lesions that have been identified with pancreatic ductal adenocarcinoma. Intraductal papillary mucinous neoplasms are cystic tumors of the pancreas characterized by excessive mucin production in either the main pancreatic duct or its branches. Conversely, pancreatic intraepithelial neoplasia are microscopic lesions in the smaller pancreatic ducts. In this article, we report the case of a 46-year-old male with a diagnosis of groove pancreatitis, main duct intraductal papillary mucinous neoplasm, and pancreatic intraepithelial neoplasia whose tumor was excised by means of a Whipple procedure. We focus on optimizing diagnosis and treatment through the application of radiological modalities.

Intrahepatic Biliary Intraductal Papillary Mucinous Neoplasm With Intermittent Jaundice: Case Report

Intraductal papillary mucinous neoplasms (IPMNs) represent a relatively new clinical entity. IPMNs have malignant potential which exhibit a broad histological spectrum, ranging from adenoma to invasive carcinoma. Although IPMNs are commonly seen within pancreas, they may develop anywhere within the biliary ductal system and produce mucin which may cause intermittent jaundice. This report details the case of 50-year-old woman presenting with intermittent jaundice who was diagnosed as hepatic IPMN.

Posterior enucleation of the pancreatic head: an alternative route of access for parenchyma-sparing pancreatic resection

BACKGROUND

Enucleation has become an alternative treatment in benign or low-malignant cystic tumors, including intraductal papillary mucinous neoplasms (IPMN). For enucleation to be a safe alternative to the standard procedures, there must be good access to the resection area. In this report, we present such a route for dorsally situated IPMNs.

METHODS

The head of the pancreas was exposed by an extended Kocher maneuver to the left lateral edge of the aorta. Stay sutures were placed along the second part of the duodenum to allow maximal rotation of the pancreatic head to the left, which exposed the posterior aspect of the pancreatic head. The cystic lesion was then enucleated followed by a protective pancreaticojejunostomy on the resection cavity.

RESULTS

Two consecutive patients with IPMNs of the dorsal pancreatic head successfully underwent dorsal enucleation. The postoperative course was uneventful in the first patient, while the course of the second patient was complicated by a clinically relevant pancreatic fistula, delayed gastric emptying, and hospital discharge on day 35.

CONCLUSION

This study shows the feasibility of a dorsal approach to the pancreatic head for enucleation as well as reconstruction by means of posterior Roux-en-Y pancreaticojejunostomy. In very selected cases in specialized centers, cystic lesions in the posterior aspect of the pancreatic head will become amenable to enucleation with preservation of pancreatic functionality. However, more research is needed to clarify postoperative outcomes of this approach.

Proteome characterization of human pancreatic cyst fluid from intraductal papillary mucinous neoplasm by liquid chromatography/tandem mass spectrometry

RATIONALE

In recent years, the molecular components of pancreatic cyst fluid have been used for diagnosis and prognosis. Because the protein markers that are currently used in clinical tests are unreliable, proteomic studies to find new protein markers are being conducted. However, such researches have been limited due to the complexity of pancreatic cyst fluid and the immaturity of proteomic techniques.

METHODS

To overcome these limitations and provide a pancreatic cyst proteome dataset, we examined cyst fluid proteome with tandem mass spectrometry. The proteomic analysis was performed using a Orbitrap-based mass spectrometer (Q-Exactive) coupled with a 50-cm-long nano-liquid chromatography column. Protein mutations were identified using mutation sequence database search.

RESULTS

A total of 5850 protein groups were identified from microliters of cyst fluid. Among those, 3934 protein groups were reported for the first time in pancreatic cyst fluid. Although high-abundance proteins were not depleted in the experiment, our dataset detected almost all pancreatic tumor markers such as mucin family members, S100 proteins, and CEA-related proteins. In addition, 590 protein mutation marker candidates were discovered.

CONCLUSIONS

We provide a comprehensive cyst proteome dataset that includes cystic cellular proteins and mutated proteins. Our findings would serve as a rich resource for further IPMN studies and clinical applications. The MS data have been deposited in the ProteomeXchange with identifier PXD005671 (http://proteomecentral.proteomexchange.org/dataset/PXD005671).

Management of patients with pancreatic cystic lesions: A case-based survey

BACKGROUND

Pancreatic cystic lesions (PCL), including intraductal papillary mucinous neoplasia (IPMN), harbor different malignant potential and the optimal management is often challenging. The present study aims to depict the compliance of experts with current consensus guidelines and the accuracy of treatment recommendations stratified by the medical specialty and hospital volume.

METHODS

An international survey was conducted using a set of 10 selected cases of PCL that were presented to a cohort of international experts on pancreatology. All presented cases were surgically resected between 2004 and 2015 and histopathological examination was available. Accuracy of the treatment recommendations was based on the European and international consensus guideline algorithms, and the histopathological result.

RESULTS

The response rate of the survey was 26% (46 of 177 contacted experts), consisting of 70% surgeons and 30% gastroenterologists/oncologists (GI/Onc). In the case of main-duct IPMN (MD-IPMN), surgeons preferred more often the surgical approach in comparison with the GI/Onc (55 versus 44%). The mean accuracy rate based on the European and international consensus guidelines, and the histopathological result, were 71/76/38% (surgeons), and 70/73/34% (GI/Onc), respectively. High-volume centers achieved insignificantly higher accuracy scores with regard to the histopathology. Small branch-duct IPMN with cysts <2 cm and malignant potential were not identified by the guideline algorithms.

CONCLUSION

The survey underlines the complexity of treatment decisions for patients with PCL; less than 40% of the recommendations were in line with the final histopathology in this selected case panel. Experts and consensus guidelines may fail to predict malignant potential in small PCL.

Main- and Branch-Duct Intraductal Papillary Mucinous Neoplasms: Extent of Surgical Resection

Background

Surgical treatment of intraductal papillary mucinous neoplasms (IPMN) requires a differentiated approach regarding indications and extent of resection.

Methods

The review summarizes the current literature on indication, timing, and surgical procedures in IPMN.

Results

The most important differentiation has to be made between main-duct and branch-duct IPMN as well as mixed-type lesions that biologically mimic main-duct types. In main-duct and mixed-type IPMN, the resection should be indicated by the time of the diagnosis – in accordance with the international consensus guidelines – and should follow oncological principles. Depending on IPMN localization, this implies partial pancreatoduodenectomy, distal pancreatectomy, or total pancreatectomy and includes the corresponding types of lymphadenectomy. Furthermore, branch-duct IPMN > 3 cm or bearing high-risk features (mural nodules in magnetic resonance imaging, computed tomography, or endoscopic ultrasound imaging; symptomatic lesions; elevated tumor markers) are similarly treated. As the risk for malignancy in smaller branch-duct IPMN is lower, the decision for surgical treatment is often individually made – despite the updated 2012 guidelines. In these lesions, limited surgical approaches, including enucleation and central pancreatectomy, are possible.

Conclusion

Timely and radical resection of IPMN offers the unique opportunity to prevent pancreatic cancer, and even in malignant IPMN surgery can offer a curative approach with excellent long-term outcome in early stages. A structured imaging follow-up should be considered to recognize IPMN recurrence and metachronous pancreatic cancer as well as gastrointestinal neoplasias by endoscopic surveillance.

Navigation surgery using an augmented reality for pancreatectomy

AIM

The aim of this study was to evaluate the utility of navigation surgery using augmented reality technology (AR-based NS) for pancreatectomy.

METHODS

The 3D reconstructed images from CT were created by segmentation. The initial registration was performed by using the optical location sensor. The reconstructed images were superimposed onto the real organs in the monitor display. Of the 19 patients who had undergone hepatobiliary and pancreatic surgery using AR-based NS, the accuracy, visualization ability, and utility of our system were assessed in five cases with pancreatectomy.

RESULTS

The position of each organ in the surface-rendering image corresponded almost to that of the actual organ. Reference to the display image allowed for safe dissection while preserving the adjacent vessels or organs. The locations of the lesions and resection line on the targeted organ were overlaid on the operating field. The initial mean registration error was improved to approximately 5 mm by our refinements. However, several problems such as registration accuracy, portability and cost still remain.

CONCLUSION

AR-based NS contributed to accurate and effective surgical resection in pancreatectomy. The pancreas appears to be a suitable organ for further investigations. This technology is promising to improve surgical quality, training, and education.

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

INTRODUCTION

The indications, the extent and type of surgery for intraductal papillary mucinous neoplasm (IPMN) are still controversial. This study aimed to investigate clinical manifestation, individualized surgical treatment, and prognosis of IPMN of pancreas.

METHODS

The clinical data of 96 IPMN cases treated in our hospital between January 2006 and December 2013 were retrospectively analyzed. Among the 96 patients (58 male and 38 female), 46 were main-duct type, 29 were branch-duct type, 21 were mixed type. Pancreatectomy was performed on 78 cases, including pancreaticoduodenectomy on 43 patients, distal pancreatectomy on 25, segmental pancreatectomy on 6, and total pancreatectomy on 4. A regular follow-up without surgical treatment was performed on 18 cases with asymptomatic side branch IPMN less than 3 cm in diameter.

RESULTS

The overall postoperative morbidity rate was 33.3%, and there was no perioperative mortality. 46 cases were non-invasive IPMN, 32 cases were invasive IPMN including 14 cases with lymph node metastasis. The five-year survival rate for patients with non-invasive and invasive carcinomas was 96.2% and 35.2%, respectively. The prognosis of invasive cases with lymph node metastasis was significantly worse than those without lymph node metastasis. No progression was found during the follow-up in 18 asymptomatic small branch duct type IPMN patients.

CONCLUSION

IPMN has a relative good prognosis. Main duct type and mixed type IPMN have a higher malignant potential, and should receive surgical treatment. Patients of branch duct type IPMN with lesion <3 cm in diameter and without clinical manifestations can be managed with close follow-up.

Progress in diagnosis and treatment of intraductal papillary mucinous neoplasms

Intraductal papillary mucinous neoplasm (IPMN) is a rare form of exocrine pancreatic neoplasm arising from the ductal epithelium, which is difficult to diagnose in early stages owing to the lack of specific clinical symptoms. In most cases, IPMN is detected incidentally during medical examination. Some imaging studies such as magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasonography (EUS) and computed tomography (CT) have been considered to be helpful to the preoperative diagnosis of IPMNs. Histologically, IPMNs may demonstrate a spectrum of cellular atypia, ranging from hyperplasia to invasive carcinoma. At present, IPMNs are classified into three types: main duct IPMN (MD-IPMN), branch duct IPMN (BD-IPMN) and mixed type IPMN (MT-IPMN) according to the dominant location of the IPMN where the ductal dilatation occurs. Once diagnosed, all patients with MD-IPMN and MT-IPMN should undergo surgical resection as soon as possible regardless of size and symptoms due to the high risk of canceration. After surgical resection, the survival rate of IPMN patient is excellent. For patients with invasive IPMNs, the 5-year survival rate is 40%-60%, while for those with noninvasive IPMNs, the 5-year survival rate is 80%-100%. Therefore, early diagnosis and timely treatment are strongly recommended for all IPMN patients. The aim of this paper is to systematically review the diagnosis and treatment of IPMNs.