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Lattimore CM, Kane WJ, Subbarao S, Venitti C, Cramer CL, Turkheimer LM, Bauer TW, Turrentine FE, Zaydfudim VM. Long-term surveillance of branch-duct intraductal papillary mucinous neoplasms without worrisome or high-risk features. J Surg Oncol 2023; 128:1087-1094. [PMID: 37530526 PMCID: PMC10592219 DOI: 10.1002/jso.27414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Long-term data evaluating clinical outcomes in patients with branch-duct Intraductal papillary mucinous neoplasms (BD-IPMN) without high-risk stigmata (HRS) or worrisome features (WF) remain limited. METHODS This observational cohort study included all patients diagnosed with BD-IPMN without HRS or WF between 2003 and 2019 who were enrolled in a prospective surveillance program. Time-to-progression analysis was performed using a cumulative incidence function plot and survival analysis was conducted using Kaplan-Meier. RESULTS The median follow-up time for the 267 patient cohort was 44.5 months (interquartile range [IQR]: 24.1-72.2). Radiographic cyst growth was observed in 123 (46.1%) patients; 65 (24.3%) patients progressed to WF/HRS. Twenty-six (9.7%) patients were selected for resection during surveillance: 21 (80.8%) WF, 4 (15.4%) HRS; 1 (3.9%) transformed to mixed-duct. Of all the patients who underwent resection, 5 (19.2%) had adenocarcinoma, and 1 (3.8%) had carcinoma-in-situ. The probability of any radiographic progression was 21.3% (5-year) and 51.3% (10-year). For the entire cohort, there was 1.1% mortality secondary to pancreatic adenocarcinoma and 8.2% all-cause mortality. The 5-year overall survival rate was 91.5%, and at 10 years, 81.5%. CONCLUSION Approximately one in four patients with nonworrisome BD-IPMN have progression to WF/HRS stigmata during surveillance. However, the risk of malignant transformation remains low. Surveillance strategy remains prudent in this patient population.
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Affiliation(s)
- Courtney M. Lattimore
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - William J. Kane
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | | | | | - Christopher L. Cramer
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - Lena M. Turkheimer
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | | | - Florence E. Turrentine
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
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Tanabe M, Onoda H, Higashi M, Morooka R, Ihara K, Tanabe M, Matsukuma M, Iida E, Furukawa M, Ito K. Three-Dimensional (3D) Breath-Hold Zoomed MR Cholangiopancreatography (MRCP): Evaluation of Additive Value to Conventional 3D Navigator Triggering MRCP in Patients With Branch Duct Intraductal Papillary Mucinous Neoplasms. J Magn Reson Imaging 2021; 55:1234-1240. [PMID: 34331482 DOI: 10.1002/jmri.27866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND To resolve drawbacks of navigator triggering (NT) three-dimensional (3D) magnetic resonance cholangiopancreatography (MRCP), several approaches were proposed to obtain 3D MRCP within a single breath-hold (BH). However, reduced field-of-view technique in the phase-encoding direction combined with two-dimensional spatially selective radiofrequency excitation pulses has not yet been applied to 3D BH MRCP. PURPOSE To investigate the feasibility and the complementary value of 3D BH zoomed MRCP to conventional 3D NT MRCP in patients with branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) of the pancreas. STUDY TYPE Retrospective. POPULATION A total of 221 patients (116 male and 105 female, median age 73 years) with BD-IPMNs. FIELD STRENGTH/SEQUENCE 3.0 T/3D turbo spin echo ASSESSMENT: MR images were analyzed by three radiologists (R.M., H.O., M.T., with 1, 13, and 17 years of experience) to compare blurring and motion artifacts, background suppression, visualization of main pancreatic duct (MPD), conspicuity of BD-IPMN, and overall image quality. STATISTICAL TESTS Wilcoxon-signed rank, Mann-Whitney U, chi-squared or Fisher's exact tests (P < 0.05). RESULTS Image quality was significantly higher on 3D NT MRCP images than on 3D BH zoomed MRCP (median (interquartile range); background suppression, 4 (4-4) vs. 3 (3-4); visualization of MPD, 4 (3-4) vs. 4 (3-4), conspicuity of BD-IPMN, 4 (3-4) vs. 3 (3-4); and overall image quality, 3 (3-4) vs. 3 (3-3)). However, in 32 (14%) patients, 3D NT MRCP showed a score of 1 or 2 in overall image quality. Regarding the conspicuity of BD-IPMN, a conspicuity score of 1 or 2 was rendered in 31 (14%) patients in 3D NT MRCP group. Conversely, 3D BH zoomed MRCP showed a score of 3 or 4 in 29 (94%) of these 31 patients. DATA CONCLUSION 3D BH zoomed MRCP plays a complementary role to 3D NT MRCP, and may improve the conspicuity of BD-IPMNs in patients with irregular breathing pattern. LEVEL OF EVIDENCE 4 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Masahiro Tanabe
- Department of Radiology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Hideko Onoda
- Department of Radiology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Mayumi Higashi
- Department of Radiology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Ryoko Morooka
- Department of Radiology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Kenichiro Ihara
- Department of Radiology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Masaya Tanabe
- Department of Radiology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Miwa Matsukuma
- Department of Radiology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Etsushi Iida
- Department of Radiology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Matakazu Furukawa
- Department of Radiology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Katsuyoshi Ito
- Department of Radiology, Yamaguchi University Graduate School of Medicine, Ube, Japan
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Surci N, Marchegiani G, Andrianello S, Pollini T, Mühlbacher J, Jomrich G, Richwien P, Tamandl D, Schindl M, Bassi C, Salvia R, Sahora K. The faith of non-surveilled pancreatic cysts: a bicentric retrospective study. Eur J Surg Oncol 2021; 48:89-94. [PMID: 34148825 DOI: 10.1016/j.ejso.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/06/2021] [Accepted: 06/02/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Incidental discovery of pancreatic cystic neoplasms (PCLs) is a common and steadily increasing occurrence. The aim of this study was to investigate a cohort of patients presenting with incidentally detected PCLs which were not included in a surveillance protocol, and to compare their risk of malignant evolution with that of systematically surveilled lesions. MATERIALS AND METHODS A population of PCLs which did not receive surveillance over a period >10 years (population A) was selected at the Medical University of Vienna. A group of "low risk" branch duct intraductal papillary mucinous neoplasm ≤15 mm in size upon diagnosis undergoing a regular follow-up of at least 5 years at the University of Verona was selected as control (population B). The incidence of pancreatic cancer (PC), cumulative risk of PC and disease-specific survival were compared. RESULTS Overall, 376 patients with non-surveilled PCLs were included in study group A and compared to 299 patients in group B. This comparison resulted in similar incidence rates of PC (1.6% vs 1.7%, p = 0.938), a strong similarity in terms of disease-specific mortality rates (1.3% vs 0.3%, p = 0.171) and the 5- and 10-year cumulative risk of PC (≅ 1% and 2%, p = 0.589) and DSS (≅ 100% and 98%, p = 0.050). CONCLUSION The "price to pay" for a negligence-based policy in the population of non-surveilled PCLs was reasonable, and the incidence of PC was comparable to that reported for a population of low-risk cysts enrolled to a standardized surveillance protocol.
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Affiliation(s)
- N Surci
- Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria; Department of General and Pancreatic Surgery, Pancreas Institute, University and Hospital Trust of Verona, "GB Rossi" Hospital, Verona, Italy
| | - G Marchegiani
- Department of General and Pancreatic Surgery, Pancreas Institute, University and Hospital Trust of Verona, "GB Rossi" Hospital, Verona, Italy.
| | - S Andrianello
- Department of General and Pancreatic Surgery, Pancreas Institute, University and Hospital Trust of Verona, "GB Rossi" Hospital, Verona, Italy
| | - T Pollini
- Department of General and Pancreatic Surgery, Pancreas Institute, University and Hospital Trust of Verona, "GB Rossi" Hospital, Verona, Italy
| | - J Mühlbacher
- Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - G Jomrich
- Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - P Richwien
- Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - D Tamandl
- Department of Radiology, Medical University of Vienna, General Hospital, Vienna, Austria
| | - M Schindl
- Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
| | - C Bassi
- Department of General and Pancreatic Surgery, Pancreas Institute, University and Hospital Trust of Verona, "GB Rossi" Hospital, Verona, Italy
| | - R Salvia
- Department of General and Pancreatic Surgery, Pancreas Institute, University and Hospital Trust of Verona, "GB Rossi" Hospital, Verona, Italy
| | - K Sahora
- Department of Surgery, Medical University of Vienna, General Hospital, Vienna, Austria
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Vaalavuo Y, Siiki A, Antila A, Rinta-Kiikka I, Sand J, Laukkarinen J. The European evidence-based guidelines on pancreatic cystic neoplasms (PCN) in clinical practice: The development of relative and absolute indications for surgery during prospective IPMN surveillance. Pancreatology 2020; 20:1393-1398. [PMID: 32938553 DOI: 10.1016/j.pan.2020.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The European evidence-based guidelines on PCN recommend surveillance for IPMN patients who are fit for surgery but who have no indication for immediate surgery. Our aim was to demonstrate the feasibility of the new guidelines in clinical practice. METHODS This is a prospective cohort study of patients included in the IPMN register in Tampere University Hospital, Finland. IPMN was diagnosed from January 1, 2013 to December 31, 2018. Patients were analyzed for surveillance and indications for surgery according to the European guidelines on PCN. RESULTS Out of 128 patients in register 23 was decided to operate upfront and 105 patients were included in the surveillance programme. Invasive carcinoma was found in 4/23 of operated patients. Median follow-up time was 26 months (6-69). Median size of the cyst at the beginning and end of the surveillance was 16 mm (4-58 mm). During surveillance 0/105 (0.0%) patients had or developed an absolute indication for surgery. Relative indication for surgery was present in 8/105 (7.6%) patients in the beginning surveillance and 9/105 (8.6%) patients developed at least one relative indication for surgery during surveillance. From the surveillance cohort 2/105 patients were operated. Surveillance was abandoned in 15/105 (14.1%) patients all due to poor general condition or other medical conditions. CONCLUSIONS In clinical practice, surveillance of IPMN according to the European guidelines on PCN is feasible. Among our patients 16% were detected to have relative indications for surgery during the median 26 (range 3-135) months of surveillance. Nearly 15% became surgically unfit during surveillance period.
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Affiliation(s)
- Yrjö Vaalavuo
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Antti Siiki
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Anne Antila
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Irina Rinta-Kiikka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Dept. of Radiology, Tampere University Hospital, Tampere, Finland
| | - Juhani Sand
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
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Penheiter AR, Deelchand DK, Kittelson E, Damgard SE, Murphy SJ, O'Brien DR, Bamlet WR, Passow MR, Smyrk TC, Couch FJ, Vasmatzis G, Port JD, Marjańska M, Carlson SK. Identification of a pyruvate-to-lactate signature in pancreatic intraductal papillary mucinous neoplasms. Pancreatology 2018; 18:46-53. [PMID: 29170050 PMCID: PMC6139027 DOI: 10.1016/j.pan.2017.11.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 11/03/2017] [Accepted: 11/13/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We used transcriptomic profiling and immunohistochemistry (IHC) to search for a functional imaging strategy to resolve common problems with morphological imaging of cystic neoplasms and benign cystic lesions of the pancreas. METHODS Resected pancreatic cancer (n = 21) and normal pancreas were laser-capture micro-dissected, and transcripts were quantified by RNAseq. Functional imaging targets were validated at the protein level by IHC on a pancreatic adenocarcinoma tissue microarray and a newly created tissue microarray of resected intraductal papillary mucinous neoplasms (IPMNs) and IPMN-associated adenocarcinomas. RESULTS Genes encoding proteins responsible for cellular import of pyruvate, export of lactate, and conversion of pyruvate to lactate were highly upregulated in pancreatic adenocarcinoma compared to normal pancreas. Strong expression of MCT4 and LDHA was observed by IHC in >90% of adenocarcinoma specimens. In IPMNs, the pyruvate-to-lactate signature was significantly elevated in high grade dysplasia (HGD) and IPMN-associated adenocarcinoma. Additionally, cores containing HGD and/or adenocarcinoma exhibited a higher number of peri-lesional stromal cells and a significant increase in peri-lesional stromal cell staining of LDHA and MCT4. Interestingly, the pyruvate-to-lactate signature was significantly upregulated in cores containing only low grade dysplasia (LGD) from patients with histologically confirmed IPMN-associated adenocarcinoma versus LGD cores from patients with non-invasive IPMNs. CONCLUSION Our results suggest prospective studies with hyperpolarized [1-13C]-pyruvate magnetic resonance spectroscopic imaging are warranted. If these IHC results translate to functional imaging findings, a positive pyruvate-to-lactate imaging signature might be a risk factor for invasion that would warrant resection of IPMNs in the absence of other worrisome features.
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Affiliation(s)
- Alan R Penheiter
- Department of Molecular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Dinesh K Deelchand
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota, 2021 6th Street SE, Minneapolis, MN 55455, USA
| | - Emily Kittelson
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota, 2021 6th Street SE, Minneapolis, MN 55455, USA
| | - Sibel Erdogan Damgard
- Department of Biochemistry and Molecular Biology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Stephen J Murphy
- Department of Molecular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Daniel R O'Brien
- Department of Health Science Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - William R Bamlet
- Department of Health Science Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Marie R Passow
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Thomas C Smyrk
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Fergus J Couch
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - George Vasmatzis
- Department of Molecular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - John D Port
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Małgorzata Marjańska
- Center for Magnetic Resonance Research and Department of Radiology, University of Minnesota, 2021 6th Street SE, Minneapolis, MN 55455, USA
| | - Stephanie K Carlson
- Department of Molecular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Aronsson L, Andersson R, Ansari D. Intraductal papillary mucinous neoplasm of the pancreas - epidemiology, risk factors, diagnosis, and management. Scand J Gastroenterol 2017; 52:803-815. [PMID: 28446039 DOI: 10.1080/00365521.2017.1318948] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Intraductal papillary mucinous neoplasm (IPMN) is one of the most common cystic neoplasms of the pancreas. It is a heterogeneous disease and can be divided into ductal types and morphological subtypes. The incidence of IPMN is increasing, likely due to the widespread use of cross-sectional imaging and a growing elderly population. IPMN poses an increasing demand on the health care system. Current guidelines provide indications for surgery and recommendations for surveillance, but management of IPMN is still challenging in routine clinical practice. In this article, we review current knowledge about IPMN and provide future directions for improving diagnosis and management.
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Affiliation(s)
- Linus Aronsson
- a Department of Clinical Sciences Lund, Surgery , Lund University, Skane University Hospital , Lund , Sweden
| | - Roland Andersson
- a Department of Clinical Sciences Lund, Surgery , Lund University, Skane University Hospital , Lund , Sweden
| | - Daniel Ansari
- a Department of Clinical Sciences Lund, Surgery , Lund University, Skane University Hospital , Lund , Sweden
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Tanaka M, Fernández-Del Castillo C, Kamisawa T, Jang JY, Levy P, Ohtsuka T, Salvia R, Shimizu Y, Tada M, Wolfgang CL. Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology 2017; 17:738-753. [PMID: 28735806 DOI: 10.1016/j.pan.2017.07.007] [Citation(s) in RCA: 1013] [Impact Index Per Article: 144.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 07/12/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023]
Abstract
The management of intraductal papillary mucinous neoplasm (IPMN) continues to evolve. In particular, the indications for resection of branch duct IPMN have changed from early resection to more deliberate observation as proposed by the international consensus guidelines of 2006 and 2012. Another guideline proposed by the American Gastroenterological Association in 2015 restricted indications for surgery more stringently and recommended physicians to stop surveillance if no significant change had occurred in a pancreatic cyst after five years of surveillance, or if a patient underwent resection and a non-malignant IPMN was found. Whether or not it is safe to do so, as well as the method and interval of surveillance, has generated substantial debate. Based on a consensus symposium held during the meeting of the International Association of Pancreatology in Sendai, Japan, in 2016, the working group has revised the guidelines regarding prediction of invasive carcinoma and high-grade dysplasia, surveillance, and postoperative follow-up of IPMN. As the working group did not recognize the need for major revisions of the guidelines, we made only minor revisions and added most recent articles where appropriate. The present guidelines include updated information and recommendations based on our current understanding, and highlight issues that remain controversial or where further research is required.
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Affiliation(s)
- Masao Tanaka
- Department of Surgery, Shimonoseki City Hospital, Shimonoseki, Japan.
| | | | - Terumi Kamisawa
- Department of Gastroenterology, Komagome Metropolitan Hospital, Tokyo, Japan
| | - Jin Young Jang
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Philippe Levy
- Pôle des Maladies de l'Appareil Digestif, Service de Gastroentérologie-Pancréatologie, Hopital Beaujon, Clichy Cedex, France
| | - Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Yasuhiro Shimizu
- Dept. of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan
| | - Minoru Tada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Christopher L Wolfgang
- Cameron Division of Surgical Oncology and The Sol Goldman Pancreatic Cancer Research Center, Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
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