1
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Pflüger MJ, Brosens LAA, Hruban RH. Precursor lesions in familial and hereditary pancreatic cancer. Fam Cancer 2024; 23:267-278. [PMID: 38319536 DOI: 10.1007/s10689-024-00359-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/24/2024] [Indexed: 02/07/2024]
Abstract
Infiltrating ductal adenocarcinoma of the pancreas, referred to here as "pancreatic cancer," is one of the deadliest of all of the solid malignancies. The five-year survival rate in the United States for individuals diagnosed today with pancreatic cancer is a dismal 12%. Many invasive cancers, including pancreatic cancer, however, arise from histologically and genetically well-characterized precursor lesions, and these precancers are curable. Precursor lesions therefore are an attractive target for early detection and treatment. This is particularly true for individuals with an increased risk of developing invasive cancer, such as individuals with a strong family history of pancreatic cancer, and individuals with a germline variant known to increase the risk of developing pancreatic cancer. There is therefore a need to understand the precursor lesions that can give rise to invasive pancreatic cancer in these individuals.
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Affiliation(s)
- Michael J Pflüger
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Carnegie Room 415, 600 North Wolfe Street, Baltimore, MD, 21287, USA.
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2
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Paolino G, Basturk O, Esposito I, Hong SM, Brosens LA, Tarcan Z, Wood LD, Gkountakos A, Omori Y, Mattiolo P, Ciulla C, Marchegiani G, Pea A, Bevere M, De Robertis R, D'Onofrio M, Salvia R, Cheng L, Furukawa T, Scarpa A, Adsay V, Luchini C. Comprehensive Characterization of Intraductal Oncocytic Papillary Neoplasm of the Pancreas: A Systematic and Critical Review. Mod Pathol 2024; 37:100554. [PMID: 38950698 DOI: 10.1016/j.modpat.2024.100554] [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: 02/08/2024] [Revised: 05/23/2024] [Accepted: 06/20/2024] [Indexed: 07/03/2024]
Abstract
Intraductal oncocytic papillary neoplasm (IOPN) of the pancreas is a recently recognized pancreatic tumor. Here, we aimed to determine its most essential features with the systematic review tool. PubMed, Scopus, and Embase were searched for studies reporting data on pancreatic IOPN. The clinicopathologic, immunohistochemical, and molecular data were extracted and summarized. Then, a comparative analysis of the molecular alterations of IOPN with those of pancreatic ductal adenocarcinoma and intraductal papillary mucinous neoplasm from reference cohorts (including The Cancer Genome Atlas) was conducted. The key findings from 414 IOPNs were as follows: 1) The male-to-female ratio was 1.5:1. Pancreatic head was the most common site (131/237; 55.3%), but a diffuse tumor extension involving more than one pancreatic segment was described in about 1 out of 5 cases (49/237; 20.6%). The mean size was 45.5 mm. An associated invasive carcinoma was present in 50% of cases (168/336). In those cases, most tumors were pT1 or pT2 and pN0 (>80%), and vascular invasion was uncommon (20.6%). Regarding survival, more than 90% of patients were alive after surgical resection. 2) Immunohistochemical and molecular features were as follows. The most commonly expressed mucins were MUC5AC (110/112; 98.2%) and MUC6 (78/84; 92.8%). Compared with pancreatic ductal adenocarcinoma and intraductal papillary mucinous neoplasm, the classic pancreatic drivers KRAS, TP53, CDKN2A, SMAD4, and GNAS were less altered in IOPN (P < .01). Moreover, fusions involving PRKACA or PRKACB gene were detected in all of the 68 cases examined, with PRKACB::ATP1B1 being the most common (27/68 cases; 39.7%). These genomic events emerged as an entity-defining molecular alteration of IOPN (P < .01). Thus, such fusions represent a promising biomarker for diagnostic purposes. Recent evidence also suggests their role in influencing the acquisition of oncocytic morphology. IOPN is a distinct pancreatic neoplasm with specific clinicopathologic and molecular features. Considering the clinical or prognostic implications, its recognition is essential for pathologists and, ultimately, patients' management.
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Affiliation(s)
- Gaetano Paolino
- Section of Pathology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy; Pathology Unit, Azienda Socio Sanitaria Territoriale Spedali Civili Di Brescia, Brescia, Italy
| | - Olca Basturk
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Irene Esposito
- Institute of Pathology, University Hospital of Duesseldorf, Duesseldorf, Germany
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Lodewijk A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Zeynep Tarcan
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Laura D Wood
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anastasios Gkountakos
- Section of Pathology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Yuko Omori
- Section of Pathology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy; Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Paola Mattiolo
- Section of Pathology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Calogero Ciulla
- Section of Pathology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Giovanni Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Antonio Pea
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Michele Bevere
- ARC-Net Research Center, University of Verona, Verona, Italy
| | - Riccardo De Robertis
- Section of Radiology, Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
| | - Mirko D'Onofrio
- Section of Radiology, Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
| | - Roberto Salvia
- Department of Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Liang Cheng
- Department of Pathology and Laboratory Medicine, The Warren Albert Medical School of Brown University, Lifespan Academic Medical Center, and the Legorreta Cancer Center at Brown University, Providence, Rhode Island
| | - Toru Furukawa
- Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Aldo Scarpa
- Section of Pathology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy; ARC-Net Research Center, University of Verona, Verona, Italy
| | - Volkan Adsay
- Department of Pathology, Koç University Hospital and Koç University Research Center for Translational Medicine, Istanbul, Turkey
| | - Claudio Luchini
- Section of Pathology, Department of Diagnostics and Public Health, University of Verona, Verona, Italy; ARC-Net Research Center, University of Verona, Verona, Italy.
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3
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Balaban DV, Coman LI, Balaban M, Costache RS, Jinga M. Novel Insights into Postoperative Surveillance in Resected Pancreatic Cystic Neoplasms-A Review. Diagnostics (Basel) 2024; 14:1056. [PMID: 38786354 PMCID: PMC11119521 DOI: 10.3390/diagnostics14101056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/11/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
Pancreatic cystic lesions (PCL) are frequently encountered in clinical practice and some are referred to surgery due to their neoplastic risk or malignant transformation. The management of PCL involves complex decision-making, with postoperative surveillance being a key component for long-term outcomes, due to the potential for recurrence and postoperative morbidity. Unfortunately, the follow-up of resected patients is far from being optimal and there is a lack of consensus on recommendations with regard to timing and methods of surveillance. Here, we summarize the current knowledge on the postoperative surveillance of neoplastic pancreatic cysts, focusing on the mechanisms and risk factors for recurrence, the recurrence rates according to the initial indication for surgery, the final result of the surgical specimen and neoplastic risk in the remaining pancreas, as well as the postsurgical morbidity comprising pancreatic exocrine insufficiency, metabolic dysfunction and diabetes after resection, according to the type of surgery performed. We analyze postsurgical recurrence rates and morbidity profiles, as influenced by different surgical techniques, to better delineate at-risk patients, and highlight the need for tailored surveillance strategies adapted to preoperative and operative factors with an impact on outcomes.
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Affiliation(s)
- Daniel Vasile Balaban
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Laura-Ioana Coman
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Marina Balaban
- Doctoral School, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Raluca Simona Costache
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
| | - Mariana Jinga
- Internal Medicine and Gastroenterology Department, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (L.-I.C.); (R.S.C.); (M.J.)
- Gastroenterology Department, Central Military Emergency University Hospital, 010825 Bucharest, Romania
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4
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Salahuddin A, Thayaparan V, Hamad A, Tarver W, Cloyd JM, Kim AC, Gebhard R, Pawlik TM, Reames BN, Ejaz A. Recurrence following Resection of Intraductal Papillary Mucinous Neoplasms: A Systematic Review to Guide Surveillance. J Clin Med 2024; 13:830. [PMID: 38337524 PMCID: PMC10856514 DOI: 10.3390/jcm13030830] [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: 11/20/2023] [Revised: 01/22/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Patients who undergo resection for non-invasive IPMN are at risk for long-term recurrence. Further evidence is needed to identify evidence-based surveillance strategies based on the risk of recurrence. We performed a systematic review of the current literature regarding recurrence patterns following resection of non-invasive IPMN to summarize evidence-based recommendations for surveillance. Among the 61 studies reviewed, a total of 8779 patients underwent resection for non-invasive IPMN. The pooled overall median follow-up time was 49.5 months (IQR: 38.5-57.7) and ranged between 14.1 months and 114 months. The overall median recurrence rate for patients with resected non-invasive IPMN was 8.8% (IQR: 5.0, 15.6) and ranged from 0% to 27.6%. Among the 33 studies reporting the time to recurrence, the overall median time to recurrence was 24 months (IQR: 17, 46). Existing literature on recurrence rates and post-resection surveillance strategies for patients with resected non-invasive IPMN varies greatly. Patients with resected non-invasive IPMN appear to be at risk for long-term recurrence and should undergo routine surveillance.
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Affiliation(s)
- Aneesa Salahuddin
- Department of Surgery, The Ohio State University, Columbus, OH 43210, USA; (A.S.); (J.M.C.); (T.M.P.)
| | - Varna Thayaparan
- Department of Surgery, The Ohio State University, Columbus, OH 43210, USA; (A.S.); (J.M.C.); (T.M.P.)
| | - Ahmad Hamad
- Department of Surgery, The Ohio State University, Columbus, OH 43210, USA; (A.S.); (J.M.C.); (T.M.P.)
| | - Willi Tarver
- Department of Internal Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Jordan M. Cloyd
- Department of Surgery, The Ohio State University, Columbus, OH 43210, USA; (A.S.); (J.M.C.); (T.M.P.)
| | - Alex C. Kim
- Department of Surgery, The Ohio State University, Columbus, OH 43210, USA; (A.S.); (J.M.C.); (T.M.P.)
| | - Robyn Gebhard
- Department of Radiology, The Ohio State University, Columbus, OH 43210, USA
| | - Timothy M. Pawlik
- Department of Surgery, The Ohio State University, Columbus, OH 43210, USA; (A.S.); (J.M.C.); (T.M.P.)
| | - Bradley N. Reames
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Aslam Ejaz
- Department of Surgery, University of Ilinois at Chicago, 840 S. Wood Street, Chicago, IL 60612, USA
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5
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Omori Y, Furukawa T, Scarpa A, Luchini C. Co-occurring IPMN and pancreatic cancer: the same or different? An overview from histology to molecular pathology. J Clin Pathol 2023; 76:734-739. [PMID: 37500498 DOI: 10.1136/jcp-2023-209012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 07/18/2023] [Indexed: 07/29/2023]
Abstract
Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is one of the most well-established precursors of pancreatic cancer. Its progression to acquire invasiveness is a complex process, based on the accumulation of morphological and genetic alterations. Recent advances in DNA sequencing also showed that co-occurring IPMNs and pancreatic cancers could be totally independent, further complicating our understanding of this complex scenario. The distinction between IPMN and related pancreatic cancer vs IPMN and co-occurring-but not related-pancreatic cancer is a challenging task in routine diagnostic activity, but may have important implications for precision oncology. Of note, recent multiregional sequencing-based studies focused not only on IPMN multi-step tumourigenesis, but also on the divergent intratumoural heterogeneity of this neoplasm. Globally considered, there are three different situations in which co-occurring IPMNs and invasive carcinomas can be found in the same pancreata, indicated with different terminologies: (1) IPMN-associated carcinoma: this definition indicates a carcinoma arising from an IPMN and can be also defined as IPMN-derived carcinoma, sequential or likely related; (2) independent IPMN and invasive carcinoma: the two lesions are not related, and this situation is defined as concomitant, de novo or likely independent; (3) branch-off pathway, where an invasive carcinoma and an adjacent IPMN develop divergently in a forked fashion from a common ancestral clone. In this review, we aim at clarifying the most important nomenclature/definitions of these different situations, also providing an overview of the molecular state-of-the-art and of the clinical implications of this complex landscape.
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Affiliation(s)
- Yuko Omori
- Department of Investigative Patholgy, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
| | - Toru Furukawa
- Department of Investigative Patholgy, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
- ARC-Net Research Center, University and Hospital Trust, Verona, Italy
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University of Verona, Verona, Italy
- ARC-Net Research Center, University and Hospital Trust, Verona, Italy
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6
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Revoredo Rego F, Reaño Paredes G, de Vinatea de Cárdenas J, Herrera Chávez G, Kometter Barrios F, Arenas Gamio J. Intraductal papillary mucinous neoplasm of pancreas: Clinicopathological features and long-term survival after surgical resection. Cir Esp 2023; 101:736-745. [PMID: 36716959 DOI: 10.1016/j.cireng.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 10/04/2022] [Accepted: 10/30/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Intraductal papillary mucinous neoplasm (IPMN) of the pancreas can progress from low-grade dysplasia to high-grade dysplasia and invasive carcinoma. METHODS In this single-center retrospective series, we analyze the clinicopathological features and long-term follow up of patients who underwent pancreatic resection for IPMN, from January 2009 to December 2019. RESULTS 31 patients were diagnosed with IPMN: 9 males and 22 females. Mean age was 67 years. Twenty-seven patients (87%) were symptomatic. Seven patients had main duct IPMN, 11 branch-type IPMN and 13 mixed-type IPMN. High-risk stigmata were found in 20 patients (64.5%) and worrisome features in 10 patients (32.2%). Thirteen patients (41.9%) had an associated invasive carcinoma, 4 (12.9%) high-grade dysplasia and 14 (45.2%) low-grade dysplasia. The follow-up was from 2 to 12 years. Median survival for patients with IPMN and associated invasive carcinoma was 45.8 months, and disease-free survival was 40.8 months. CONCLUSIONS IPMN had a higher prevalence in females, mostly symptomatic and high incidence of associated invasive carcinoma with branch type. The 5-year survival was good even with associated invasive carcinoma.
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Affiliation(s)
- Fernando Revoredo Rego
- Servicio de Cirugía de Páncreas, Bazo y Retroperitoneo, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru.
| | - Gustavo Reaño Paredes
- Servicio de Cirugía de Páncreas, Bazo y Retroperitoneo, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - José de Vinatea de Cárdenas
- Servicio de Cirugía de Páncreas, Bazo y Retroperitoneo, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Guillermo Herrera Chávez
- Servicio de Cirugía de Páncreas, Bazo y Retroperitoneo, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Fritz Kometter Barrios
- Servicio de Cirugía de Páncreas, Bazo y Retroperitoneo, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - José Arenas Gamio
- Servicio de Anatomía Patológica, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
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Wood LD, Adsay NV, Basturk O, Brosens LAA, Fukushima N, Hong SM, Kim SJ, Lee JW, Luchini C, Noë M, Pitman MB, Scarpa A, Singhi AD, Tanaka M, Furukawa T. Systematic review of challenging issues in pathology of intraductal papillary mucinous neoplasms. Pancreatology 2023; 23:878-891. [PMID: 37604731 DOI: 10.1016/j.pan.2023.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/03/2023] [Accepted: 08/08/2023] [Indexed: 08/23/2023]
Abstract
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.
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Affiliation(s)
- Laura D Wood
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - N Volkan Adsay
- Department of Pathology, Koç University Hospital and Koç University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey
| | - Olca Basturk
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Noriyoshi Fukushima
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Joo Kim
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae W Lee
- Department of Pathology, Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Claudio Luchini
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134, Verona, Italy; ARC-Net Research Center, University of Verona, 37134, Verona, Italy
| | - Michaël Noë
- Department of Pathology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Martha B Pitman
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aldo Scarpa
- Department of Diagnostics and Public Health, Section of Pathology, University and Hospital Trust of Verona, 37134, Verona, Italy; ARC-Net Research Center, University of Verona, 37134, Verona, Italy
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mariko Tanaka
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toru Furukawa
- Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
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8
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Arnelo U, Valente R, Scandavini CM, Halimi A, Mucelli RMP, Rangelova E, Svensson J, Schulick RD, Torphy RJ, Fagerström N, Moro CF, Vujasinovic M, Matthias Löhr J, Del Chiaro M. Intraoperative pancreatoscopy can improve the detection of skip lesions during surgery for intraductal papillary mucinous neoplasia: A pilot study. Pancreatology 2023; 23:704-711. [PMID: 37336668 DOI: 10.1016/j.pan.2023.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 05/09/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVES Intraoperative pancreatoscopy is a promising procedure that might guide surgical resection for suspected main duct (MD) and mixed type (MT) intraductal papillary mucinous neoplasms (IPMNs). The aim of the present study was to assess the diagnostic yield and clinical impact of intraoperative pancreatoscopy in patients operated on for MD and MT-IPMNs. METHODS This is a retrospective cohort study. Patients undergoing surgery for suspected MD or MT-IPMN underwent intraoperative pancreatoscopy and frozen section analysis. In all patients who required extended resection due to pancreatoscopic findings, we compared the final histology with the results of the intraoperative frozen section analysis. RESULTS In total, 46 patients, 48% females, mean age (range) 67 years (45-82 years) underwent intraoperative pancreatoscopy. No mortality or procedure related complications were observed. Pancreatoscopy changed the operative course in 30 patients (65%), leading to extended resections in 20 patients (43%) and to parenchyma sparing procedures in 10 patients (22%). Analyzing the group of patients who underwent extended resections, 7 (35%) displayed lesions that needed further surgical treatment (six high grade dysplasia and one with G1 pancreatic neuroendocrine tumor) and among those 7, just 1 (14%) would have been detected exclusively with histological frozen section analysis of the transection margin. The combination of both pancreatoscopy and frozen section analysis lead to 86% sensitivity and 92% specificity for the detection of pathological tissue in the remnant pancreas. CONCLUSION Intraoperative pancreatoscopy is a safe and feasible procedure and might allow the detection of skip lesions during surgery for suspect MD-involving IPMNs.
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Affiliation(s)
- Urban Arnelo
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden.
| | - Roberto Valente
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Asif Halimi
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Raffaella M Pozzi Mucelli
- Department of Radiology Huddinge, Karolinska University Hospital, O-huset 42, 14186, Stockholm, Sweden; Division of Radiology, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Elena Rangelova
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Section for Upper Abdominal Surgery at Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Svensson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert J Torphy
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Niklas Fagerström
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Carlos Fernández Moro
- Department of Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, Huddinge, Sweden; Department of Laboratory Medicine, Division of Pathology, Karolinska Institutet, Huddinge, Sweden
| | - Miroslav Vujasinovic
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Johannes Matthias Löhr
- Division of Surgery, Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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9
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Fong ZV, Hernandez-Barco YG, Castillo CFD. A Clinical Guide to the Management of Intraductal Papillary Mucinous Neoplasms: the Need for a More Graded Approach in Clinical Decision-making. J Gastrointest Surg 2023; 27:1988-1998. [PMID: 37495820 DOI: 10.1007/s11605-022-05536-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/30/2022] [Indexed: 07/28/2023]
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) have become a very common diagnosis and represent a spectrum of disease that ranges from benign to malignant lesions. Presently, clinical and radiographic features are used to predict the presence of high-grade dysplasia and invasive cancer to inform treatment decisions of whether to pursuit surgical resection or continued surveillance. However, the natural history of IPMNs is still not completely understood, with guidelines from different societies providing contradictory recommendations. This underscores the challenge in balancing the risk of missing cancer with long-term surveillance and the morbidity associated with surgical resection. In this review, we aim to reconcile the differences in the guidelines' recommendations and provide a clinical framework to the management of IPMNs with hopes of adding clarity to how treatment decisions should be made. We also highlight recent advances made in the field and future efforts that can minimize rates of missing cancer while also reducing the number of unnecessary operations.
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Affiliation(s)
- Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, Boston, MA, 02114-3117, USA
| | - Yasmin G Hernandez-Barco
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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10
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Wilson GC. A Growing Armamentarium for the Robotic Pancreas Surgeon? ANNALS OF SURGERY OPEN 2023; 4:e282. [PMID: 37601480 PMCID: PMC10431389 DOI: 10.1097/as9.0000000000000282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 08/22/2023] Open
Affiliation(s)
- Gregory C. Wilson
- From the Department of surgery, Division of Surgical Oncology, University of Cincinnati Medical Center, Cincinnati
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11
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Vaalavuo Y, Vornanen M, Ahola R, Antila A, Rinta-Kiikka I, Sand J, Laukkarinen J. Long-term (10-year) outcomes and prognostic factors in resected intraductal papillary mucinous neoplasm tumors in Finland: A nationwide retrospective study. Surgery 2023:S0039-6060(23)00059-4. [PMID: 37062604 DOI: 10.1016/j.surg.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 12/21/2022] [Accepted: 02/07/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND The degree of dysplasia is the most important prognostic factor for patients with resected intraductal papillary mucinous neoplasms. Intraductal papillary mucinous neoplasms are predominantly premalignant conditions; in most cases, surveillance is an adequate treatment. If worrisome features are present, surgery should be considered. However, there is limited data on the long-term prognosis of resected intraductal papillary mucinous neoplasms. We aimed to ascertain the nationwide survival of patients with resected intraductal papillary mucinous neoplasms and identify factors associated with survival. METHODS This is a retrospective nationwide cohort study. All intraductal papillary mucinous neoplasms operated on in Finland between 2000 and 2008 were identified. Patient records were evaluated, and original radiologic data and histologic samples were re-evaluated. Survival data were collected after a 10-year follow-up period. RESULTS Out of 2,024 pancreatic resections, 88 were performed for intraductal papillary mucinous neoplasm. The median age of the patients was 65 years. Histologic diagnoses were main duct intraductal papillary mucinous neoplasm 47/88 (53,4%), mixed-type intraductal papillary mucinous neoplasm 27/88 (30.7%), and branchduct intraductal papillary mucinous neoplasm 14/88 (15.9%). Of the tumors, 40/88 (45.5%) were low-grade dysplasia, 9/88 (10.2%) high-grade, and 39/88 (44.3%) were invasive cancer. The median survival was 121 (range 0-252) months. Ten-year survival was 72.5%, 66.7%, and 23.1% in the low-grade dysplasia, high-grade dysplasia, invasive cancer groups, respectively. Ten-year mortality for pancreatic cancer was 5%, 9.1%, and 71.8% in the low-grade dysplasia, high-grade dysplasia, invasive cancer groups, respectively. CONCLUSION Overall, 44.3% of the patients had a malignant tumor, and three-quarters (74.5%) of the main duct intraductal papillary mucinous neoplasms were malignant or high-grade dysplasia at the time of surgery. Ten-year survival was significantly better in patients operated on at the stage of a premalignant tumor (low-grade dysplasia + high-grade dysplasia) than in patients operated on at the stage of a malignant tumor.
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Affiliation(s)
- Yrjö Vaalavuo
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University, Finland; Faculty of Medicine and Health Technology, Tampere University, Finland
| | - Martine Vornanen
- Department of Pathology, Fimlab Laboratories, Tampere University Hospital, Finland
| | - Reea Ahola
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University, Finland; Faculty of Medicine and Health Technology, Tampere University, Finland
| | - Anne Antila
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University, Finland; Faculty of Medicine and Health Technology, Tampere University, Finland
| | - Irina Rinta-Kiikka
- Faculty of Medicine and Health Technology, Tampere University, Finland; Department of Radiology, Tampere University Hospital, Finland
| | - Juhani Sand
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University, Finland; Faculty of Medicine and Health Technology, Tampere University, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University, Finland; Faculty of Medicine and Health Technology, Tampere University, Finland.
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12
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Liffers ST, Godfrey L, Frohn L, Haeberle L, Yavas A, Vesce R, Goering W, Opitz FV, Stoecklein N, Knoefel WT, Schlitter AM, Klöppel G, Espinet E, Trumpp A, Siveke JT, Esposito I. Molecular heterogeneity and commonalities in pancreatic cancer precursors with gastric and intestinal phenotype. Gut 2023; 72:522-534. [PMID: 35944927 PMCID: PMC9933174 DOI: 10.1136/gutjnl-2021-326550] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 07/31/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Due to the limited number of modifiable risk factors, secondary prevention strategies based on early diagnosis represent the preferred route to improve the prognosis of pancreatic ductal adenocarcinoma (PDAC). Here, we provide a comparative morphogenetic analysis of PDAC precursors aiming at dissecting the process of carcinogenesis and tackling the heterogeneity of preinvasive lesions. DESIGN Targeted and whole-genome low-coverage sequencing, genome-wide methylation and transcriptome analyses were applied on a final collective of 122 morphologically well-characterised low-grade and high-grade PDAC precursors, including intestinal and gastric intraductal papillary mucinous neoplasms (IPMN) and pancreatic intraepithelial neoplasias (PanIN). RESULTS Epigenetic regulation of mucin genes determines the phenotype of PDAC precursors. PanIN and gastric IPMN display a ductal molecular profile and numerous similarly regulated pathways, including the Notch pathway, but can be distinguished by recurrent deletions and differential methylation and, in part, by the expression of mucin-like 3. Intestinal IPMN are clearly distinct lesions at the molecular level with a more instable genotype and are possibly related to a different ductal cell compartment. CONCLUSIONS PDAC precursors with gastric and intestinal phenotype are heterogeneous in terms of morphology, genetic and epigenetic profile. This heterogeneity is related to a different cell identity and, possibly, to a different aetiology.
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Affiliation(s)
- Sven-Thorsten Liffers
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, Essen, Germany.,Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK, partner site Essen) and German Cancer Research Center, DKFZ, Heidelberg, Germany
| | - Laura Godfrey
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, Essen, Germany.,Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK, partner site Essen) and German Cancer Research Center, DKFZ, Heidelberg, Germany
| | - Lisa Frohn
- Institute of Pathology, Heinrich-Heine University and University Hospital of Dusseldorf, Dusseldorf, Germany
| | - Lena Haeberle
- Institute of Pathology, Heinrich-Heine University and University Hospital of Dusseldorf, Dusseldorf, Germany
| | - Aslihan Yavas
- Institute of Pathology, Heinrich-Heine University and University Hospital of Dusseldorf, Dusseldorf, Germany
| | - Rita Vesce
- Institute of Pathology, Heinrich-Heine University and University Hospital of Dusseldorf, Dusseldorf, Germany
| | - Wolfgang Goering
- Institute of Pathology, Heinrich-Heine University and University Hospital of Dusseldorf, Dusseldorf, Germany
| | - Friederike V Opitz
- Institute of Pathology, Heinrich-Heine University and University Hospital of Dusseldorf, Dusseldorf, Germany
| | - Nickolas Stoecklein
- Department of General, Visceral and Pediatric Surgery, Heinrich-Heine-University and University Hospital of Dusseldorf, Dusseldorf, Germany
| | - Wolfram Trudo Knoefel
- Department of General, Visceral and Pediatric Surgery, Heinrich-Heine-University and University Hospital of Dusseldorf, Dusseldorf, Germany
| | | | - Guenter Klöppel
- Institute of Pathology, Technische Universitaet Muenchen, Munich, Germany
| | - Elisa Espinet
- HI-STEM-Heidelberg Institute for Stem Cell Technology and Experimental Medicine GmbH, Heidelberg, Germany.,Division of Stem Cells and Cancer, German Cancer Research Centre and DKFZ-ZMBH Alliance, Heidelberg, Germany.,German Cancer Consortium, (DKTK), Heidelberg, Germany
| | - Andreas Trumpp
- HI-STEM-Heidelberg Institute for Stem Cell Technology and Experimental Medicine GmbH, Heidelberg, Germany.,Division of Stem Cells and Cancer, German Cancer Research Centre and DKFZ-ZMBH Alliance, Heidelberg, Germany.,German Cancer Consortium, (DKTK), Heidelberg, Germany
| | - Jens T Siveke
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, Essen, Germany.,Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK, partner site Essen) and German Cancer Research Center, DKFZ, Heidelberg, Germany
| | - Irene Esposito
- Institute of Pathology, Heinrich-Heine University and University Hospital of Dusseldorf, Dusseldorf, Germany
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13
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Revoredo Rego F, Reaño Paredes G, de Vinatea de Cárdenas J, Herrera Chávez G, Kometter Barrios F, Arenas Gamio J. Neoplasia mucinosa papilar intraductal del páncreas: características clínico-patológicas y supervivencia a largo plazo de pacientes sometidos a pancreatectomía. Cir Esp 2023. [DOI: 10.1016/j.ciresp.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
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14
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Correa-Gallego C, Miyasaka Y, Hozaka Y, Nishino H, Kawamoto M, Vieira DL, Ohtsuka T, Wolfgang C. Surveillance after resection of non-invasive intraductal papillary mucinous neoplasms (IPMN). A systematic review. Pancreatology 2023; 23:258-265. [PMID: 36906508 DOI: 10.1016/j.pan.2023.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/21/2023] [Accepted: 02/25/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND The ideal surveillance strategy after partial pancreatectomy for non-invasive IPMN remains undefined and existing guidelines provide conflicting recommendations. The present study was developed in anticipation of the joint meeting of the International Association of Pancreatology (IAP) and the Japan Pancreas Society (JPS) held in Kyoto in July 2022. METHODS An international team of experts developed the four clinical questions (CQ) to operationalize issues pertaining to surveillance of patients in this context. A systematic review was designed following the PRISMA guidelines and registered in PROSPERO. The search strategy was executed in PubMed/Medline (Ovid), Embase, the Cochrane Library and Web of Science databases. Four investigators individually extracted data from the selected studies and drafted recommendations for each CQ. These were subsequently discussed and agreed upon that the IAP/JPS meeting. RESULTS From a total of 1098 studies identified through the initial search, 41 studies were included in the review and informed the recommendations. No studies providing level one data were identified in this systematic review, all studies included were cohort or case-control studies. CONCLUSIONS There is a lack of level 1 data addressing the issue of surveillance of patients following partial pancreatectomy for non-invasive IPMN. The definition of remnant pancreatic lesion in this setting is largely heterogeneous across all studies evaluated. Herein we propose an inclusive definition of remnant pancreatic lesions to guide future prospective efforts for reporting the natural history and long-term outcomes of these patients.
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Affiliation(s)
| | - Yoshihiro Miyasaka
- Department of Surgery, Fukuoka University Chikushi Hospital, Japan; Department of Surgery and Oncology, Kyushu University, Japan
| | - Yuto Hozaka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University, Japan
| | - Hitoe Nishino
- Department of General Surgery, Chiba University, Japan
| | - Makoto Kawamoto
- Department of Surgery, Fukuoka University Chikushi Hospital, Japan; Department of Surgery and Oncology, Kyushu University, Japan
| | - Dorice L Vieira
- NYU Health Sciences Library, NYU Langone Health, NYU Grossman School of Medicine, USA
| | - Takao Ohtsuka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University, Japan.
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15
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Leonhardt CS, Hinz U, Kaiser J, Hank T, Tjaden C, Bergmann F, Hackert T, Büchler MW, Strobel O. Presence of low-grade IPMN at the pancreatic transection margin does not have prognostic significance after resection of IPMN-associated pancreatic adenocarcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:113-121. [PMID: 35965217 DOI: 10.1016/j.ejso.2022.08.003] [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: 05/20/2022] [Revised: 07/12/2022] [Accepted: 08/03/2022] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Resection margin status is a well-established prognosticator in pancreatic cancer. The prognostic impact of IPMN dysplasia at the pancreatic transection margin in IPMN-associated carcinoma (IPMN-Ca) remains unclear, hence institutional practices on additional resections vary. METHODS Patients undergoing partial pancreatectomy or attempted partial pancreatectomy converted to total pancreatectomy for IPMN-Ca between 04/2002 and 12/2018 were identified. Final pathology of the definitive pancreatic transection margin was identified. The association between the presence of IPMN dysplasia at the margin and overall survival (OS) was assessed. RESULTS Of 302 patients with IPMN-Ca, 181 (59.9%) patients received partial pancreatoduodenectomy, 61 (20.2%) distal pancreatectomy, and 60 (19.9%) were converted to total pancreatectomy. Median OS was 98.6 months in R0 (≥1 mm), 39.3 months in R1 (<1 mm), and 22.0 months in R1(direct) resected patients, respectively (p < 0.0001). No IPMN dysplasia at the definitive margin was present in 103 (34.1%), low-grade in 131 (43.4%), and high-grade/R1 in 8 (2.6%) patients. Low-grade dysplasia or total pancreatectomy were not associated with shorter OS compared to dysplasia-free margin across the entire cohort. Sensitivity analyses confirmed a lack of prognostic relevance of low-grade IPMN dysplasia at the pancreatic margin in R0 resected IPMN-Ca and in R0 resected UICC stage IA/IB IPMN-Ca. CONCLUSIONS Low-grade IPMN at the transection margin is not associated with shorter overall survival after partial pancreatectomy for IPMN-Ca. Additional resections for low-grade dysplasia, up to total pancreatectomy do not result in a survival benefit and should be omitted. Due to limited sample size, high-grade dysplasia could not be analyzed.
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Affiliation(s)
- Carl-Stephan Leonhardt
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany; Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Jörg Kaiser
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Thomas Hank
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany; Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Christine Tjaden
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Frank Bergmann
- Institute of Pathology, University Hospital Heidelberg, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany; Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
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16
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Intraoperative pancreatoscopy in pancreaticoduodenectomy for intraductal papillary mucinous neoplasms of the pancreas: Application to the laparoscopic approach. Asian J Surg 2023; 46:166-173. [PMID: 35331591 DOI: 10.1016/j.asjsur.2022.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/30/2021] [Accepted: 03/03/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND /Purpose: Owing to the characteristics of IPMNs, which have variable skipped lesions along the main pancreatic duct (MPD), determining the surgical margins is very difficult. This study aimed to investigate the efficacy and potential oncologic impact of intraoperative pancreatoscopy (IOP) compared to frozen section biopsy (FSB) in pancreaticoduodenectomy (PD) for pancreatic head IPMNs. METHODS Data of patients who underwent PD for IPMNs of the pancreas between October 2007 and May 2020 were retrospectively reviewed. IOP was performed in selected patients with IPMNs with inconclusive MPD involvement based on preoperative evaluations. Patients were divided into two groups, IOP group, FSB group. Clinicopathologic features and oncologic outcomes were compared between two groups. RESULTS 60 patients underwent PD (laparoscopic or robotic, 42; open, 18) for pancreatic head IPMNs. IOP was safely performed in 28 patients, including minimally invasive approach used in 21 patients (35%). IOP group had a significantly larger MPD size (9.15 ± 4.79 mm vs 6.43 ± 4.11 mm, p = 0.021). Based on IOP, the initial surgical plan could be changed in 5 patients (17.8%) for complete resection. Recurrence occurred in 2 patients in FSB group and 3 patients in IOP group during the follow-up period (33.2 months, [range, 3.5-131.4 months]). Overall disease-free survival rate did not significantly differ between two groups (p = 0.529). CONCLUSIONS IOP can be safely performed in patients with pancreatic head IPMNs with MPD dilatation, even in the laparoscopic approach. Further studies evaluating the long-term oncologic effect of IOP for the management of IPMNs are required.
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17
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Habib JR, Kinny-Köster B, Amini N, Shoucair S, Cameron JL, Thompson ED, Fishman EK, Hruban RH, Javed AA, He J, Wolfgang CL. Predictors, Patterns, and Timing of Recurrence Provide Insight into the Disease Biology of Invasive Carcinomas Arising in Association with Intraductal Papillary Mucinous Neoplasms. J Gastrointest Surg 2022; 26:2311-2320. [PMID: 35915375 DOI: 10.1007/s11605-022-05428-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/10/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To identify predictors, patterns, and timing of recurrence after resection of invasive carcinomas arising in association with an IPMN. BACKGROUND Postoperative management of an invasive carcinoma arising in association with an intraductal papillary mucinous neoplasm (IPMN), a biologically distinct entity from PanIN-derived pancreatic ductal adenocarcinoma (PDAC), remains largely based on guidelines for PanIN-derived PDAC. To minimize treatment failure and inform disease-specific management, cancer recurrence must be better characterized. METHODS Patients were identified from a prospectively maintained registry between 1996 and 2018. Predictors of recurrence were evaluated by employing Cox regression models to determine risk-adjusted hazard ratios (HR) with 95% confidence intervals (95%CI). The patterns and timing of recurrence were recognized and compared utilizing a log-rank test, respectively. RESULTS Of the 213 patients included, 92 (43.2%) recurred with a median RFS of 23.7 months (16.7-30.7). The predominant pattern of recurrence included any systemic (65.2%). The median time to local recurrence was longer than systemic (21.6 versus 11.4 months, p = 0.05). Poor differentiation [HR: 3.01, 95%CI (1.06-8.61)] and nodal disease [N1, HR: 2.23, 95%CI (1.12-4.60); and N2, HR: 5.67 95%CI (2.93-10.99)] emerged as independent predictors of systemic recurrence. For local-specific recurrences, poor differentiation [HR: 3.73, 95%CI (1.04-13.45)] and an R1 margin [high-grade dysplasia or invasive carcinoma; HR: 2.66, 95%CI (1.14-6.21)] emerged as independent predictors. CONCLUSIONS The predominant pattern of recurrence after resection of invasive carcinomas arising in association with IPMNs is systemic, and occurs earlier than local recurrence. Poor differentiation and nodal disease are associated with systemic recurrence while poor differentiation and an R1 margin are associated with local recurrence. Future studies should investigate the role of systemic (chemotherapy) versus local (radiation) therapies and surveillance strategies in a personalized manner.
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Affiliation(s)
- Joseph R Habib
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Benedict Kinny-Köster
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neda Amini
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sami Shoucair
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John L Cameron
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth D Thompson
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elliot K Fishman
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ammar A Javed
- Division of Hepatobiliary and Pancreatic Surgery, NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016, USA
| | - Jin He
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Division of Hepatobiliary and Pancreatic Surgery, NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016, USA.
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18
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Invasive and Noninvasive Progression After Resection of Noninvasive Intraductal Papillary Mucinous Neoplasms. Ann Surg 2022; 276:370-377. [PMID: 33201121 PMCID: PMC9844542 DOI: 10.1097/sla.0000000000004488] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To define frequencies, pattern of progression (invasive vs noninvasive), and risk factors of progression of resected noninvasive intraductal papillary mucinous neoplasms (IPMNs). BACKGROUND There is a risk of progression in the remnant pancreas after resection of IPMNs. METHODS Four hundred forty-nine consecutive patients with resected IPMNs from 1995 to 2018 were included to the study. Patients with invasive carcinoma or with follow-up <6 months were excluded. Noninvasive progression was defined as a new IPMN, increased main pancreatic duct size, and increased size of an existing lesion (5 mm compared with preoperative imaging). Invasive progression was defined as development of invasive cancer in the remnant pancreas or metastatic disease. RESULTS With a median follow-up of 48.9 months, progression was identified in 124 patients (27.6%); 108(24.1%) with noninvasive and 16(3.6%) with invasive progression. Median progression follow-up was longer for invasive progression (85.4 vs 55.9 months; P = 0.001). Five-and 10-year estimates for a cumulative incidence of invasive progression were 6.4% and 12.9% versus 26.9% and 41.5% for noninvasive progression. After risk adjustment, multifocality (HR 4.53, 95% CI 1.34-15.26; P = 0.02) and high-grade dysplasia (HGD) in the original resection (HR 3.60, 95% CI 1.13-11.48; P = 0.03) were associated with invasive progression. CONCLUSIONS Progression to invasive carcinoma can occur years after the surgical resection of a noninvasive IPMN. HGD in the original resection is a risk factor for invasive progression but some cases of low-grade dysplasia also progressed to cancer. Patients with high-risk features such as HGD and multifocal cysts should be considered for more intensive surveillance and represent an important cohort for future trials such as anti-inflammatory or prophylactic immunotherapy.
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Zelga P, Hernandez-Barco YG, Qadan M, Ferrone CR, Kambadakone A, Horick N, Jah A, Warshaw AL, Lillemoe KD, Balakrishnan A, Fernández-Del Castillo C. Number of Worrisome Features and Risk of Malignancy in Intraductal Papillary Mucinous Neoplasm. J Am Coll Surg 2022; 234:1021-1030. [PMID: 35703792 DOI: 10.1097/xcs.0000000000000176] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The 2017 revised International Association of Pancreatology guidelines for management of intraductal papillary mucinous neoplasm (IPMN) describe worrisome features (WF) and high-risk stigmata (HRS), recommending resection in the latter and further work-up and close surveillance for patients with WF. The effect of multiple WF on the likelihood of malignancy has not been evaluated. STUDY DESIGN Eight hundred ten patients who underwent pancreatic resection for IPMN in 2 tertiary referral centers were identified from prospective institutional databases. Patients were retrospectively categorized into subgroups according to the number of WF or HRS and presence of malignancy, defined as high-grade dysplasia (HGD) or invasive cancer on final pathology. RESULTS Three hundred seventy-nine (47%) patients had HRS, 370 (46%) had 1 or more WF, and 61 patients (7%) had neither. Malignancy was present in 70% (n = 267) of patients with HRS and in 30% (n = 127) of those with WF. Only 3 of 61 patients without WF/HRS had malignancy, and all only in the form of HGD. The risk of malignancy increased in a stepwise fashion with the number of WF, to 22%, 34%, and 59% with 1, 2, and 3 WF, respectively (p = 0.001), and reached 100% in patients with 4 or more WF. Although the relative risks differed for particular WF, the areas under the curve were not statistically different. CONCLUSION We confirm that presence of HRS in IPMN is associated with a very high likelihood of malignancy. The presence of a single WF has a malignancy risk of 22%, and additional WF increase this risk significantly. When 3 or more WF are present, the risk is similar to that of HRS.
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Affiliation(s)
- Piotr Zelga
- From the Department of Surgery (Zelga, Qadan, Ferrone, Warshaw, Lillemoe, Fernández-del Castillo), Massachusetts General Hospital and Harvard Medical School, Boston, MA.,Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom (Zelga, Jah, Balakrishnan)
| | - Yasmin G Hernandez-Barco
- Division of Gastroenterology (Hernandez-Barco), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Motaz Qadan
- From the Department of Surgery (Zelga, Qadan, Ferrone, Warshaw, Lillemoe, Fernández-del Castillo), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Cristina R Ferrone
- From the Department of Surgery (Zelga, Qadan, Ferrone, Warshaw, Lillemoe, Fernández-del Castillo), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Avinash Kambadakone
- Department of Radiology (Kambadakone), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Nora Horick
- Biostatistics Center, Division of Clinical Research (Horick), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Asif Jah
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom (Zelga, Jah, Balakrishnan)
| | - Andrew L Warshaw
- From the Department of Surgery (Zelga, Qadan, Ferrone, Warshaw, Lillemoe, Fernández-del Castillo), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Keith D Lillemoe
- From the Department of Surgery (Zelga, Qadan, Ferrone, Warshaw, Lillemoe, Fernández-del Castillo), Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Anita Balakrishnan
- Department of Surgery, Addenbrookes Hospital, NIHR Comprehensive Biomedical Research and Academic Health Sciences Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom (Zelga, Jah, Balakrishnan)
| | - Carlos Fernández-Del Castillo
- From the Department of Surgery (Zelga, Qadan, Ferrone, Warshaw, Lillemoe, Fernández-del Castillo), Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Fuji T, Umeda Y, Takagi K, Yoshida R, Yoshida K, Yasui K, Matsumoto K, Kato H, Yagi T, Fujiwara T. Optimal surveillance of intraductal papillary mucinous neoplasms of the pancreas focusing on remnant pancreas recurrence after surgical resection. BMC Cancer 2022; 22:588. [PMID: 35643422 PMCID: PMC9148522 DOI: 10.1186/s12885-022-09650-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/26/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The international consensus guidelines for intraductal papillary mucinous neoplasm of the pancreas (IPMN) presented clinical features as indications for surgery. Whereas surveillance for recurrence, including de novo lesions, is essential, optimal surveillance protocols have not been established. AIM AND METHODS This study aimed to assess the clinical features of recurrence at the remnant pancreas (Rem-Panc) and extra-pancreas (Ex-Panc) after surgery for IPMN. Ninety-one patients of IPMN that underwent detailed preoperative assessment and pancreatectomy were retrospectively analyzed, focusing especially on the type of recurrence. RESULTS The IPMNs were finally diagnosed as low-grade dysplasia (LDA, n = 42), high-grade dysplasia (HAD, n = 19), and invasive carcinoma (IPMC, n = 30). Recurrence was observed in 26 patients (29%), of which recurrence was seen at Rem-Panc in 19 patients (21%) and Ex-Panc in 7 patients (8%). The frequency of Rem-Panc recurrence was 10% in LDA, 21% in HDA, and 37% in IPMC. On the other hand, Ex-Panc recurrence was observed only in IPMC (23%). Ex-Panc recurrence showed shorter median recurrence-free survival (RFS) and overall survival (OS) than Rem-Panc recurrence (median RFS 8 months vs. 35 months, p < 0.001; median OS 25 months vs. 72 months, p < 0.001). Regarding treatment for Rem-Panc recurrence, repeat pancreatectomy resulted in better OS than no repeat pancreatectomy (MST 36 months vs. 15.5 months, p = 0.033). On multivariate analysis, main duct stenosis or disruption as a preoperative feature (hazard ratio [HR] 10.6, p = 0.002) and positive surgical margin (HR 4.4, p = 0.018) were identified as risk factors for Rem-Panc recurrence. CONCLUSIONS The risk factors for Rem-Panc and Ex-Panc recurrence differ. Therefore, optimal surveillance on these features is desirable to ensure that repeat pancreatectomy for Rem-Panc recurrence can be an appropriate surgical intervention.
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Affiliation(s)
- Tomokazu Fuji
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
| | - Yuzo Umeda
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan.
| | - Kosei Takagi
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
| | - Ryuichi Yoshida
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
| | - Kazuhiro Yoshida
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
| | - Kazuya Yasui
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
| | - Kazuyuki Matsumoto
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takahito Yagi
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
| | - Toshiyoshi Fujiwara
- Department of Gastroenterological Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
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Brunner M, Häberle L, Esposito I, Grützmann R. [Pancreatic cystic space-occupying lesions-Diagnostics, treatment and follow-up care : Current recommendations taking the current German S3 guidelines on pancreatic cancer into account]. Chirurg 2022; 93:461-475. [PMID: 35316346 DOI: 10.1007/s00104-022-01616-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2022] [Indexed: 11/03/2022]
Abstract
Due to their increased detection pancreatic cystic space-occupying lesions are becoming increasingly relevant in the clinical routine and represent a morphologically and biologically heterogeneous and thus clinically demanding as well as potentially (pre)malignant entity. As a result, recommendations for the diagnostics and treatment of pancreatic cystic tumors have now been incorporated into the current German S3 guidelines on pancreatic cancer. The diagnostics of pancreatic cystic space-occupying lesions are based on the following three elements: collection of relevant clinical information, performance of high-resolution imaging procedures and if diagnostic uncertainty persists, puncture diagnostics. Differentiated diagnostics are of essential importance as these represent the basis for an adequate treatment decision. Pancreatic cystic lesions with a relevant risk of malignant transformation, e.g., main duct intraductal papillary mucinous neoplasms (IPMN), followed by mucinous cystic neoplasms (MCN), solid pseudopapillary neoplasms (SPN) and generally pancreatic cystic lesions with risk factors independent of the entity, should be resected, whereas a differentiated and individualized approach is necessary, especially for branch-duct IPMNs. The serous cystic neoplasms (SCN) have no malignant potential and do not require any treatment if they are asymptomatic. Important principles in surgery of pancreatic cancer, such as adequate surgical resection taking oncological standards into account and standardized appropriate histopathological processing of the specimens as well as intraoperative frozen section analysis also play an important role in pancreatic cystic space-occupying lesions. An annual follow-up seems to be meaningful, especially for IPMNs.
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Affiliation(s)
- Maximilian Brunner
- Klink für Allgemein- und Viszeralchirurgie, Universitätsklinikum der Friedrich-Alexander-Universität Erlangen, Erlangen, Deutschland
| | - Lena Häberle
- Institut für Pathologie, Universitätsklinikum der Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland
| | - Irene Esposito
- Institut für Pathologie, Universitätsklinikum der Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
| | - Robert Grützmann
- Klink für Allgemein- und Viszeralchirurgie, Universitätsklinikum der Friedrich-Alexander-Universität Erlangen, Erlangen, Deutschland.
- , Krankenhausstr. 12, 91054, Erlangen, Deutschland.
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22
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Jee KN. Metachronous occurrence of main-duct intraductal papillary mucinous neoplasm (IPMN) and adenocarcinoma in a chronic pancreatitis patient: A case report. Medicine (Baltimore) 2022; 101:e28770. [PMID: 35147102 PMCID: PMC8830832 DOI: 10.1097/md.0000000000028770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/19/2022] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Chronic pancreatitis (CP) is a risk factor for developing pancreatic ductal adenocarcinoma (PDAC). In addition, a patient with partial pancreatectomy for intraductal papillary mucinous neoplasm (IPMN) can also lead to PDAC. In contrast, IPMN is a distinct disease entity, independent of CP, and there have been few reports that CP is the cause of IPMN. To the best of our knowledge, this is the first clinical case report of the metachronous occurrence of main-duct IPMN and PDAC with a 9 and half-year interval in a patient with chronic alcoholic pancreatitis. PATIENT CONCERNS A 50-year-old man with a long medical history of recurrent alcoholic pancreatitis and hepatitis over a decade was diagnosed with another episode of acute pancreatitis based on laboratory findings and clinical symptoms. The patient underwent pylorus-preserving pancreaticoduodenectomy (PPPD) for a small nodular lesion in the main duct of the pancreatic head and was diagnosed with main-duct IPMN low-grade dysplasia and associated fibrosing CP. Nine and a half years later, a 59-year-old man lost 7 kg over 3 months and was diagnosed with new-onset diabetes mellitus. DIAGNOSIS The patient was diagnosed with metachronous, well-differentiated PDAC with concomitant CP. INTERVENTIONS The patient underwent radical antegrade modular pancreatosplenectomy (RAMPS) for a small nodular mass in the remnant pancreas. OUTCOMES The patient was healthy for 44 months without evidence of tumor recurrence during clinical follow-up examinations including laboratory findings, tumor marker, and imaging studies. LESSONS Early diagnosis of metachronous pancreatic neoplasia in a patient with chronic pancreatitis could be made by correlating newly developed clinical symptoms and signs with careful radiological examinations.
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Chi Z, Dhall D, Mertens R. The Use of Intraoperative Frozen Sections in Guiding the Extent of Pancreatic Resections for Intraductal Papillary Mucinous Neoplasms: A Single Institution Experience and Review of the Literature. Pancreas 2022; 51:63-74. [PMID: 35195597 DOI: 10.1097/mpa.0000000000001963] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The utility of frozen section evaluation of the pancreatic parenchymal resection margin(s) in the surgical management of intraductal papillary mucinous neoplasm (IPMN) remains controversial. We investigated the frequency of its use in IPMN resections and its impact on achievement of negative final parenchymal margin(s). METHODS Sixty-two IPMN resections (11 with invasive carcinoma) performed over a 12-year period were studied. RESULTS Frozen sections of the parenchymal margin(s) were performed on 44 of the 62 resections (71%), 30 (68%) of which had 10 positive and 22 indefinite margins on frozen section. Additional margin resections were performed in 14 of these 30 cases (47%), boosting the complete resection rate from 14% (2 of 14) on the initial margin(s) to 71% (10 of 14) on the final margin(s) (P = 0.002). Overall, negative final parenchymal margin(s) were achieved more frequently when evaluation of the initial margin(s) by frozen section was performed (35 of 44; 80%) than when it was not (11 of 18; 61%) (P = 0.13). CONCLUSIONS In the intraoperative management of IPMN, frozen sections are highly reliable for margin evaluation and are useful for guiding the extent of pancreatic resection.
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Affiliation(s)
- Zhikai Chi
- From the Department of Pathology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Deepti Dhall
- Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL
| | - Richard Mertens
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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Salvia R, Burelli A, Perri G, Marchegiani G. State-of-the-art surgical treatment of IPMNs. Langenbecks Arch Surg 2021; 406:2633-2642. [PMID: 34738168 PMCID: PMC8803623 DOI: 10.1007/s00423-021-02349-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/05/2021] [Indexed: 12/28/2022]
Abstract
Background A “pandemic” of incidentally discovered pancreatic cyst neoplasms (PCNs) is ongoing. Among PCNs, intraductal papillary mucinous cystic neoplasms (IPMNs) are the most common and with their complex biology could represent a precursor lesion of pancreatic cancer. Although multiple guidelines exist to guide their treatment, there are still many “gray areas” on indications for surgery for IPMNs. Methods The current indications for surgery of IPMNs were reappraised, considering potential discrepancies between available evidence and guidelines policies. The practice at a high-volume center for the diagnosis and treatment of PCN was presented and discussed. Results Most IPMNs do not and will never require surgery, as they won’t progress to malignancy. The current literature is solid in identifying high-grade dysplasia (HGD) as the right and timely target for IPMN resection, but how to precisely assess its presence remains controversial and guidelines lack of accuracy in this regard. Multiple tumorigenic pathways of progression of IPMNs exist, and their knowledge will likely lead to more accurate tests for malignancy prediction in the future. Conclusions The surgical management of IPMNs still is a matter of debate. Indication for resection should be considered only in highly selected cases with the ideal target of HGD. Clinicians should critically interpret the guidelines’ indications, refer to a multidisciplinary team discussion, and always consider the outcome of an adequate counselling with the patient.
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Affiliation(s)
- Roberto Salvia
- Department of General and Pancreatic Surgery, Verona University Hospital, Piazzale Scuro 10, 37134, Verona, Italy
| | - Anna Burelli
- Department of General and Pancreatic Surgery, Verona University Hospital, Piazzale Scuro 10, 37134, Verona, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Piazzale Scuro 10, 37134, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, Verona University Hospital, Piazzale Scuro 10, 37134, Verona, Italy.
- Department of Surgery, Dentistry, Paediatrics and Gynaecology, Verona University Hospital (Policlinico G.B. Rossi), Piazzale Scuro 10, 37134, Verona, Italy.
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Li J, Wei T, Zhang J, Liang T. Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Review of Their Genetic Characteristics and Mouse Models. Cancers (Basel) 2021; 13:cancers13215296. [PMID: 34771461 PMCID: PMC8582516 DOI: 10.3390/cancers13215296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/09/2021] [Accepted: 10/19/2021] [Indexed: 12/28/2022] Open
Abstract
Simple Summary Pancreatic cancer is one of the deadliest cancers with the lowest survival rate. Little progress has been achieved in prolonging the survival for patients with pancreatic adenocarcinoma. Hence, special attention should be paid to pre-cancerous lesions, for instance, an intraductal papillary mucinous neoplasm (IPMN). Here, we reviewed its genetic characteristics and the mouse models involving mutations in specific pathways, and updated our current perception of how this lesion develops into a precursor of invasive cancer. Abstract The intraductal papillary mucinous neoplasm (IPMN) is attracting research attention because of its increasing incidence and proven potential to progress into invasive pancreatic ductal adenocarcinoma (PDAC). In this review, we summarized the key signaling pathways or protein complexes (GPCR, TGF, SWI/SNF, WNT, and PI3K) that appear to be involved in IPMN pathogenesis. In addition, we collected information regarding all the genetic mouse models that mimic the human IPMN phenotype with specific immunohistochemistry techniques. The mouse models enable us to gain insight into the complex mechanism of the origin of IPMN, revealing that it can be developed from both acinar cells and duct cells according to different models. Furthermore, recent genomic studies describe the potential mechanism by which heterogeneous IPMN gives rise to malignant carcinoma through sequential, branch-off, or de novo approaches. The most intractable problem is that the risk of malignancy persists to some extent even if the primary IPMN is excised with a perfect margin, calling for the re-evaluation and improvement of diagnostic, pre-emptive, and therapeutic measures.
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Affiliation(s)
- Jin Li
- Department of Hepatobiliary and Pancreatic Surgery, School of Medicine, The First Affiliated Hospital of Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China; (J.L.); (T.W.); (J.Z.)
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou 310000, China
- Innovation Center for the Study of Pancreatic Diseases, Hangzhou 310000, China
- Zhejiang Provincial Clinical Research Center for the Study of Hepatobiliary & Pancreatic Diseases, Hangzhou 310000, China
- Cancer Center, Zhejiang University, Hangzhou 310058, China
| | - Tao Wei
- Department of Hepatobiliary and Pancreatic Surgery, School of Medicine, The First Affiliated Hospital of Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China; (J.L.); (T.W.); (J.Z.)
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou 310000, China
- Innovation Center for the Study of Pancreatic Diseases, Hangzhou 310000, China
- Zhejiang Provincial Clinical Research Center for the Study of Hepatobiliary & Pancreatic Diseases, Hangzhou 310000, China
- Cancer Center, Zhejiang University, Hangzhou 310058, China
| | - Jian Zhang
- Department of Hepatobiliary and Pancreatic Surgery, School of Medicine, The First Affiliated Hospital of Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China; (J.L.); (T.W.); (J.Z.)
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou 310000, China
- Innovation Center for the Study of Pancreatic Diseases, Hangzhou 310000, China
- Zhejiang Provincial Clinical Research Center for the Study of Hepatobiliary & Pancreatic Diseases, Hangzhou 310000, China
- Cancer Center, Zhejiang University, Hangzhou 310058, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, School of Medicine, The First Affiliated Hospital of Zhejiang University, 79 Qingchun Road, Hangzhou 310003, China; (J.L.); (T.W.); (J.Z.)
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou 310000, China
- Innovation Center for the Study of Pancreatic Diseases, Hangzhou 310000, China
- Zhejiang Provincial Clinical Research Center for the Study of Hepatobiliary & Pancreatic Diseases, Hangzhou 310000, China
- Cancer Center, Zhejiang University, Hangzhou 310058, China
- Correspondence: ; Tel./Fax: +86-571-87236688
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Abstract
The latest WHO classification of tumors of the digestive system (2019) has introduced new concepts for the stratification of intraductal neoplasms of the pancreas, mostly based on molecular genetics and malignant potential. Among them, pancreatic intraepithelial neoplasias (PanINs) and intraductal papillary mucinous neoplasms (IPMN) are both precursors of pancreatic ductal adenocarcinoma, whereas intraductal oncocytic papillary neoplasms (IOPN) and intraductal tubulopapillary neoplasms (ITPN) are usually associated with less aggressive subtypes of pancreatic cancer and therefore have a much better prognosis. Hence, it is of utmost importance to correctly classify these lesions and to distinguish them from each other as well as from other nonductal types of neoplasms, which can rarely display an intraductal growth, such as neuroendocrine tumors and acinar cell carcinomas. PanIN are microscopic lesions with limited clinical significance. In contrast, all other intraductal neoplasms can be identified as cystic processes and/or solid tumors by means of imaging, thereby setting an indication for a potential surgical resection. This review presents diagnostically relevant aspects of intraductal neoplasms of the pancreas, which are instrumental for the discussion within interdisciplinary tumor boards (resection vs. watch-and-wait strategies) as well as to determine the extent of resection intraoperatively.
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Intraductal Papillary Mucinous Carcinoma Versus Conventional Pancreatic Ductal Adenocarcinoma: A Comprehensive Review of Clinical-Pathological Features, Outcomes, and Molecular Insights. Int J Mol Sci 2021; 22:ijms22136756. [PMID: 34201897 PMCID: PMC8268881 DOI: 10.3390/ijms22136756] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 06/18/2021] [Accepted: 06/20/2021] [Indexed: 12/18/2022] Open
Abstract
Intraductal papillary mucinous neoplasms (IPMN) are common and one of the main precursor lesions of pancreatic ductal adenocarcinoma (PDAC). PDAC derived from an IPMN is called intraductal papillary mucinous carcinoma (IPMC) and defines a subgroup of patients with ill-defined specificities. As compared to conventional PDAC, IPMCs have been associated to clinical particularities and favorable pathological features, as well as debated outcomes. However, IPMNs and IPMCs include distinct subtypes of precursor (gastric, pancreato-biliary, intestinal) and invasive (tubular, colloid) lesions, also associated to specific characteristics. Notably, consistent data have shown intestinal IPMNs and associated colloid carcinomas, defining the “intestinal pathway”, to be associated with less aggressive features. Genomic specificities have also been uncovered, such as mutations of the GNAS gene, and recent data provide more insights into the mechanisms involved in IPMCs carcinogenesis. This review synthetizes available data on clinical-pathological features and outcomes associated with IPMCs and their subtypes. We also describe known genomic hallmarks of these lesions and summarize the latest data about molecular processes involved in IPMNs initiation and progression to IPMCs. Finally, potential implications for clinical practice and future research strategies are discussed.
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Abe K, Kitago M, Masugi Y, Iwasaki E, Yagi H, Abe Y, Hasegawa Y, Fukuhara S, Hori S, Tanaka M, Nakano Y, Yokose T, Shimane G, Sakamoto M, Kitagawa Y. Indication for resection and possibility of observation for intraductal papillary mucinous neoplasm with high-risk stigmata. Pancreatology 2021; 21:755-762. [PMID: 33632666 DOI: 10.1016/j.pan.2021.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/22/2021] [Accepted: 02/12/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND/OBJECTIVES According to the revised international intraductal papillary mucinous neoplasm (IPMN) guidelines (2017), the indication for surgery is based on risk classification. However, some IPMNs with high-risk stigmata (HRS) can be observed for long periods without resection. Hence, we need to reconsider the risk stratification, and this study aimed to propose a novel risk stratification for HRS-IPMNs. METHODS We enrolled 328 patients diagnosed with IPMN using endoscopic ultrasound between 2012 and 2019. We compared clinicopathological features between HRS and worrisome features (WF) and evaluated outcomes of HRS-IPMN. RESULTS Fifty-three patients (HRS 38, WF 15) underwent resection at initial diagnosis and 275 patients were observed. Following observation for 30 months, 22 patients (17 HRS, 5 WF) underwent resection. Analysis of resected IPMNs (n = 75) revealed that HRS had dominantly pancreatobiliary mucin subtype. Pancreatobiliary-type IPMN had larger nodule sizes and lymphatic invasion and high recurrence with poor prognosis. Seventy-four patients were diagnosed with HRS, 55 underwent resection, and 19 continue to be observed. The resected group had larger nodule sizes (median 8 mm vs. 5 mm; P = 0.060), whereas the observed group had more main pancreatic duct (MPD) dilation (median 10 mm vs. 5 mm; P = 0.005). In the resected HRS group, only patients with MPD dilation ≥10 mm (n = 10) had no recurrence but had a favorable prognosis compared with those nodule size ≥5 mm (n = 45). CONCLUSIONS Large nodule size may be associated with pancreatobiliary subtype and poor prognosis; however, patients with MPD dilation ≥10 mm with nodule size <5 mm did not require resection.
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Affiliation(s)
- Kodai Abe
- Department of Surgery, Keio University School of Medicine, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Japan.
| | - Yohei Masugi
- Department of Pathology, Keio University School of Medicine, Japan
| | - Eisuke Iwasaki
- Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Hiroshi Yagi
- Department of Surgery, Keio University School of Medicine, Japan
| | - Yuta Abe
- Department of Surgery, Keio University School of Medicine, Japan
| | - Yasushi Hasegawa
- Department of Surgery, Keio University School of Medicine, Japan
| | - Seiichiro Fukuhara
- Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Shutaro Hori
- Department of Surgery, Keio University School of Medicine, Japan
| | - Masayuki Tanaka
- Department of Surgery, Keio University School of Medicine, Japan
| | - Yutaka Nakano
- Department of Surgery, Keio University School of Medicine, Japan
| | - Takahiro Yokose
- Department of Surgery, Keio University School of Medicine, Japan
| | - Gaku Shimane
- Department of Surgery, Keio University School of Medicine, Japan
| | - Michiie Sakamoto
- Department of Pathology, Keio University School of Medicine, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Japan
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Sun LQ, Peng LS, Guo JF, Jiang F, Cui F, Huang HJ, Jin ZD. Validation of serum tumor biomarkers in predicting advanced cystic mucinous neoplasm of the pancreas. World J Gastroenterol 2021; 27:501-512. [PMID: 33642824 PMCID: PMC7896439 DOI: 10.3748/wjg.v27.i6.501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 12/30/2020] [Accepted: 01/12/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Early detection of advanced cystic mucinous neoplasms [(A-cMNs), defined as high-grade dysplasia or malignancy] of the pancreas is of great significance. As a simple and feasible detection method, serum tumor markers (STMs) may be used to predict advanced intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs). However, there are few studies on the usefulness of STMs other than carbohydrate antigen (CA) 19-9 for early detection of A-cMNs.
AIM To study the ability of five STMs-CA19-9, carcinoembryonic antigen (CEA), CA125, CA724, and CA242 to predict A-cMNs and distinguish IPMNs and MCNs.
METHODS We mainly measured the levels of each STM in patients pathologically diagnosed with cMNs. The mean levels of STMs and the number of A-cMN subjects with a higher STM level than the cutoff were compared respectively to identify the ability of STMs to predict A-cMNs and distinguish MCNs from IPMNs. A receiver operating characteristic curve with the area under curve (AUC) was also created to identify the performance of the five STMs.
RESULTS A total of 187 patients with cMNs were identified and 72 of them showed A-cMNs. We found that CA19-9 exhibited the highest sensitivity (SE) (54.2%) and accuracy (76.5%) and a moderate ability (AUC = 0.766) to predict A-cMNs. In predicting high-grade dysplasia IPMNs, the SE of CA19-9 decreased to 38.5%. The ability of CEA, CA125, and CA724 to predict A-cMNs was low (AUC = 0.651, 0.583, and 0.618, respectively). The predictive ability of CA242 was not identified. The combination of STMs improved the SE to 62.5%. CA125 may be specific to the diagnosis of advanced MCNs.
CONCLUSION CA19-9 has a moderate ability, and CEA, CA125, and CA724 have a low ability to predict A-cMNs. The combination of STM testing could improve SE in predicting A-cMNs.
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Affiliation(s)
- Li-Qi Sun
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Li-Si Peng
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Jie-Fang Guo
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Fei Jiang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Fang Cui
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Hao-Jie Huang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Zhen-Dong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
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Min JH, Kim YK, Kim H, Cha DL, Ahn S. Prognosis of resected intraductal papillary mucinous neoplasm of the pancreas: using revised 2017 international consensus guidelines. Abdom Radiol (NY) 2020; 45:4290-4301. [PMID: 32583137 DOI: 10.1007/s00261-020-02627-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/10/2020] [Accepted: 06/13/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Although there has been considerable effort to define pre-operative features to predict the malignant potential of intraductal papillary mucinous neoplasms (IPMNs), the prognostic value of pre-operative clinical and MRI features has not been assessed. The aim of this study was to determine pre-operative clinical and MRI features that are predictive of disease-specific death or recurrence in patients undergoing pancreatic resection for IPMNs. METHODS We performed a retrospective analysis of 167 patients (mean age, 65 years; 114 men and 53 women) who underwent pre-operative MRI and surgical resection of IPMN of pancreas between 2009 and 2019. We evaluated disease-specific survival (DSS) and recurrence-free survival (RFS). Prognostic factor analysis was performed using clinical and MRI features according to the 2017 international consensus guidelines. RESULTS Of 167 patients, 86 (51.5%) had benign IPMNs and 81 (48.5%) had malignant IPMNs (48 [28.7%] invasive carcinoma and 33 [19.8%] high grade). On multivariable analysis, mural nodule size (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.04-1.18 and HR 1.07; 95% CI 1.03-1.12) and obstructive jaundice (HR 5.01; 95% CI 1.44-17.46 and HR 5.60; 95% CI 2.42-12.99) were the significant variables that were associated with DSS and RFS. The presence of lymphadenopathy (HR 50.7; 95% CI 4.0-643.0; P = 0.002) was the significant factor for DSS. IPMNs with mural nodule showed a significantly lower 5-year DSS (83.7% vs. 100%, P value < 0.01) and RFS (73.1% vs. 95.0%, P value < 0.01) compared with IPMNs with no mural nodule. CONCLUSIONS Mural nodule size on MRI and obstructive jaundice were prognostic markers in the pre-operative evaluation of patients with IPMN of pancreas.
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The Impact of Clinical and Pathological Features on Intraductal Papillary Mucinous Neoplasm Recurrence After Surgical Resection: Long-Term Follow-Up Analysis. Ann Surg 2020; 275:1165-1174. [PMID: 33214420 PMCID: PMC9516436 DOI: 10.1097/sla.0000000000004427] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study aimed to identify risk factors for recurrence after pancreatic resection for intraductal papillary mucinous neoplasm (IPMN). SUMMARY BACKGROUND DATA Long-term follow-up data on recurrence after surgical resection for IPMN are currently lacking. Previous studies have presented mixed results on the role of margin status in risk of recurrence after surgical resection. METHODS A total of 126 patients that underwent resection for noninvasive IPMN were followed for a median of 9.5 years. Dedicated pathological and radiological reviews were performed to correlate clinical and pathological features (including detailed pathological features of the parenchymal margin) with recurrence after surgical resection. In addition, in a subset of 32 patients with positive margins, we determined the relationship between the margin and original IPMN using driver gene mutations identified by next-generation sequencing. RESULTS Family history of pancreatic cancer and high-grade IPMN was identified as risk factors for recurrence in both uni- and multivariate analysis (adjusted hazard ratio 3.05 and 1.88, respectively). Although positive margin was not significantly associated with recurrence in our cohort, the size and grade of the dysplastic focus at the margin were significantly correlated with recurrence in margin-positive patients. Genetic analyses showed that the neoplastic epithelium at the margin was independent from the original IPMN in at least 9 of 32 cases (28%). The majority of recurrences (74%) occurred after 3 years, and a significant minority (32%) occurred after 5 years. CONCLUSION Sustained postoperative surveillance for all patients is indicated, particularly those with risk factors such has family history and high-grade dysplasia.
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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. Ann Surg 2020; 276:e231-e238. [PMID: 32941274 DOI: 10.1097/sla.0000000000004478] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Tsumura A, Hirono S, Kawai M, Okada KI, Miyazawa M, Kitahata Y, Kobayashi R, Hayami S, Ueno M, Yanagisawa A, Yamaue H. Surgical indication for intraductal papillary mucinous neoplasm without mural nodule ≥5 mm. Surgery 2020; 169:388-395. [PMID: 32859391 DOI: 10.1016/j.surg.2020.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/13/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In intraductal papillary mucinous neoplasm, a mural nodule ≥5 mm is an important predictor of malignancy. Surgical indication is less clear in cases of intraductal papillary mucinous neoplasm without mural nodule ≥5 mm. This is a retrospective study evaluating predictors of high-grade dysplasia or invasive intraductal papillary mucinous carcinoma for intraductal papillary mucinous neoplasm without mural nodule ≥5 mm. METHODS Among consecutive patients who underwent surgery for intraductal papillary mucinous neoplasm between 1999 and 2018, 174 had intraductal papillary mucinous neoplasm with mural nodule ≥5 mm (mural nodule[+] ≥5 mm group). The remaining 155 patients had intraductal papillary mucinous neoplasm but did not have mural nodule ≥5 mm: 24 patients with mural nodule <5 mm (mural nodule[+] <5 mm group) and 131 patients without mural nodule (mural nodule[-] group). We investigated predictors of high-grade dysplasia or invasive intraductal papillary mucinous neoplasm in cases of intraductal papillary mucinous neoplasm without mural nodule ≥5 mm. RESULTS The frequency of high-grade dysplasia invasive intraductal papillary mucinous neoplasm was significantly higher in the mural nodule(+) ≥5 mm group (87.4%) than in the mural nodule(+) <5 mm group (37.5%, P < .001) and mural nodule(-) group (45.0%, P < .001). However, frequency was not significantly different between mural nodule(+) <5 mm and mural nodule(-) groups (P = .494). Multivariate analysis showed three independent predictors of high-grade dysplasia invasive intraductal papillary mucinous carcinoma in intraductal papillary mucinous neoplasm without mural nodule ≥5 mm: branch cyst ≥40 mm (P = .038, odds ratio 3.704; 95% confidence interval, 1.075-12.821), positive cytology of pancreatic juice (P = .039, odds ratio 16.792; 95% confidence interval, 1.152-244.744), and carcinoembryonic antigen in pancreatic juice ≥30 mg/mL (P < .001, odds ratio 14.925; 95% confidence interval, 4.525-50.0). CONCLUSION For cases of intraductal papillary mucinous neoplasm without mural nodule ≥5 mm, large cysts, positive cytology of the pancreatic juice, and high levels of carcinoembryonic antigen in pancreatic juice may be useful to determine surgical indication, although further studies are needed to confirm these results.
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Affiliation(s)
- Ayako Tsumura
- Second Department of Surgery, School of Medicine, Wakayama Medical University
| | - Seiko Hirono
- Second Department of Surgery, School of Medicine, Wakayama Medical University.
| | - Manabu Kawai
- Second Department of Surgery, School of Medicine, Wakayama Medical University
| | - Ken-Ichi Okada
- Second Department of Surgery, School of Medicine, Wakayama Medical University
| | - Motoki Miyazawa
- Second Department of Surgery, School of Medicine, Wakayama Medical University
| | - Yuji Kitahata
- Second Department of Surgery, School of Medicine, Wakayama Medical University
| | - Ryohei Kobayashi
- Second Department of Surgery, School of Medicine, Wakayama Medical University
| | - Shinya Hayami
- Second Department of Surgery, School of Medicine, Wakayama Medical University
| | - Masaki Ueno
- Second Department of Surgery, School of Medicine, Wakayama Medical University
| | - Akio Yanagisawa
- Department of Surgical Pathology, Kyoto Prefectural University of Medicine
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University
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Takigawa Y, Kitago M, Matsui J. Independent predictors of secondary invasive pancreatic remnant tumors after initial resection of an intraductal papillary mucinous neoplasm: a nationwide large-scale survey in Japan. Surg Today 2020; 50:1672-1680. [PMID: 32661567 PMCID: PMC7677271 DOI: 10.1007/s00595-020-02074-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 06/01/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE There is no standardized surveillance protocol after intraductal papillary mucinous neoplasm (IPMN) resection. We report the findings of a large-scale survey in Japan, investigating the independent predictors of secondary invasive tumors by analyzing the epidemiology of secondary tumors of the remnant pancreas after initial IPMN resection. METHODS An institutional questionnaire about the remnant pancreas after pancreas resection was distributed at the 41st Annual Meeting of the Japanese Society of Pancreatic Surgery in Tokyo. We retrospectively analyzed the patient data including pathological diagnosis, postoperative outcomes, and evaluation methods. RESULTS Redo pancreatectomy was performed for secondary disease in 213 (1.4%) of a total 15,777 patients. Eighty-eight of these 213 patients had undergone initial resection of IPMN. The types of secondary tumors after IPMN resection significantly depended on those of the primary tumors. Through short-interval and long-term follow-up, most of the secondary tumors were detected within 1-4 years. Logistic regression analysis revealed that the initial pathological diagnosis of invasive IPMN was an independent predictor of secondary invasive tumors in the remnant pancreas. CONCLUSION Primary invasive IPMN proved to be a significant predictor of secondary invasive IPMN. Both short-interval and long-term follow-up may help to determine the prognosis of patients after IPMN resection.
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Affiliation(s)
- Yutaka Takigawa
- Department of Surgery, Tokyo Dental College Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba, 272-8513, Japan.
| | - Minoru Kitago
- Department of Surgery, School of Medicine, Keio University, Shinjuku, Tokyo, Japan
| | - Junichi Matsui
- Department of Surgery, Tokyo Dental College Ichikawa General Hospital, 5-11-13, Sugano, Ichikawa, Chiba, 272-8513, Japan
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Pollini T, Andrianello S, Caravati A, Perri G, Malleo G, Paiella S, Marchegiani G, Salvia R. The management of intraductal papillary mucinous neoplasms of the pancreas. MINERVA CHIR 2020; 74:414-421. [PMID: 31795628 DOI: 10.23736/s0026-4733.19.08145-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are one of the most common preneoplastic entities among pancreatic cystic neoplasms (PCN). Their incidence is increasing due to an extensive use of cross-sectional imaging, but management still remains controversial. Among IPMNs, the main duct (MD-IPMN) and mixed (MT-IPMN) types harbor a high risk of malignant degeneration requiring resection in most of cases. The branch duct type (BD-IPMN), on the other side, can be safely surveilled as surgical resection is limited to selected cases deemed at high risk of malignant progression according to specific clinical and radiological features. An accurate diagnosis and a correct assessment of malignant potential are often hard to achieve, and clinical management still relies on the experience of the gastroenterologist/surgeon that is called to choose between a major pancreatic resection burdened by high morbidity and mortality rates and a life-long surveillance. The purpose of this report is to summarize the available evidence supporting the current practice for the management of IPMN and to offer a useful practical guide from first observation to postoperative follow-up.
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Affiliation(s)
- Tommaso Pollini
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy -
| | - Stefano Andrianello
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Andrea Caravati
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Ciprani D, Morales-Oyarvide V, Qadan M, Hank T, Weniger M, Harrison JM, Rodrigues C, Horick NK, Mino-Kenudson M, Ferrone CR, Warshaw AL, Lillemoe KD, Fernández-Del Castillo C. An elevated CA 19-9 is associated with invasive cancer and worse survival in IPMN. Pancreatology 2020; 20:729-735. [PMID: 32332003 DOI: 10.1016/j.pan.2020.04.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/27/2020] [Accepted: 04/06/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Current guidelines for IPMN include an elevated serum carbohydrate antigen (CA) 19-9 among the worrisome features. However, the correlation of CA 19-9 with histological malignant features and survival is unclear. Serum CEA is also currently used for preoperative management of IPMN, although its measurement is not evidence-based. Accordingly, we aimed to assess the role of these tumor markers as predictors of malignancy in IPMN. METHODS IPMN resected between 1998 and 2018 at Massachusetts General Hospital were analyzed. Clinical, pathological and survival data were collected and compared to preoperative levels of CA 19-9 and CEA. Receiver operating characteristic (ROC) and Cox regression analyses were performed considering cut-offs of 37 U/ml (CA 19-9) and 5 μg/l (CEA). RESULTS Analysis of 594 patients showed that preoperative CA 19-9 levels > 37 U/ml (n = 128) were associated with an increased likelihood of invasive carcinoma when compared to normal levels (45.3% vs. 18.0%, P < 0.001), while there was no difference with respect to high-grade dysplasia (32.9% vs 31.9%, P = 0.88). The proportion of concurrent pancreatic cancer was higher in patients with CA 19-9 > 37 U/ml (17.2% vs 4.9%, P < 0.001). An elevated CA 19-9 was also associated with worse overall and disease-free survival (HR = 1.943, P = 0.007 and HR = 2.484, P < 0.001 respectively). CEA levels did not correlate with malignancy. CONCLUSION In patients with IPMN, serum CA19-9 > 37 U/ml is associated with invasive IPMN and concurrent pancreatic cancer as well as worse survival, but not with high-grade dysplasia. Serum CEA appears to have minimal utility in the management of these patients.
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Affiliation(s)
- D Ciprani
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - V Morales-Oyarvide
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M Qadan
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - T Hank
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M Weniger
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - J M Harrison
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - C Rodrigues
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - N K Horick
- Biostatistics Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - C R Ferrone
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - A L Warshaw
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - K D Lillemoe
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - C Fernández-Del Castillo
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Metachronous intraductal papillary mucinous neoplasms disseminate via the pancreatic duct following resection. Mod Pathol 2020; 33:971-980. [PMID: 31723240 DOI: 10.1038/s41379-019-0405-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/11/2019] [Accepted: 10/12/2019] [Indexed: 02/07/2023]
Abstract
Metachronous development of intraductal papillary mucinous neoplasms in the remnant pancreas following resection is a significant clinical burden. Our aim was to characterize the clinicopathological and molecular features of the patients with metachronous tumor development to identify predictive factors and the possible route(s) of dissemination. Seventy-four patients who underwent resection of intraductal papillary mucinous neoplasms with no invasive compartment or associated carcinoma were retrospectively analyzed. In patients with metachronous tumor development, targeted sequencing of 18 genes associated with pancreatic tumorigenesis and immunohistochemical detection of four proteins (p53, SMAD4, p16, and β-catenin) were performed on both primary and metachronous tumors. The distributions of microscopic neoplastic lesions were examined at surgical margins and in apparently normal tissue apart from the primary tumor. During the median follow-up period of 52 months, 9 patients (12%) developed metachronous tumors in the remnant pancreas. Primary tumors located in the body/tail of the pancreas (odds ratio, 15; 95% confidence interval, 1.6-131) and of the pancreatobiliary type (odds ratio, 6.1; 95% confidence interval, 1.1-35.7) were identified as significant risk factors for subsequent metachronous tumor development. Eight of the nine patients shared molecular aberrations between their primary and metachronous tumors, suggesting migrations from the primary tumor to the pancreatic duct as the cause of metachronous tumor development. Our data suggest that these post-resection metachronous tumors develop by skip dissemination of the primary tumor, potentially via the pancreatic duct. The development of strategies to better predict and prevent this form of tumor progression is necessary.
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Wu JY, Wang YF, Ma H, Li SS, Miao HL. Nomograms predicting long-term survival in patients with invasive intraductal papillary mucinous neoplasms of the pancreas: A population-based study. World J Gastroenterol 2020; 26:535-549. [PMID: 32089629 PMCID: PMC7015718 DOI: 10.3748/wjg.v26.i5.535] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/06/2020] [Accepted: 01/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There are few effective tools to predict survival in patients with invasive intraductal papillary mucinous neoplasms of the pancreas.
AIM To develop comprehensive nomograms to individually estimate the survival outcome of patients with invasive intraductal papillary mucinous neoplasms of the pancreas.
METHODS Data of 1219 patients with invasive intraductal papillary mucinous neoplasms after resection were extracted from the Surveillance, Epidemiology, and End Results database, and randomly divided into the training (n = 853) and the validation (n = 366) cohorts. Based on the Cox regression model, nomograms were constructed to predict overall survival and cancer-specific survival for an individual patient. The performance of the nomograms was measured according to discrimination, calibration, and clinical utility. Moreover, we compared the predictive accuracy of the nomograms with that of the traditional staging system.
RESULTS In the training cohort, age, marital status, histological type, T stage, N stage, M stage, and chemotherapy were selected to construct nomograms. Compared with the American Joint Committee on Cancer 7th staging system, the nomograms were generally more discriminative. The nomograms passed the calibration steps by showing high consistency between actual probability and nomogram prediction. Categorial net classification improvements and integrated discrimination improvements suggested that the predictive accuracy of the nomograms exceeded that of the American Joint Committee on Cancer staging system. With respect to decision curve analyses, the nomograms exhibited more preferable net benefit gains than the staging system across a wide range of threshold probabilities.
CONCLUSION The nomograms show improved predictive accuracy, discrimination capability, and clinical utility, which can be used as reliable tools for risk classification and treatment recommendations.
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Affiliation(s)
- Jia-Yuan Wu
- Department of Clinical Research, the Affiliated Hospital of Guangdong Medical University, Zhanjiang 524001, Guangdong Province, China
| | - Yu-Feng Wang
- School of Public Health, Guangdong Medical University, Zhanjiang 524023, Guangdong Province, China
| | - Huan Ma
- School of Public Health, Guangdong Medical University, Zhanjiang 524023, Guangdong Province, China
| | - Sha-Sha Li
- School of Public Health, Guangdong Medical University, Zhanjiang 524023, Guangdong Province, China
| | - Hui-Lai Miao
- Department of Clinical Research, the Affiliated Hospital of Guangdong Medical University, Zhanjiang 524001, Guangdong Province, China
- Department of Hepatobiliary Surgery, the Affiliated Hospital of Guangdong Medical University, Zhanjiang 524001, Guangdong Province, China
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Guangdong Medical University, Zhanjiang 524003, Guangdong Province, China
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Caravati A, Andrianello S, Pollini T, Biancotto M, Balduzzi A, Malleo G, Salvia R, Marchegiani G. Branch Duct Intraductal Papillary Mucinous Neoplasms: Recommendations for Follow-Up and Surgery. Scand J Surg 2020; 109:34-41. [PMID: 32009571 DOI: 10.1177/1457496919900414] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Pancreatic cysts are increasingly diagnosed, mainly during abdominal imaging performed for other reasons. Between pancreatic cystic neoplasm, intraductal papillary mucinous neoplasms are the most common pre-malignant entities. Intraductal papillary mucinous neoplasms involving side branches overall harbor a low risk of malignancy, and in the recent past, a progressively more conservative approach has been consolidated. Purpose of this report is to summarize the evidence supporting the current practice for the management of branch duct intraductal papillary mucinous neoplasm and to offer a useful practical guide from first observation to post-operative follow-up. MATERIALS AND METHODS Review of the most important scientific literature on intraductal papillary mucinous neoplasms was made. In this review article, we also report the experience of a high volume center in managing Pancreatic cystic neoplasms. RESULTS The correct management during surveillance still is a matter of debate, since many guidelines have been published suggesting different clinical approaches. Recently, follow-up discontinuation has also been proposed in selected cases. CONCLUSION Despite significant improvements made by the increase of evidence, selecting surgical candidates because of an increased risk of malignant progression remains an unsolved issue and a hot topic for pancreatologists.
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Affiliation(s)
- A Caravati
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - S Andrianello
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - T Pollini
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - M Biancotto
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - A Balduzzi
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - G Malleo
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - R Salvia
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - G Marchegiani
- General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Recurrence patterns after surgical resection of intraductal papillary mucinous neoplasm (IPMN) of the pancreas; a multicenter, retrospective study of 1074 IPMN patients by the Japan Pancreas Society. J Gastroenterol 2020; 55:86-99. [PMID: 31463655 DOI: 10.1007/s00535-019-01617-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 08/08/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although there are numerous reports focusing on surgical indication for intraductal papillary mucinous neoplasm (IPMN), the recurrence patterns following surgery are less widely reported. To ascertain optimal treatment and postoperative surveillance for IPMN patients, we analyzed patterns and risk factors for recurrence after surgery for IPMN. METHODS This study is a retrospective, multi-institutional, observational study, including 1074 patients undergoing surgery for IPMN at 11 academic institutions. We analyzed the risk factors for recurrence after classifying postoperative recurrences into metachronous high-risk lesions (malignant progression of IPMN and/or metachronous pancreatic ductal adenocarcinoma) in the remnant pancreas and extra-pancreatic recurrence. RESULTS Of 1074 patients undergoing surgery for IPMN, 155 patients (14.4%) developed postoperative recurrence. We found that 34.3% of 70 high-risk lesions in the remnant pancreas occurred over 5 years after surgery, and survival of 36 patients undergoing second operation for high-risk lesions was better than that of 34 patients who did not (P = 0.04). We found four independent risk factors for metachronous high-risk lesions in remnant pancreas: symptoms [P = 0.005, hazard ratio (HR) 1.988], location of pancreatic body/tail (P < 0.001, HR 3.876), main duct size ≥ 10 mm (P = 0.021, HR 1.900), and high-grade dysplasia/invasive intraductal papillary mucinous carcinoma (IPMC) (P < 0.001, HR 3.204). Although six patients (0.7%) with low- or high-grade dysplasia IPMN developed extra-pancreatic recurrence, invasive IPMC was the strongest risk factor for extra-pancreatic recurrence (P < 0.001, HR 39.667). CONCLUSION We suggest that life-time continuous surveillance might be necessary for IPMN patients. Second surgery for metachronous high-risk lesions in remnant pancreas should be considered to improve survival.
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Hirono S, Yamaue H. Surgical strategy for intraductal papillary mucinous neoplasms of the pancreas. Surg Today 2020; 50:50-55. [PMID: 31807871 PMCID: PMC6923258 DOI: 10.1007/s00595-019-01931-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 10/08/2019] [Indexed: 12/17/2022]
Abstract
The current treatment strategy for intraductal papillary mucinous neoplasms (IPMNs), based on the international consensus guideline, has been accepted widely. However, reported outcomes after surgical resection for IPMN show that once the tumor progresses to invasive intraductal papillary mucinous carcinoma (IPMC), recurrence is not uncommon. The surgical treatment for IPMN is invasive and sometimes followed by complications. Therefore, the best timing for resection might be at the point when high-grade dysplasia (HGD) is evident. According to previous reports, main duct type IPMN has a high malignant potential and its surgical resection is universally accepted, whereas, the incidence of HGD/invasive IPMC in branch duct and mixed type IPMNs is thought to be lower. In addition to mural nodules and a dilated main pancreatic duct, cytology and measurement of the carcinoembryonic antigen level in the pancreatic juice might be useful to differentiate HGD/invasive IPMC from low-grade dysplasia. The nomogram proposed recently to predict the risk of HGD/invasive IPMC in IPMN patients might help surgeons decide on the best treatment strategy, depending on the patient's age and general condition. Second resection for high-risk lesions in the remnant pancreas might improve the survival of IPMN patients.
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Affiliation(s)
- Seiko Hirono
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan.
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
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Kwon JE, Jang KT, Ryu Y, Kim N, Shin SH, Heo JS, Choi DW, Han IW. Subtype of intraductal papillary mucinous neoplasm of the pancreas is important to the development of metachronous high-risk lesions after pancreatectomy. Ann Hepatobiliary Pancreat Surg 2019; 23:365-371. [PMID: 31825003 PMCID: PMC6893048 DOI: 10.14701/ahbps.2019.23.4.365] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/26/2019] [Indexed: 12/22/2022] Open
Abstract
Backgrounds/Aims Although intraductal papillary mucinous neoplasm (IPMN) has showed a favorable prognosis compared to pancreatic ductal adenocarcinoma, its recurrence patterns have somewhat questionable in detail. After partial pancreatectomy for IPMN, the evaluation for risk of metachronous occurrence of high-risk lesions (HRL) in the residual pancreas is important to establish a postoperative surveillance modality and duration of follow-up. This study aimed to evaluate the factors that may predict the metachronous occurrence of HRL in the remnant pancreas after surgery of the IPMN. Methods From 2005 to 2016, clinicopathologic and surveillance data for 346 consecutive patients who underwent surgical resection for IPMN were reviewed retrospectively. Histologic subtype was classified as gastric, intestinal, pancreato-biliary, or oncocytic type. Results All of IPMN were classified as main duct (n=64, 18.5%), branch duct (n=171, 49.4%), and mixed type (n=111, 32.1%). Forty-eight patients (13.9%) experienced recurrence during follow-up. Among these, 9 patients (2.6%) were identified to metachronous development of HRL in the remnant pancreas. After multivariate analysis, high-grade dysplasia (HGD) or invasive carcinoma (IC) compared to low- or intermediate dysplasia was only independent risk factor for recurrence (HR 3.688, 95% CI 2.124– 12.524, p=0.009). The independent risk factors for metachronous development were HGD/IC (HR 8.414, 95% CI 4.310– 16.426, p=0.001), and intestinal/pancreato-biliary subtype compared to gastric subtype (HR 7.874, 95% CI 3.650– 27.027, p=0.010). Conclusions Patients with high-grade dysplasia or invasive carcinoma, and with intestinal or pancreatobiliary subtype should undergo close, long-term surveillance of the remnant pancreas after initial resection.
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Affiliation(s)
- Ji Eun Kwon
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Kee-Taek Jang
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Youngju Ryu
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Naru Kim
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Sang Hyun Shin
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Jin Seok Heo
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Dong Wook Choi
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - In Woong Han
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea
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van Huijgevoort NCM, Del Chiaro M, Wolfgang CL, van Hooft JE, Besselink MG. Diagnosis and management of pancreatic cystic neoplasms: current evidence and guidelines. Nat Rev Gastroenterol Hepatol 2019; 16:676-689. [PMID: 31527862 DOI: 10.1038/s41575-019-0195-x] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/31/2019] [Indexed: 12/11/2022]
Abstract
Pancreatic cystic neoplasms (PCN) are a heterogeneous group of pancreatic cysts that include intraductal papillary mucinous neoplasms, mucinous cystic neoplasms, serous cystic neoplasms and other rare cystic lesions, all with different biological behaviours and variable risk of progression to malignancy. As more pancreatic cysts are incidentally discovered on routine cross-sectional imaging, optimal surveillance for patients with PCN is becoming an increasingly common clinical problem, highlighting the need to balance cancer prevention with the risk of (surgical) overtreatment. This Review summarizes the latest developments in the diagnosis and management of PCN, including the quality of available evidence. Also discussed are the most important differences between the PCN guidelines from the American Gastroenterological Association, the International Association of Pancreatology and the European Study Group on Cystic Tumours of the Pancreas, including diagnostic and follow-up strategies and indications for surgery. Finally, new developments in the management of patients with PCN are addressed.
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Affiliation(s)
- Nadine C M van Huijgevoort
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marco Del Chiaro
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christopher L Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
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Umemoto K, Tsuchikawa T, Nakamura T, Okamura K, Noji T, Asano T, Nakanishi Y, Tanaka K, Hirano S. Postoperative nutritional benefits of proximal parenchymal pancreatectomy for low-grade malignant lesions in the pancreatic head. HPB (Oxford) 2019; 21:1491-1496. [PMID: 30962138 DOI: 10.1016/j.hpb.2019.03.359] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 03/11/2019] [Accepted: 03/13/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Outcomes of proximal parenchymal pancreatectomy (PPP) as compared to pancreatoduodenectomy (PD) have not been reported. The aim of this study was to describe the short- and long-term outcomes of patients with low-grade pancreatic head lesions who underwent PPP or PD. METHODS Patients who underwent PPP or PD for low-grade lesions between 2009 and 2017 were included. Operative factors including postoperative complications and nutritional indicators during the first-year postoperatively were compared. RESULTS A total of 13 and 14 patients underwent PPP and PD respectively. The PPP group demonstrated significantly less intraoperative blood loss and shorter postoperative hospital stay than the PD group. No significant differences were noted in the incidence of postoperative complications between the two groups. Nutritional indices were significantly better in the PPP group at 3 months post-surgery, but these nutritional indices were not significantly different at 6 months and 1-year. None of 12 patients who underwent PPP and did not require biliary resection developed postoperative cholangitis. None of the 12 PPP patients without preoperative diabetes developed impaired glucose tolerance after surgery. DISCUSSION The complication rate of PPP is equivalent to that of PD. PPP demonstrated better short-term nutritional status than PD. Moreover, preservation of the total duodenum and bile duct may reduce the risk of developing postoperative diabetes and cholangitis.
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Affiliation(s)
- Kazufumi Umemoto
- Department of Gastroenterological Surgery II, Division of Surgery, Faculty of Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Division of Surgery, Faculty of Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Division of Surgery, Faculty of Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II, Division of Surgery, Faculty of Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery II, Division of Surgery, Faculty of Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Toshimichi Asano
- Department of Gastroenterological Surgery II, Division of Surgery, Faculty of Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery II, Division of Surgery, Faculty of Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery II, Division of Surgery, Faculty of Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Division of Surgery, Faculty of Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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Wang YZ, Lu J, Jiang BL, Guo JC. Intraductal oncocytic papillary neoplasm of the pancreas: A systematic review. Pancreatology 2019; 19:858-865. [PMID: 31375434 DOI: 10.1016/j.pan.2019.07.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Intraductal oncocytic papillary neoplasm of the pancreas (IOPN-P) is a rare subtype of intraductal papillary mucinous neoplasm (IPMN). This study was performed to summarize the clinicopathological features and management of IOPN-P. METHODS English-language articles were searched from MEDLINE and EMBASE from the first report of IOPN-P in 1996 until 1 May 2019 following the methodology in the PRISMA guidelines. RESULTS In total, 66 patients from 24 full articles were included in the final data analysis. The patients' average age was 61 years, and the male/female ratio was 1. Most lesions were large (average size, 5.50 cm), located in the pancreatic head, and found either incidentally or by uncharacteristic abdominal symptoms. IOPN-P was usually a cystic and solid lesion with or without mural nodules on radiological examination. A definitive diagnosis was often acquired from fine needle aspiration biopsy or postoperative pathology. All tumors were diagnosed as carcinoma in situ or minimally invasive carcinoma, necessitating surgical resection. The prognosis of IOPN-P was better than that of other IPMN subtypes, even when metastasis occurred. Recurrence after surgical resection of IOPN-P was rare. CONCLUSIONS IOPN-P is rare among IPMN subtypes with unique pathological characteristics. Because of the nontypical symptoms and radiological findings, a definitive preoperative diagnosis usually depends on multimodal examinations. Management and surveillance of IOPN-P after surgical resection should be differentiated from those of other pancreatic benign cystic lesions because of its relative malignancy, but IOPN-P should also be differentiated from other IPMN subtypes and malignant cystic tumors because of its favorable prognosis.
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Affiliation(s)
- Yi-Zhi Wang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, 100730, China
| | - Jun Lu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, 100730, China
| | - Bo-Lun Jiang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, 100730, China
| | - Jun-Chao Guo
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, 100730, China.
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Does Surgical Margin Impact Recurrence in Noninvasive Intraductal Papillary Mucinous Neoplasms?: A Multi-institutional Study. Ann Surg 2019; 268:469-478. [PMID: 30063495 PMCID: PMC10182406 DOI: 10.1097/sla.0000000000002923] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The relevance of margin positivity on recurrence after resection of intraductal papillary mucinous neoplasms (IPMNs) is poorly defined and represents one reason controversy remains regarding optimal surveillance recommendations. METHODS Patients undergoing surgery for noninvasive IPMN at 8 academic medical centers from the Central Pancreas Consortium were analyzed. A positive margin was defined as presence of IPMN or pancreatic intraepithelial neoplasia. RESULTS Five hundred two patients underwent surgery for IPMN; 330 (66%) did not have invasive cancer on final pathology and form the study cohort. Of these, 20% harbored high grade dysplasia. A positive margin was found in 20% of cases and was associated with multifocal disease (P = 0.02). The majority of positive margins were associated with low grade dysplasia. At a median follow-up of 36 months, 34 (10.3%) patients recurred, with 6.7% developing recurrent cystic disease and 3.6% developing invasive cancer. On multivariate analysis, margin positivity was not associated with recurrence of either IPMN or invasive cancer (P > 0.05). No association between margin status and development of recurrence at the margin was found. Only 6% of recurrences developed at the resection margin and median time to recurrence was 22 months. Of note, 18% of recurrences occurred > 5 years following surgery. CONCLUSION Margin positivity after resection for noninvasive IPMNs is primarily due to low grade dysplasia and is not associated with developing recurrence in the remnant pancreas or at the resection margin. Long-term surveillance is required for all patients, as a significant number of recurrences developed over 5 years after the index operation.
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Marchegiani G, Andrianello S, Dal Borgo C, Secchettin E, Melisi D, Malleo G, Bassi C, Salvia R. Adjuvant chemotherapy is associated with improved postoperative survival in specific subtypes of invasive intraductal papillary mucinous neoplasms (IPMN) of the pancreas: it is time for randomized controlled data. HPB (Oxford) 2019; 21:596-603. [PMID: 30366881 DOI: 10.1016/j.hpb.2018.09.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/04/2018] [Accepted: 09/27/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Very little is known about adjuvant chemotherapy for invasive Intraductal Papillary Mucinous Neoplasms (IPMNs) of the pancreas. The aim was to assess whether adjuvant chemotherapy affects survival. METHODS Retrospective evaluation of invasive IPMNs. Patients treated with surgery alone or followed by adjuvant chemotherapy were compared in terms of survival. RESULTS A total of 102 invasive IPMNs were analyzed. Median follow-up was 72 (5-318) months and 18.6% received adjuvant chemotherapy. Overall, recurrence rate was 40.2%, while 5-year overall survival and disease specific survival (DSS) were 65.3% and 69.4%, respectively. N1 disease (HR5.58, CI95% 2.49-12.51, p < 0.01), tubular type (HR2.35, CI95% 1.71-4.82, p = 0.05) and G3 tumors (HR4.54, CI95% 2.12-15.49, <0.01) were predictors of reduced DSS. Overall, there was no difference in the 5-year DSS comparing patients treated with adjuvant chemotherapy to surgery alone (61.8 vs. 69.4%, p = 0.8). Adjuvant chemotherapy significantly improved DSS only in N1 (5-years-DSS 76 vs. 35.8%, p = 0.01) and tubular carcinomas (5-years-DSS 88.9 vs. 53%, p = 0.03). CONCLUSIONS Adjuvant therapy improves survival only in invasive IPMNs with nodal disease or tubular differentiation. Future trials are needed to improve the level of evidence about adjuvant chemotherapy.
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Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Stefano Andrianello
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Chiara Dal Borgo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Erica Secchettin
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Davide Melisi
- Department of Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy.
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Gaujoux S, Parvanescu A, Cesaretti M, Silve C, Bieche I, Rebours V, Lévy P, Sauvanet A, Cros J. GNAS but Not Extended RAS Mutations Spectrum are Associated with a Better Prognosis in Intraductal Pancreatic Mucinous Neoplasms. Ann Surg Oncol 2019; 26:2640-2650. [DOI: 10.1245/s10434-019-07389-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Indexed: 12/28/2022]
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Santoro E, Visca P, Santoro R, Mancini P, Santoro E. Disease-free long survival after stump recurrence and reoperation of pancreatic IPMN with invasive carcinoma. Chirurgia (Bucur) 2019. [DOI: 10.23736/s0394-9508.18.04824-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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50
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Sharib JM, Fonseca AL, Swords DS, Jaradeh K, Bracci PM, Firpo MA, Hatcher S, Scaife CL, Wang H, Kim GE, Mulvihill SJ, Maitra A, Koay EJ, Kirkwood KS. Surgical overtreatment of pancreatic intraductal papillary mucinous neoplasms: Do the 2017 International Consensus Guidelines improve clinical decision making? Surgery 2018; 164:1178-1184. [DOI: 10.1016/j.surg.2018.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/24/2018] [Accepted: 07/10/2018] [Indexed: 12/17/2022]
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