A resected case of recurrent ITPN in the remnant pancreas after pancreatoduodenectomy

Intraductal Tubulopapillary Neoplasm Diagnosed Before Surgery: A Case Report

Intraductal tubulopapillary neoplasm (ITPN) is a rare disease in the pancreas with a better prognosis than pancreatic ductal adenocarcinoma (PDAC) and a different treatment strategy. Therefore, it is important to confirm its diagnosis before the surgery. However, few cases have been diagnosed preoperatively. In this report, we present a case of ITPN that was successfully diagnosed preoperatively. A 70-year-old female patient was incidentally diagnosed with a pancreatic tumor. The patient was asymptomatic, and her blood tests were all within the normal range. A dynamic computed tomography scan showed an indistinct mass with small cysts and a dilated pancreatic duct. The mass was well contrasted in the arterial phase. These findings were not enough to confirm ITPN. Therefore, endoscopic ultrasonography fine needle aspiration biopsy was performed. The specimen had no mucin and the neoplastic cells exhibited a tubulopapillary growth pattern. Moreover, the neoplastic cells were immunohistochemically positive for MUC1, CK7, and CK20, but negative for MUC2, MUC5AC, synaptophysin, and Bcl-10. Consequently, the preoperative diagnosis was confirmed as ITPN. Hence, a subtotal-stomach-preserving pancreaticoduodenectomy was performed, and the patient had a good postoperative course and was discharged after 26 days. Tegafur, gimeracil, and oteracil were administered as postoperative adjuvant chemotherapies for one year. Seventeen months after the surgery, no recurrence has been detected. ITPN and PDAC have different prognoses and treatment strategies. In this report, we experienced a case of ITPN preoperatively diagnosed and successfully treated.

Intraductal tubulopapillary neoplasm (ITPN) of the pancreas: A distinct entity among pancreatic tumors

Aims

Intraductal tubulopapillary neoplasm (ITPN) of the pancreas is a recently recognized pancreatic tumor entity. Here we aimed to determine the most important features with a systematic review coupled with an integrated statistical approach.

Methods and results

PubMed, SCOPUS, and Embase were searched for studies reporting data on pancreatic ITPN. The clinicopathological, immunohistochemical, and molecular data were summarized. Then a comprehensive survival analysis and a comparative analysis of the molecular alterations of ITPN with those of pancreatic ductal adenocarcinoma (PDAC) and intraductal papillary mucinous neoplasm (IPMN) from reference cohorts (including the International Cancer Genome Consortium‐ ICGC dataset and The Cancer Genome Atlas, TCGA program) were conducted. The core findings of 128 patients were as follows: (i) Clinicopathological parameters: pancreatic head is the most common site; presence of an associated adenocarcinoma was reported in 60% of cases, but with rare nodal metastasis. (ii) Immunohistochemistry: MUC1 (>90%) and MUC6 (70%) were the most frequently expressed mucins. ITPN lacked the intestinal marker MUC2; unlike IPMN, it did not express MUC5AC. (iii) Molecular landscape: Compared with PDAC/IPMN, the classic pancreatic drivers KRAS, TP53, CDKN2A, SMAD4, GNAS, and RNF43 were less altered in ITPN (P < 0.001), whereas MCL amplifications, FGFR2 fusions, and PI3KCA mutations were commonly altered (P < 0.001). (iv) Survival analysis: ITPN with a “pure” branch duct involvement showed the lowest risk of recurrence.

Conclusion

ITPN is a distinct pancreatic neoplasm with specific clinicopathological and molecular characteristics. Its recognition is fundamental for its clinical/prognostic implications and for the enrichment of potential targets for precision oncology.

Systematic review of resectable intraductal tubulopapillary neoplasm with special reference to recurrence patterns

PURPOSE

Intraductal tubulopapillary neoplasm is a rare pancreatic tumor. The purpose of this study was to clarify the recurrence type and prognosis in recurrent cases after intraductal tubulopapillary neoplasm resection.

METHODS

PubMed was searched for previous reports on surgical resection of intraductal tubulopapillary neoplasm of the pancreas that were published from 2009 to July 2020. The clinical features obtained from these reports were summarized and analyzed.

RESULTS

The clinicopathological data of 35 intraductal tubulopapillary neoplasm cases were obtained. Of these, 21 were males, and 14 were females, with an average age of 57.9 years old. Invasive findings were observed in 21 of 35 patients (60%). Recurrence was observed in 11 of the 35 cases (31.4%), including remnant pancreatic recurrence in 6 cases (17.1%) and liver metastasis in 5 cases (14.3%). The tumor size was significantly larger in the liver metastasis group than in the remnant pancreas recurrence group (P = 0.04), and patients with liver metastases tended to have a poorer prognosis than those with remnant pancreas recurrence.

CONCLUSIONS

The recurrence type of intraductal tubulopapillary neoplasm resection was mainly remnant pancreatic recurrence and liver metastasis recurrence. Total pancreatectomy for remnant pancreatic recurrence may be suitable because of its good prognosis.

A case of intraductal tubulopapillary neoplasm of the pancreas in a branch duct: a rare case report and literature review

BACKGROUND

Intraductal tubulopapillary neoplasm (ITPN) of the pancreas is a new disease concept defined by the World Health Organization in 2010. ITPN progresses with tubulopapillary growth in the pancreatic duct and is known to have a fair prognosis. Localization in the main pancreatic duct (MPD) is one characteristic. There are few case reports of ITPN in a branch of the pancreatic duct (BD).

CASE PRESENTATION

We encountered a case of ITPN localized in BD. An 85-year-old man was followed after colonic surgery for rectal carcinoma. An abdominal computed tomography scan revealed a cystic mass in the pancreatic head and further examination was done. A T2 weighted intension picture in magnetic resonance imaging showed a 20 mm cystic lesion with an internal mass of 15 mm. Duodenal papilla were slightly open and endoscopic retrograde pancreatography revealed mild and diffuse dilatation of the main pancreatic duct and mucin in the MPD. In consideration with the image examinations, we diagnosed the tumor as an intraductal papillary mucinous neoplasm with carcinoma because of its large mural nodule (> 10 mm in size) in a cyst. Consequently, a pancreaticoduodenectomy was performed. Macroscopically, a white solid tumor sized 2.5 × 1.8 × 1.0 was identified in the head of the pancreas. The cut surface of the resected pancreas showed a side-branch type intraductal tumor with tubulopapillary architecture without mucin secretion. Immunohistochemical staining was positive for MUC1, and negative for MUC2 and MUC5AC. The final diagnosis was determined to be pancreatic ITPN from BD. At the time of this report (48 months post-surgery), the patient remains disease-free without evidence of recurrence.

CONCLUSION

ITPNs localized in BD are rare and diagnosis prior to surgery is difficult. In our case, the shape was round, not papillary, and with little fluid. These characteristics are different from a branch duct type IPMN and can be a clue to suspect ITPN in BD.

Total Pancreatectomy with Splenectomy for Multifocal Intraductal Tubulopapillary Neoplasm (ITPN) of the Pancreas Associated with Invasive Component: Report of a Rare Case

Patient: Male, 82-year-old

Final Diagnosis: Pancreatic intraductal tubulopappilary neoplasm (ITPN)

Symptoms: Abdominal pain • anorexia • weakness • weight loss

Medication: Amlodipine 5 mg/valsartan 160 mg • nebivolol 5 mg • metformin 850 mg • pancreatin 25 000 IU

Clinical Procedure: Total pancreatectomy with splenectomy

Specialty: Oncology • Pathology • Radiology • Surgery