Resection of pancreatic cystic neoplasms in recurrent acute pancreatitis prevents recurrent pancreatitis but does not identify more malignancies

Acute pancreatitis in intraductal papillary mucinous neoplasm: Associations with epithelial subtype, degree of dysplasia, and risk of recurrence

BACKGROUND

Acute pancreatitis is an uncommon presentation of intraductal papillary mucinous neoplasm; however, it is considered a worrisome feature in current guidelines and can be an indication for surgery. There is controversy regarding its association with malignancy, and there is little information regarding the recurrence of pancreatitis after surgical resection.

METHODS

We retrospectively reviewed patients who underwent resection for intraductal papillary mucinous neoplasm at a single institution between January 1990 and December 2023. Patients with and without acute pancreatitis as part of the clinical presentation were compared.

RESULTS

A total of 812 patients were reviewed. Of these, 156 patients (19.2%) had intraductal papillary mucinous neoplasms associated with acute pancreatitis, and in 92% of them pancreatitis was the symptom leading to the diagnosis. Half of the patients had a single episode of pancreatitis (n = 77, 49.4%), and 42 (26.9%) had had 3 or more episodes before diagnosis. Acute pancreatitis was significantly associated with high-grade dysplasia (odds ratio 2.07) but had a lower likelihood of invasive cancer (odds ratio 0.62). It was also significantly associated with main duct and mixed duct-type intraductal papillary mucinous neoplasm (odds ratio 1.97) and intestinal epithelial subtype (odds ratio 2.28). Median follow-up for all patients was 61 months, and the likelihood of recurrent pancreatitis after surgical resection was 9% (14 patients), whereas pancreatitis after resection in patients without prior history occurred in only 0.9% (6 patients, P < .001).

CONCLUSIONS

Almost 1 in 5 patients undergoing resection for intraductal papillary mucinous neoplasm have a history of acute pancreatitis and are twice as likely to have high-grade dysplasia, supporting its categorization as a worrisome feature. Recurrence of pancreatitis after resection was 9%.

Diagnosis and Management of Pancreatic Cysts: A Comprehensive Review of the Literature

The prevalence of pancreatic cysts has been rising due to the widespread use of cross-sectional imaging (CT scan and MRI) of the abdomen. While most pancreatic cysts are benign and do not require treatment or surveillance, a significant minority are premalignant and rarely malignant. The risk stratification of these lesions is not straightforward, and individual risk assessment, cyst size, distribution, and alarming morphologic features (when present) can guide the next steps in management. Neoplastic pancreatic cysts are mucinous or non-mucinous. Endoscopic ultrasound with fine-needle aspiration is often required to classify pancreatic cysts into mucinous and non-mucinous cysts and to assess the malignant potential. Advances in endoscopic techniques (confocal laser endomicroscopy, microforceps biopsy) can provide a definitive diagnosis of pancreatic cysts in some cases; however, the use of these techniques involves a higher risk of adverse events.

Endoscopic pancreatic sphincterotomy in patients with IPMN-related recurrent pancreatitis: A single center experience

BACKGROUND

Acute recurrent pancreatitis (ARP) is a rare manifestation of Intraductal Papillary Mucinous Neoplasms (IPMN) of the pancreas; ARP is a relative indication for pancreatic surgery in the setting of IPMN. Endoscopic pancreatic sphincterotomy (EPS) has been described as a minimal invasive treatment to reduce the episodes of ARP secondary to mucus migration in IPMN.

METHODS

patients with IPMN-related ARP treated with ESP from January 2004 to December 2020 were retrospectively selected. Clinical and technical data were recorded. A clinical follow-up (minimum 12 months) was performed to assess the number of episodes of AP occurring after EPS.

RESULTS

25 patients were included. The mean follow-up after ESP was 93.4 months (SD± 56.6). The mean number of AP before and after EPS were respectively 3.29 (SD ± 1.04) and 0.51 (SD ± 0.71). A complete response (no further episodes of AP) and a partial response (>50% reduction of AP episodes) were obtained in 64% and 24% of the cases, respectively, with an overall response rate of 88%. One post-EPS bleeding and one minor-papilla stenosis were reported and were endoscopically managed. Two patients underwent pancreatic resection for the occurrence of high-risk stigmata for cancer progression.

CONCLUSIONS

EPS is a safe and effective treatment to reduce the number of episodes of AP in selected patients with IPMNs-related ARP. Prospective trials are needed to confirm these data.

Modern aspects of the management of pancreatic intraductal papillary mucinous neoplasms: a narrative review

Intraductal papillary mucinous neoplasms (IPMNs) account for approximately 35% of all cystic tumors in the pancreas and represent the largest subgroup. They are characterized by mucin production and intraductal papillary epithelium growth. IPMNs range from benign to malignant lesions. Biomarkers combined with 18F-Fluorodeoxyglucose-positron emission tomography (18FDG-PET) is the best diagnostic tool. The risk of malignant transformation for main-duct IPMNs is between 34-68% and for low-risk branch-duct (BD)-IPMNs it is 1.1%. Monitoring is crucial for determining the optimal time of surgical excision. Novel artificial intelligence combining clinical, tumor biomarkers, imaging and molecular genomics plays a determinant role in the evaluation of such lesions. The first diagnostic tool is multidetector helical computed tomography (MDHCT) or up-to-date magnetic resonance imaging (MRI). MRI detects malignancy by enhancing mural nodules ≥3 mm. Novel endosonographic interventional techniques have been added to the diagnostic armamentarium. Pancreatoscopy is feasible and effective but challenging for evaluating the diagnosis, invasiveness, and extent of IPMNs. Its findings may change the surgical approach. Pancreatic juice and duodenal fluid have been used recently for molecular biological analysis. The genes most frequently altered include Kirsten rat sarcoma viral proto-oncogene (KRAS), tumor protein p53 (TP53), cyclin-dependent kinase inhibitor 2A (CDKN2A), SMAD family member 4 (SMAD4), and guanine nucleotide-binding protein, alpha stimulating (GNAS). Despite the advances in diagnostic modalities, assessment of this premalignant lesion of pancreatic cancer, with its poor prognosis, is a challenging task. Pancreatectomy is the indicated approach for malignant or high-risk IPMNs with potent malignancy. Conservative management or enucleation for preserving the pancreas of low-risk BD-IPMNs is recommended, but long-term follow-up for recurrence is necessary. The management of IPMNs must be individualized based on preoperative high-risk stigmata and worrisome features.