Reoperation for heterochronic intraductal papillary mucinous neoplasm of the pancreas after bile duct neoplasm resection:A case report

BACKGROUND Intraductal papillary neoplasm of the bile duct(IPNB)and intraductal papillary mucinous neoplasm(IPMN)of the pancreas have similar pathological manifestations.However,they often develop separately and it is rare for both to occur together.Patients presenting with heterochronic IPMN after IPNB are prone to be misdiagnosed with tumor recurrence.CASE SUMMARY A 67-year-old male patient was admitted 8.5 years after IPNB carcinoma and 4 years after the discovery of a pancreatic tumor.A left hepatic bile duct tumor with distal bile duct dilatation was found 8.5 years ago by the computed tomography;therefore,a left hepatectomy was performed.The postoperative pathological diagnosis was malignant IPNB with negative cutting edge and pathological stage T1N0M0.Magnetic resonance imaging 4 years ago showed cystic lesions in the pancreatic head with pancreatic duct dilatation,and carcinoembryonic antigen continued to increase.Positron emission tomography showed a maximum standard uptake value of 11.8 in the soft tissue mass in the pancreatic head,and a malignant tumor was considered.Radical pancreatoduodenectomy was performed.Postoperative pathological diagnosis was pancreatic head IPMN with negative cutting edge,pancreaticobiliary type,stage T3N0M0.He was discharged 15 d after the operation.Follow-up for 6 mo showed no tumor recurrence,and quality of life was good.CONCLUSION IPNB and IPMN are precancerous lesions with similar pathological characteristics and require active surgery and long-term follow-up.

Expression of the tumor suppressor gene maspin and its significance in intraductal papillary mucinous neoplasms of the pancreas

BACKGROUND: Maspin is a member of the serpin family of protease inhibitors and is thought to inhibit carcinoma invasion, metastasis, and angiogenesis and induce apoptosis. We examined maspin expression immunohistochemically and assessed its significance in intraductal papillary mucinous neoplasm (IPMN) of the pancreas. METHODS: We examined 39 surgically resected specimens of IPMN that included 17 adenomas (IPMAs), 5 borderline tumors (IPMBs), 4 non-invasive carcinomas (non-invasive IPMCs), and 13 invasive carcinomas (invasive IPMCs). Immunostaining was performed according to the EnVision ChemMate method. The degree of maspin expression was scored and assessed according to the percentage and staining intensity of positive cells. RESULTS: Maspin expression was minimal in normal pancreatic duct epithelium, whereas in IPMNs, maspin was expressed in neoplasms of all stages. Maspin expression increased with increasing grade from IPMAs, IPMBs, to non-invasive IPMCs but decreased significantly in invasive IPMCs. No specific association between maspin expression and mucin type was found. Analysis of maspin expression with respect to clinicopathologic factors in cases of invasive IPMC revealed a greater extent of invasion in cases of low maspin expression and significantly fewer apoptotic cells in the tumor.CONCLUSIONS: Maspin was expressed at high levels in IPMNs at various stages from adenoma to invasive carcinoma, and our results suggest that maspin may be involved in the occurrence and progression of IPMN. In addition, our data suggest that the apoptosis-inducing action of maspin suppresses invasion and progression of IPMN.

Differences between main-duct and branch-duct intraductal papillary mucinous neoplasms of the pancreas

In the last decade,intraductal papillary mucinous neoplasms(IPMNs) have become commonly diagnosed.From a morphological standpoint,they are classified in main-duct IPMNs(MD-IPMNs) and branch-duct IPMNs(BD-IPMNs),depending on the type of involvement of the pancreatic ductal system by the neoplasm.Despite the fact that our understanding of their natural history is still incomplete,recent data indicate that MD-IPMNs and BD-IPMNs show significant differences in terms of biological behaviour with MD-IPMNs at higher risk of malignant degeneration.In the present paper,clinical and epidemiological characteristics,rates of malignancy and the natural history of MD-IPMNs and BD-IPMNs are analyzed.The profile of IPMNs involving both the main pancreatic duct and its side branches(combined-IPMNs) are also discussed.Finally,general recommendations for management based on these differences are given.

Pathological features and diagnosis of intraductal papillary mucinous neoplasm of the pancreas

Intraductal papillary mucinous neoplasm(IPMN) of the pancreas is a noninvasive epithelial neoplasm of mucinproducing cells arising in the main duct(MD) and/or branch ducts(BD) of the pancreas.Involved ducts are dilated and filled with neoplastic papillae and mucus in variable intensity.IPMN lacks ovarian-type stroma,unlike mucinous cystic neoplasm,and is defined as a grossly visible entity(≥ 5 mm),unlike pancreatic intraepithelial neoplasm.With the use of high-resolution imaging techniques,very small IPMNs are increasingly being identified.Most IPMNs are solitary and located in the pancreatic head,although 20%-40% are multifocal.Macroscopic classification in MD type,BD type and mixed or combined type reflects biological differences with important prognostic and preoperative clinical management implications.Based on cytoarchitectural atypia,IPMN is classified into low-grade,intermediategrade and high-grade dysplasia.Based on histological features and mucin(MUC) immunophenotype,IPMNs are classified into gastric,intestinal,pancreatobiliary and oncocytic types.These different phenotypes can be observed together,with the IPMN classified according to the predominant type.Two pathways have been suggested:gastric phenotype corresponds to less aggressive uncommitted cells(MUC1-,MUC2-,MUC5 AC +,MUC6 +) with the capacity to evolve to intestinal phenotype(intestinal pathway)(MUC1-,MUC2 +,MUC5 AC +,MUC6- or weak +) or pancreatobiliary /oncocytic phenotypes(pyloropancreatic pathway)(MUC1 +,MUC 2-,MUC5 AC +,MUC 6 +) becoming more aggressive.Prognosis of IPMN is excellent but critically worsens when invasive carcinoma arises(about 40% of IPMNs),except in some cases of minimal invasion.The clinical challenge is to establish which IPMNs should be removed because of their higher risk of developing invasive cancer.Once resected,they must be extensively sampled or,much better,submitted in its entirety for microscopic study to completely rule out associated invasive carcinoma.

molecular pathology of intraductal papillary mucinous neoplasms of the pancreas

Since the first description of intraductal papillary mucinous neoplasms(IPMNs)of the pancreas in the eighties,their identification has dramatically increased in the last decades,hand to hand with the improvements in diagnostic imaging and sampling techniques for the study of pancreatic diseases.However,the heterogeneity of IPMNs and their malignant potential make difficult the management of these lesions.The objective of this review is to identify the molecular characteristics of IPMNs in order to recognize potential markers for the discrimination of more aggressive IPMNs requiring surgical resection from benign IPMNs that could be observed.We briefly summarize recent research findings on the genetics and epigenetics of intraductal papillary mucinous neoplasms,identifying some genes,molecular mechanisms and cellular signaling pathways correlated to the pathogenesis of IPMNs and their progression to malignancy.The knowledge of molecular biology of IPMNs has impressively developed over the last few years.A great amount of genes functioning as oncogenes or tumor suppressor genes have been identified,in pancreatic juice or in blood or in the samples from the pancreatic resections,but further researches are required to use these informations for clinical intent,in order to better define the natural history of these diseases and to improve their management.

Imaging considerations in intraductal papillary mucinous neoplasms of the pancreas

With the widespread use of cross-sectional imaging,particularly computed tomography(CT) and magnetic resonance imaging(MRI),and the continuous improvement in the image quality of these techniques,the diagnosis of incidental pancreatic cysts has increased dramatically in the last decades.While the vast majority of these cysts are not clinically relevant,a small percentage of them will evolve into an invasive malignant tumor making their management challenging.Mucinous cystic neoplasms and intraductal papillary mucinous neoplasms(IPMN) are the most common pancreatic cystic lesions with malignant potential.Imaging findings on CT and MRI correlate tightly with the presence of malignant degeneration in these neoplasms.IPMN can be classified based on their distribution as main duct,branch duct or mixed type lesions.MRI is superior to CT in demonstrating the communication of a branch duct IPMN with the main pancreatic duct(MPD).Most branch duct lesions are benign whereas tumors involving the MPD are frequently associated with malignancy.The presence of solid nodules,thick enhancing walls and/or septae,a wide(> 1 cm) connection of a side-branch lesion with the MPD and the size of the tumor > 3 cm are indicative of malignancy in a branch and mixed type IPMN.A main pancreatic duct > 6 mm,a mural nodule > 3 mm and an abnormal attenuating area in the adjacent pancreatic parenchyma on CT correlates with malignant disease in main duct and mixed type IPMN.An accurate characterization of these neoplasms by imaging is thus crucial for selecting the best management options.In this article,we review the imaging findings of IPMN including imaging predictors of malignancy and surgical resectability.We also discuss follow-up strategies for patients with surgically resected IPMN and patients with incidental pancreatic cysts.

Extrapancreatic malignancies and intraductal papillary mucinous neoplasms of the pancreas

Over the last two decades multiple studies have demonstrated an increased incidence of additional malignancies in patients with intraductal papillary mucinous neoplasms(IPMNs).Additional malignancies have been identified in 10%-52% of patients with IPMNs.The majority of these additional cancers occur before or concurrent with the diagnosis of IPMN.The gastrointestinal tract is most commonly involved in secondary malignancies,with benign colon polyps and colon cancer commonly seen in western countries and gastric cancer commonly seen in Asian countries.Other extrapancreatic malignancies associated with IPMNs include benign and malignant esophageal neoplasms,gastrointestinal stromal tumors,carcinoid tumors,hepatobiliary cancers,breast cancers,prostate cancers,and lung cancers.There is no clear etiology for the development of secondary malignancies in patients with IPMN.Although population-based studies have shown different results from single institution studies regarding the exact incidence of additional primary cancers in IPMN patients,both have reached the same conclusion:there is a higher incidence of extrapancreatic malignancies in patients with IPMNs than in the general population.This f inding has signif icant clinical implications for both the initial evaluation and the subsequent long-term followup of patients with IPMNs.If a patient has not had recent colonoscopy,this should be performed during the evaluation of a newly diagnosed IPMN.Upper endoscopy should be performed in patients from Asian countries or for those who present with symptoms suggestive of upper gastrointestinal disease.Routine screening studies(breast and prostate) should be carried out as currently recommended for patient's age both before and after the diagnosis of IPMN.

Malignancies associated with intraductal papillary mucinous neoplasm of the pancreas

AIM: As intraductal papillary mucinous neoplasm (IPMN)has a favorable prognosis, associated malignancies have potential significance in these patients. We examined the incidence and characteristics of pre-existing, coexisting and subsequent malignancies in patients with IPMN. METHODS: Seventy-nine cases of IPMN were diagnosed by detection of mucous in the pancreatic duct during endoscopic retrograde pancreatography. Histological diagnosis was confirmed in 30 cases (adenoma (n = 19)and adenocarcinoma (n = 11). Other primary malignancies associated with IPMN, occurring in the prediagnostic or postdiagnostic period, were investigated. Postdiagnostic follow-up period was 3.3±0.5 years (range, 0.2-20 years).RESULTS: Other 40 malignancies occurred in 28 patients (35%). They were found before (n = 15), at (n = 19) and after (n = 6) the diagnosis of IPMT. Major associated malignancies were gastric cancer (n = 12), colonic cancer (n = 7), esophageal cancer (n = 4), pulmonary cancer (n = 4), and independent pancreatic cancer (n = 3).Pancreatic cancer was synchronous with IPMN in two patients and metachronous in one (3 years after diagnosis of IPMN). Thirty-one lesions were treated surgically or endoscopically. Fourteen patients died of associated cancers. Development of other malignancies was related to age (71.9±8.2 vs66.8±9.3, P＜0.05), but not to gender or site of the tumor.CONCLUSION: IPMN is associated with a high incidence of other malignancies, particularly gastric and colonic cancers. Common genetic mechanisms between IPMN and other associated malignancies might be present. Clinicians should pay attention to the possibility of associated malignancies in preoperative screening and follow-up of patients with IPMN.

Imaging features of intraductal papillary mucinous neoplasms of the pancreas in multi-detector row computed tomography

AIM:To retrospectively evaluate the imaging features of pancreatic intraductal papillary mucinous neoplasms (IPMNs) in multi-detector row computed tomography (MDCT).METHODS: A total of 20 patients with pathologically-confirmed intraductal papillary mucinous neoplasms (IPMNs) were included in this study. Axial MDCT images combined with CT angiography (CTA) and multiplanar volume reformations (MPVR) or curved reformations (CR) were preoperatively acquired. Two radiologists (Tan L and Wang DB) reviewed all the images in consensus using an interactive picture archiving and communication system. The disputes in readings were resolved through consultation with a third experienced radiologist (Chen KM). Finally, the findings and diagnoses were compared with the pathologic results.RESULTS: The pathological study revealed 12 malignant IPMNs and eight benign IPMNs. The diameters of the cystic lesions and main pancreatic ducts (MPDs) were significantly larger in malignant IPMNs compared with those of the benign IPMNs (P<0.05). The combined-type IPMNs had a higher rate of malignancy than the other two types of IPMNs (P<0.05). Tumors with mural nodules and thick septa had a significantly higher incidence of malignancy than tumors without these features (P<0.05). Communication of side-branch IPMNs with the MPD was present in nine cases at pathologic examination. Seven of them were identified from CTA and MPVR or CR images. From comparison with the pathological diagnosis, the sensitivity, specificity, and accuracy of MDCT in characterizing the malignancy of IPMN of the pancreas were determined to be 100%, 87.5% and 95%, respectively.CONCLUSION: MDCT with CTA and MPVR or CR techniques can elucidate the imaging features of IPMNs and help predict the malignancy of these tumors.

Prognosis of invasive intraductal papillary mucinous neoplasms of the pancreas

Intraductal papillary mucinous neoplasms(IPMN) are mucin producing cystic neoplasms of the pancreas histologically classified as having non-invasive and invasive components.The five-year survival rates for non-invasive and associated invasive carcinoma are 90% and 40%,respectively in resected IPMN lesions.Invasive carcinoma within IPMN lesions can be further classified by histological subtype into colloid carcinoma and tubular carcinoma.Estimated five-year survival rates following resection of colloid carcinoma range from 57%-83% and estimated five-year survival following resection of tubular carcinoma range from 24%-55%.The difference in survival outcome between invasive colloid and tubular IPMN appears to be a function of disease biology,as patients with the tubular subtype tend to have larger tumors with a propensity for metastasis to regional lymph nodes.When matched to resected conventional pancreatic adenocarcinoma lesions by the Memorial Sloan Kettering Cancer Center pancreatic adenocarcinoma nomogram,the colloid carcinoma histological subtype has an improved estimated five-year survival outcome compared to conventional pancreatic adenocarcinoma,87% and 23%(P = 0.0001),respectively.Resected lesions with the tubular carcinoma subtype overall have a similar five-year survival outcome compared to conventional pancreatic adenocarcinoma.However,when these groups were stratified by regional lymph node status patients with negative regional lymph nodes and the tubular subtype experienced significantly better survival than patients with a similar nodal status and ductal adenocarcinoma with estimated five-year survival rates of 73% and 27%(P = 0.01),respectively.

Nomograms predicting long-term survival in patients with invasive intraductal papillary mucinous neoplasms of the pancreas: A population-based study

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.

Outcomes of nonresected main-duct intraductal papillary mucinous neoplasms of the pancreas

AIM:To compare characteristics and outcomes of resected and nonresected main-duct and mixed intraductal papillary mucinous neoplasms of the pancreas(IPMN).METHODS:Over a 14-year period,50 patients who did not undergo surgery for resectable main-duct or mixed IPMN,for reasons of precluding comorbidities,age and/or refusal,were compared with 74 patients who underwent resection to assess differences in rates of survival,recurrence/occurrence of malignancy,and prognostic factors.All study participants had dilatation of the main pancreatic duct by ≥ 5 mm,with or without dilatation of the branch ducts.Some of the nonsurgical patients showed evidence of mucus upon perendoscopic retrograde cholangiopancreatography or endoscopic ultrasound and/or after fine needle aspiration.For the surgical patients,pathologic analysis of resected specimens confirmed a diagnosis of IPMN with involvement of the main pancreatic duct or of both branch ducts as well as the main pancreatic duct.Clinical and biologic follow-ups were conducted for all patients at least annually,through hospitalization or consultation every six months during the first year of follow-up,together with abdominal imaging analysis(magnetic resonance cholangiopancreatography or computed tomography) and,if necessary,endoscopic ultrasound with or without fine needle aspiration.RESULTS:The overall five-year survival rate of patients who underwent resection was significantly greater than that for the nonsurgical patients(74% vs 58%; P =0.019).The parameters of age(< 70 years) and absence of a nodule were associated with better survival(P < 0.05); however,the parameters of main pancreatic duct diameter > 10 mm,branch ductdiameter > 30 mm,or presence of extra pancreatic cancers did not significantly influence the prognosis.In the nonsurgical patients,pancreatic malignancy occurred in 36% of cases within a mean time of 33 mo(median:29 mo; range:8-141 mo).Comparison of the nonsurgical patients who experienced disease progression with those who did not progress showed no significant differences in age,sex,symptoms,subtype of IPMN,or follow-up period; only the size of the main pancreatic duct was significantly different between these two sub-groups,with the nonsurgical patients who experienced progression showing a greater diameter at the time of diagnosis(> 10 mm).CONCLUSION:Patients unfit for surgery have a 36% greater risk of developing pancreatic malignancy of the main-duct or mixed IPMN within a median of 2.5 years.

Multifocal intraductal papillary mucinous neoplasm of the pancreas-A case report

Cystic neoplasms of the pancreas are relatively rare, comprising 10 percent of pancreatic cysts and only 1 percent of pancreatic cancers. Cystic neoplasms include mucinous cystic neoplasms, serous cystadenomas, papillary cystic tumors, cystic islet cell tumors and intraductal papillary mucinous neoplasms of the pancreas (IPMNs). IPMN was first described in 1982. It has been most commonly described in 60 to 70 years old males, and represents a relatively ''new'' but increasingly recognized disease. The improvement and widespread use of modern imaging equipments and heightened awareness of physicians contribute to the increasing incidence of IPMN. The majority of IPMNs are located in the pancreatic head (75%) while the rest involves the body/tail regions. Multifocal IPMNs have been hypothesized, but the true presence of multifocality is unknown. Here we present a 72-yearold male diagnosed with IPMN (carcinoma in situ ) in the pancreatic head and a branch duct type IPMN (duct atypia) in the pancreatic body and tail. The patient underwent a Whipple intervention and a distal pancreatectomy. A three-year disease-free survival has been observed so far.

Validation and head-to-head comparison of four models for predicting malignancy of intraductal papillary mucinous neoplasm of the pancreas: A study based on endoscopic ultrasound findings

BACKGROUND Several models are currently available for predicting the malignancy of pancreatic intraductal papillary mucinous neoplasm(IPMN),namely,the Pancreatic Surgery Consortium(PSC),the Japan Pancreas Society(JPS),the Johns Hopkins Hospital(JHH),and the Japan-Korea(JPN-KOR)models.However,a head-to-head comparison that shows which model is more accurate for this individualized prediction is lacking.AIM To perform a head-to-head comparison of the four models for predicting the malignancy of pancreatic IPMN.METHODS A total of 181 patients with IPMN who had undergone surgical resection were identified from a prospectively maintained database.The characteristics of IPMN in patients were recorded from endoscopic ultrasound imaging data and report archives.The performance of all four models was examined using Harrell’s concordance index(C-index),calibration plots,decision curve analyses,and diagnostic tests.RESULTS Of the 181 included patients,94 were categorized as having benign disease,and the remaining 87 were categorized as having malignant disease.The C-indexes were 0.842[95%confidence interval(CI):0.782-0.901],0.704(95%CI:0.626-0.782),0.754(95%CI:0.684-0.824),and 0.650(95%CI:0.483-0.817)for the PSC,JPS,JHH,and JPN-KOR models,respectively.Calibration plots showed that the PSC model had the least pronounced departure from ideal predictions.Of the remaining three models,the JPS and JHH models underestimated the probability of malignancy,while the JPN-KOR model overestimated the malignant potential of branch duct-IPMN.Decision curve analysis revealed that the PSC model resulted in a better clinical net benefit than the three other models.Diagnostic tests also showed a higher accuracy(0.801)for the PSC model.CONCLUSION The PSC model exhibited the best performance characteristics.Therefore,the PSC model should be considered the best tool for the individualized prediction of malignancy in patients with pancreatic IPMN.

Small invasive ductal carcinoma of the pancreas distinct from branch duct intraductal papillary mucinous neoplasm

Endoscopic ultrasonography(EUS)is a highly sensitive diagnostic method for the detection of small pancreatic carcinomas.Recently,there have been some reports describing the utility of contrast-enhanced harmonic EUS(CEH-EUS)which uses sonographic contrast agent for differentiation of a pancreatic mass.This report describes a case of small adenocarcinoma of the pancreas distinct from branch duct intraductal papillary mucinous neoplasm(IPMN)in which investigation by EUS took place every 6 mo and diagnosis was made accurately by additional CEH-EUS during the follow- up of the branch duct IPMN.A 68-year-old female was admitted to our hospital because of a branch duct IPMN in the pancreatic body.She had been followedup by EUS every 6 mo.However,after 2 years EUSdemonstrated a low echoic area distinct from the branch duct IPMN which was vaguely discernible by EUS,and accurate sizing and differential diagnosis were considered difficult on the EUS imaging.CHEUS with Sonazoid revealed a hypovascular tumor and we suspected small pancreatic carcinoma.The histopathological diagnosis was adenocarcinoma (10 mm)in the pancreatic tail,distinct from the branch duct IPMN of the pancreatic body.EUS and CEH-EUS may play an important role in the correct diagnosis of small pancreatic tumors,including synchronous and metachronous occurrence of IPMN and ductal adenocarcinoma of the pancreas.

Intraductal papillary mucinous neoplasm originating from a jejunal heterotopic pancreas:A case report

BACKGROUND Intraductal papillary mucinous neoplasm(IPMN)is a rare pancreatic tumor and has the potential to become malignant.Surgery is the most effective treatment at present,but there is no consensus on the site of resection.Heterotopic pancreas occurs in the gastrointestinal tract,especially the stomach and duodenum but is asymptomatic and rare.We report a case of ectopic pancreas with IPMN located in the jejunum.CASE SUMMARY A 56-year-old male patient suffered from severe pain,nausea and vomiting due to a traffic accident and sought emergency treatment at our hospital.Contrast-enhanced computed tomography of the whole abdomen suggested splenic congestion,which was considered to be splenic rupture.Emergency laparotomy was performed,and the ruptured spleen was removed during the operation.Unexpectedly,a cauliflower-like mass of about 2.5 cm×2.5 cm in size was incidentally found about 80 cm from the ligament of Treitz during the operation.A partial small bowel resection was performed,and postoperative pathology confirmed the small bowel mass as heterotopic pancreas with low-grade IPMN.CONCLUSION Ectopic pancreas occurs in the jejunum and is pathologically confirmed as IPMN after surgical resection.

Synchronous manifestation of colorectal cancer and intraductal papillary mucinous neoplasms

High rates of extrapancreatic malignancies,in particular colorectal cancer(CRC),have been detected in patients with intraductal papillary mucinous neoplasm(IPMN).So far,there is no distinct explanation in the literature for the development of secondary or synchronous malignancies in patients with IPMN.In the past few years,some data related to common genetic alterations in IPMN and other affiliated cancers have been published.This review elucidated the association between IPMN and CRC,shedding light on the most relevant genetic alterations that may explain the possible relationship between these entities.In keeping with our findings,we suggested that once the diagnosis of IPMN is made,special consideration of CRC should be undertaken.Presently,there are no specific guidelines regarding colorectal screening programs for patients with IPMN.We recommend that patients with IPMNs are at high-risk for CRC,and a more rigorous colorectal surveillance program should be implemented.

Ultrasonographic Characteristics of Intraductal Papillary Mucinous Neoplasm of the Pancreas

Objective To analyze the clinical and ultrasonographic imaging features of intraductal papillary mucinous neoplasm(IPMN) of the pancreas.Methods Twelve patients with IPMN underwent surgery between May 2005 and December 2008,including 4(33.3%) with adenoma and 8(66.7%) with adenocarcinoma.IPMN was classified preoperatively into 3 types based on sonographic findings of different sites:main duct,branch duct,and combined type.All clinical presentations and ultrasonographic findings of those patients were reviewed and the correlation between ultrasonographic findings and histopathological results was analyzed.Results There were 9 men and 3 women with a mean age of 60.1±9.6 years(range,32-73).Of all the 12 patients with IPMN,9(75.0%) had experienced some symptoms of epigastric discomfort and/or pain as well as backache;7 cases were with medical history of acute pancreatitis,5 cases with diabetes,4 cases with elevated CA19-9,and 2 cases with steatorrhea.All lesions of IPMN have been revealed by transabdominal ultrasonography.The mean diameters of the lesions were 1.4±0.8 cm(range,0.5-2.0) and 6.3±6.0 cm(range,2.0-20.0) in adenomas and adenocarcinomas,respectively.And the mean diameters of the main duct in adenomas and adenocarcinomas were 1.0±0.8 cm and 1.6±1.0 cm,respectively.Among the 4 adnomas,3(75.0%) cases were classified as branch type based on sonographic findings,and 2 were demonstrated as mural nodules in which no color signals was detected.Among the 8 adenocarcinomas,5(62.5%) cases were classified as main duct type,and 3(37.5%) as combined type.In 7 of the 8 adenocarcinomas,mural nodules were detected within the dilated ducts or cysts of the lesions in which color flow signals were detected.Conclusions Transabdominal ultrasonography can reveal the pancreatic cystic lesions of IPMN as well as dilated pancreatic ducts.Some characteristics should be noticed as suggesting the possibility of malignancy:clinical symptoms of pancreatic insufficiency,large tumor size,and mural nodules with color Doppler flow signals.Transabdominal ultrasonography could be a useful tool to help diagnose and make appropriate management of IPMN.

Evolution of incidental branch-duct intraductal papillary mucinous neoplasms of the pancreas: A study with magnetic resonance imaging cholangiopancreatography

AIM To investigate the type and timing of evolution of incidentally found branch-duct intraductal papillary mucinous neoplasms(bd-IPMN) of the pancreas addressed to magnetic resonance imaging cholangiopancreatography(MRCP) follow-up.METHODS We retrospectively evaluated 72 patients who underwent, over the period 2006-2016, a total of 318 MRCPs(mean 4.4) to follow-up incidental, presumed bdIPMN without signs of malignancy, found or confirmedat a baseline MRCP examination. Median follow-up time was 48.5 mo(range 13-95 mo). MRCPs were acquired on 1.5T and/or 3.0T systems using 2D and/or 3D technique. Image analysis assessed the rates of occurrence over the follow-up of the following outcomes:(1) imaging evolution, defined as any change in cysts number and/or size and/or appearance; and(2) alert findings, defined as worrisome features and/or high risk stigmata(e.g., thick septa, parietal thickening, mural nodules and involvement of the main pancreatic duct). Time to outcomes was described with the Kaplan-Meir approach. Cox regression model was used to investigate clinical or initial MRCP findings predicting cysts changes.RESULTS We found a total of 343 cysts(per-patient mean 5.1) with average size of 8.5 mm(range 5-25 mm). Imaging evolution was observed in 32/72 patients(44.4%; 95%CI: 32-9-56.6), involving 47/343 cysts(13.7%). There was a main trend towards small(< 10 mm) increase and/or decrease of cysts size at a median time of 22.5 mo. Alert findings developed in 6/72 patients(8.3%; 95%CI: 3.4-17.9) over a wide interval of time(13-63 mo). No malignancy was found on endoscopic ultrasound with fine-needle aspiration(5/6 cases) or surgery(1/6 cases). No clinical or initial MRCP features were significantly associated with changes in bd-IPMN appearance(P > 0.01).CONCLUSION Changes in MRCP appearance of incidental bd-IPNM were frequent over the follow-up(44.4%), with relatively rare(8.3%) occurrence of non-malignant alert findings that prompted further diagnostic steps. Changes occurred at a wide interval of time and were unpredictable, suggesting that imaging followup should be not discontinued, though MRCPs might be considerably delayed without a significant risk of missing malignancy.

Simultaneous intraductal papillary neoplasms of the bile duct and pancreas treated with chemoradiotherapy

Some authors have suggested that intraductal papillary mucinous neoplasms of the bile duct(IPMN-B) could be the the biliary counterpart of IPMN of the pancreas(IPMN-P) since they share several clinical-pathological features.These include prominent intraductal papil-lary proliferation pattern,a gastrointestinal phenotype,frequent mucin hyper-secretion and progression to mu-cinous carcinoma.To date there are just four reported cases of patients with synchronous IPMN-B and IPMN-P all of which were treated surgically.We hereby report the case of a 76-year-old woman who was incidentally diagnosed with both an asymptomatic 3 cm bulky uid lesion obstructing the bile duct lumen,diagnosed as a malignant IPMN-B,and synchronous multiple pancreatic cystic lesions(10-13 mm) communicating with an irreg-ular Wirsung,diagnosed as branch duct IPMN-P.Since surgery was ruled-out because of the patient's age and preferences,she underwent a conservative manage-ment regimen comprising both chemotherapy and radio-therapy.This was effective in decreasing the mass size and in resolving subsequent jaundice.This is also the f irst reported case of IPMN-B successfully treated with chemoradiotherapy.Clinicians should consider medical treatment as an option in this clinical scenario,in pa-tients who may be unf it for surgery.