Clinical Features and Radiological Findings of Cystic Tumor of the Pancreas

PURPOSE: Most cystic tumors of the pancreas are composed of serous cystic tumor, mucinous cystic tumor, solid pseudo- papillary epithelial neoplasm (SPEN) and intraductal papillary mucinous tumor (IPMT). With advancements in diagnostic imaging, cystic lesions of the pancreas are being detected with increasing frequency; however, there is still difficulty determining the appropriate diagnostic and therapeutic plan. METHODS: A retrospective review was performed of 15 cases that underwent surgery for pancreatic cystic tumors in our department between July 1995 and August 2005. All 15 cases identified had their records and radiological images reviewed. Radiological findings were characterized and analyzed by one radiologist. RESULTS: The median age was 55.9 years. Six cases were male and nine were female. Common symptoms included: epigastirc pain 6/14 (43%) and palpable mass 2/14 (14%). The accuracy of the preop radiological diagnosis including abdominal CT and US was 12/15 (80%). One case of serous cystic tumor, one of chronic pancreatitis and one SPEN were misdiagnosed; the preoperative diagnosis for these cases was mucinous cystic tumor. Serous cystic tumors were seen with central calcification 2/3 (67%), external lobulation 3/3 (100%); however, the mucinous cystic tumors were seen with peripheral calcification 4/5 (80%), no external lobulation 5/5 (100%) by radiological evaluation. There was no calcification, but external lobulation was common in the IPMT. The SPEN had no specific radiological findings except for peripheral calcification. CONCLUSION: Future multicenter studies with endoscopic sonography and aspiration cytology is needed for improved accuracy of diagnosis.

Surgical Management for Intraductal Papillary Mucinous Tumor (IPMT) of the Pancreas Confined to Branch Duct

PURPOSE: Intraductal papillary mucinous tumor (IPMT) of the branch duct type has been reported that it is associated with less aggressive histologic features than the main duct type. The purpose of this study was to evaluate the clinicopathologic features and the optimal management of branch duct type IPMT. METHODS: From October 1994 to November 2004, 30 cases who underwent operations with branch duct type IPMT were reviewed retrospectively. Clinicopathologic findings and late results of treatment were studied in 20 cases of the benign (adenoma, borderline malignancy) group and in 10 cases of the malignant (carcinoma in situ, invasive carcinoma) group. RESULTS: There were statistically significant difference in the 3 factors (mural nodule (P=0.030), diameter of the main pancreatic duct (P=0.036), main location of the tumor (P= 0.031)). There was no statistically significant difference in th survival analysis between the main duct type IPMT including combined type IPMT and the branch duct type IPMT (P=0.572), but there was significant difference between the benign group and the malignant group of the branch duct type IPMT (P=0.049). CONCLUSION: The long-term follow up result of the branch duct type IPMT is similar to that of the main and combined duct type IPMT. Therefore, it is not safe just to monitor the branch duct type IPMT. Our results suggest that surgery is certainly the gold standard treatment for the branch duct type IPMT. And after operation, close long term follow up with appropriate treatment is necessary due to tumor recurrence.

Analysis of Clinical Features and Factors Predictive of Malignancy in Intraductal Papillary Mucinous Tumor of the Pancreas: Multi-center Analysis in Korea / 한국간담췌외과학회지

BACKGROUND/AIMS: Despite of increasing numbers of reports on intraductal papillary mucinous tumor (IPMT), there is still difficulty in its' diagnosis, treatment and prediction of prognosis. The purpose of this multicenter study was to evaluate the clinico-pathological features of IPMT in Korea and suggest the prediction criteria of malignancy in IPMT. METHODS: We retrospectively reviewed the clinico-pathological data of 208 patients who underwent operations with IPMT between 1993 and 2002 at 28 institutes in Korea. RESULTS: Of the 208 patients with a mean age of 60.5+/-9.7 years, 147 were men and 61 were women. 124 patients underwent pancreatoduodenectomy, 42 distal pancreatectomy, 17 total pancreatectomy, 25 limited pancreas resection. Benign cases were 128 (adenoma (n=62), borderline (n=66)) and malignant cases were 80 (non-invasive (n=29), invasive (n=51)). A significant difference in 5-year survival was observed between benign and malignant group (92.6% vs. 65.3%; p=0.006). Of the 6 factors (age, location, duct dilatation, tumor appearance, main duct type, and tumor size) that showed the statistical difference in univariate analysis between benign and malignant group, we found three significant factors (tumor appearance (p=0.009), tumor size (p=0.023), and dilated duct size (p=0.010)) by multivariate analysis. CONCLUSION: Although overall prognosis of IPMT is superior to ordinary pancreatic cancer, more curative surgery is recommended in malignant IPMT. Tumor appearance (papillary), tumor size (> or =30 mm) and dilated duct size (> or = 12 mm) can be used as preoperative indicators of malig-nancy in IPMT.

Clinical & Pathological Characteristics of Intraductal Papillary Mucinous Tumor of the Pancreas

PURPOSE: Intraductal papillary mucinous tumors of the pancreas (IPMT) are becoming increasingly recognized. Despite a better understanding of these conditions, IPMT still present difficulty relating to the predictive factors and the risk of relapse after surgery. The aim of this study was to investigate the clinical, and pathological characteristics of IPMT. METHODS: Between October 1998 and July 2002, 22 patients with IPMT underwent surgery. We retrospectively examined the clinicopathological features and surgical outcomes of these patients. RESULTS: The types of IPMT were as follows: dysplasia (1); adenoma (4); borderline malignancy (9); carcinoma in situ (3); and carcinoma, both non-invasive (3) and invasive (2). Lymph node metastasis was not found, but stromal invasion was found in the 2 cases of invasive carcinoma. The locations of the IPMT were as follows: head (6); uncinate process (11); body (4); and tail (1). There were 11 main duct types, 10 branched duct types and 1 combined. All patients underwent surgical resection, including 3 pancreaticoduodenectomies, 12 pylorus-preserving pancreaticoduodenectomies, 4 distal pancreatectomies with splenectomies, 2 near-total pancreatectomies with splenectomies, and 1 enucleation. There were no operative or hospital deaths. A recurrence of the IPMT following surgery occurred in 2 cases. Their pathological features were a carcinoma in situ and a borderline malignancy, but not the invasive type. However, one case of recurrence expired 7 month after surgery. A combination of other malignancies in these patients was found in 2 cases. CONCLUSION: IPMT has a favorable prognosis, when compared with pancreatic duct carcinoma. However, long-term follow-up after surgery is necessary, even for a curative resection due to a recurrence or a combination of other malignancies. Because combination of other malignancies exist infrequently, surgeons should be aware of the possibility of co-existing other malignancies.

Intraductal Papillary Mucinous Tumor of the Pancreas Still Resectable 5 Years after Diagnosis / 대한소화기내시경학회지

Intraductal papillary mucinous tumor (IPMT) of the pancreas is a spectrum of conditions ranging from benign to malignant. It is known that the biologic behavior of IPMT is slower and less aggressive than that of pancreatic ductal carcinoma. We report a case of IPMT of pancreas resected 5 years after diagnosis. The carcinoma remained localized without evident stromal invasion or lymph node metastasis with the background of adenoma, suggesting a adenomacarcinoma sequence. This is a case report that may be helpful to study the natural history of IPMT, particularly slow progression of IPMT.

Surgical Treatment for Intraductal Papillary Mucinous Tumor of the Pancreas

PURPOSE: The surgical strategy for patients with a pancreatic intraductal papillary mucinous tumor (IPMT) is still controversial. In this study the clinicopathologic findings in a series of patients were used to rationalize surgical choice and reassess the need for a total pancreatectomy. METHODS: Between Oct. 1994 and Nov. 2001, 25 patients with IPMT underwent surgery. We retrospectively examined the clinicopathologic features and surgical treatment. The factors evaluated included: symptoms, tumor site, operation type, histological findings, resection margin, follow-up and survival. RESULTS: Pancreaticoduodenectomy was the most frequent surgical treatment (10 patients: 40%) followed by distal pancreatectomy (6), pylorus-preserving-pancreatico-duodenectomy (5) and total pancreatectomy (4). Histological assessment revealed the tumors to be an adenoma in 11 patients (44%), a borderline tumor in 8 patients (32%) and a carcinoma in 6 patients (24%). There were no operative or hospital deaths. All of the cases with hyperplasia, adenoma and noninvasive carcinoma survived. Only two of the patients with invasive carcinoma died. Mild to moderate dysplasia was present at the resection margin in two patients (8%), and carcinoma in one. A total pancreatectomy was performed in four patients. Invasive carcinoma patient survival was significantly associated with the presence of peri- pancreatic lymph node involvement. CONCLUSION: Our study and review of the literature indicates that preoperative indicators of malignancy in IPMT are still lacking. These results suggest that resection should be the treatment for IPMT. Sometimes IPMT is best treated by a total pancreatectomy, although lesser subtotal resections should definitely be considered. When selecting a surgical procedure for treating these tumors, it is useful to confirm the tumors' extent by intra-operative imaging modalities. In the cases with invasion, a radical resection is required.

A Case of Intraductal Papillary Mucinous Tumor Arising from the Accessory Pancreatic Duct / 대한소화기내시경학회지

Mucin-producing tumors of the pancreas were first reported by Ohhashi and Takagi in 1980. Since then, many cases of intraductal papillary mucinous tumor (IPMT) of the pancreas, which is almost homonymous to mucin-producing tumors of the pancreas, have been reported. IPMTs are generally regarded as tumors with a favorable prognosis. Some IPMTs have invasiveness and this is always associated with a poor prognosis. Most IPMTs arise from the main pancreatic duct and IPMTs arising from the accessory pancreatic duct are relatively rare. Only 6 cases have been reported in the literature so far. Our patient was a 43-year old man who was admitted to the hospital due to recurrent pancreatitis. An endoscopic retrograde pancreatography revealed a patulous minor papilla orifice extruding mucin and a cystic lesion in a branch of the accessory duct. A pancreaticoduodenectomy was performed and a pathologic examination of the resected specimen showed intraductal papaillary mucinous neoplasm, low grade malignancy, in the accessory pancreatic duct and its branch. We herein report this interesting case with a review of the literature.

An Intraductal Papillary Mucinous Tumors (IPMT) of the Pancreas: Clinical, Radiologie, and Pathologie Findings Acccrding to Its Subtypes / 대한소화기내시경학회지

BACKGRONDS/AIMS: Patients with a branch duct type intraductal papillary mucinous tumor (IPMT) of the pancreas with hyperplasia are suggested to be followed up without resection. The aims of this study were to compare the clinical, radiologic, and pathologic findings among the subtypes of IPMT and to find the factors that could predict a hyperplastic lesion preoperatively. METHODS: Twenty two patients with IPMT of the pancreas who underwent surgical resection were investigated. The subtypes of IPMT were classified into the main duct type (7 patients), branch duct type (6 patients), and combined type (9 patients) based on the pathologic findings of the surgical specimens. The clinical, radirologic, and pathoiogic findings of each subtype were analyzed. RESULTS: Asymptomatic patients were more common in the branch duct type of IPMT (p=0.01). The diameter of the main pancreatic duct was <7 mm in most of the branch duet types of IPMT (5/6). Hyperplastic lesions were more likely to be the branch ciuct type (5/6, p=0.01). CONCLUSIONS: A hyperplastic lesion can be predicted if a lesion is the branch duct type of IPMT with the diameter of the main pancreatic duct < 7 mm and without symptoms. Therefore, IPMT of the pancreas with these findings can be followed up without an operation.

A Case of Intraductal Papillary Mucinous Tumor of the Pancreas Presenting with Refractory Acute Pancreatitis / 대한소화기내시경학회지

The clinical presentation of intraductal papillary mucinous tumor (IPMT) of the pancreas is characterized by chronic or recurrent attacks of abdominal discomfort often in association with low level pancreatic enzyme elevations. The episodes of pancreatitis due to IPMT of the pancreas are usually mild in severity. Recently, however, we experienced a case of IPMT of the pancreas causing severe acute pancreatitis with a protracted course in a 65 year-old woman. Initially, she presented with pancreatic ascites and hyperenzynemia without duct ectasia and mucus extrusion through the papillary orifice. Refeeding caused aggravation of hyperenzynemia and abdominal pain. The 4th follow-up abdominal computed tomography taken about 2 months after admission only revealed marked dilatation of the main pancreatic duct. Distal pancreatectomy disclosed IPMT, combined type and carcinoma in situ histologically. The patient has been followed for 2 years after operation with an uneventful clinical course. We herein report a case of IPMT of the pancreas with an unusual presentation.

A case of minute intraductal papillary mucinous tumor of the pancreas presenting with recurrent acute pancreatitis

Intraductal papillary mucinous tumor (IPMT) of the pancreas, a lesion consisting of mucin-producing cells with neoplastic potential, is characterized by duct ectasia, mucin hypersecretion, often extensive papillary intraductal growth, varying degrees of cytologic atypia, and relatively indolent growth. The clinical presentation of IPMT of the pancreas is characterized by chronic or recurrent attacks of abdominal discomfort often in association with low level pancreatic enzyme elevations. Less commonly these lesions may be detected as asymptomatic radiographic abnormalities. Interestingly, a case of a minute IPMT (2 mm in height and 7 mm in length, adenoma) in the main pancreatic duct presenting with acute pancreatitis in a 55 year-old man has been reported in the Japanese literature. Recently, we also experienced a case of a minute IPMT in a branch pancreatic duct causing repeated bouts of acute pancreatitis in a 75 year-old man. A filling defect at the neck of the main pancreatic duct seen on an endoscopic retrograde pancreatogram performed after recovery of the second attack of acute pancreatitis led the patient to undergo an exploratory laparotomy. After a near-total pancreatectomy was carried out, a minute (3 x 7 mm) IPMT of borderline malignancy was discovered in a branch duct at the head portion near the pancreatic neck without any lesions in the main pancreatic duct. Surprisingly, despite the resective surgery the patient died of carcinomatosis 8.5 months after the operation. We herein report a case of a minute but aggressive IPMT of the pancreas with a review of the literature.

A Case of Minute Intraductal Papillary Mucinous Tumor of the Pancreas Presenting with Recurrent Acute Pancreatitis / 대한소화기내시경학회지

Intraductal papillary mucinous tumors (IPMT) of the pancreas is a lesion consisting of mucin-producing cells with neoplastic potential. This unique group of tumors is characterized by duct ectasia, mucin hypersecretion, often extensive papillary intraductal growth, varying degrees of cytologic atypia, and relatively indolent growth. Now IPMT of the pancreas also includes intraductal papillary neoplasms that do not hypersecrete mucin. The clinical presentation of IPMT of the pancreas is characterized by chronic or recurrent attacks of abdominal discomfort often in association with low level pancreatic enzyme elevations. The episodes of pancreatitis due to IPMT of the pancreas are mild in severity. Recently, we was experienced a case of a minute IPMT causing repeated bouts of acute pancreatitis in a 75 year-old man. An endoscopic retrograde pancreatogram revealed a filling defect at the neck of the main pancreatic duct. A near-total pancreatectomy was performed and a minute (3x7 mm) IPMT of borderline malignancy was found in a branch duct at the pancreatic head. Surprisingly, despite the resective surgery the patient died of carcinomatosis. 8.5 months after the operation. This case of a minute but aggressive IPMT of the pancreas is herein reported with a review of the relevant literature.

A Case of Mucin-Hypersecreting Intrahepatic Bile Duct Tumor Combined with Pancreatic Intraductal Papillary Mucinous Tomor (IPMT) / 대한소화기내시경학회지

Intraductal papillary mucinous tumor (IPMT) of the pancreas is a recently understood unique clinicopathologic disease entity comprising approximately 1% of all exocrine pancreatic tumors and 11% of cystic neoplasms of pancreas. It has been reported worldwide, mostly in Japan. It is generally characterized by recurrent pancreatitis, mucin oozing from the papilla of Vater, and dilated pancreatic duct with intraductal filling defects. Microscopically, the mucin-producing columnar epithelium forms papillary proliferation into the dilated pancreatic duct and this feature differentiates IPMT of the pancreas from the more common mucinous cystic neoplasms of the pancreas which usually do not communicate with the pancreatic duct. On the other hand, mucin-hypersecreting bile duct tumors have been rarely reported in the English literature. We herein present the first case of mucin-hypersecreting bile duct tumor combied with IPMT of the pancreas with a review of the related literature.

Eight Cases of Mucin-hypersecreting Cholangiocarcinoma Similar to Intraductal Papillary Mucinous Tumor of the Pancreas / 대한소화기내시경학회지

BACKGROUND/AIMS: Mucin-hypersecreting cholangiocarcinoma is very similar to intraductal papillary mucinous tumor (IPMT) of the pancreas. But this disease is rare and its clinicopathologic features are not well known. The purposes of this study are to report our experience of eight patients with the tumor and to analyze the characteristics of its clinical, radiological and pathological finding. METHODS: Eight patients (3 men and 5 women, mean age 52 years) were diagnosed as having a mucin-hypersecreting cholangiocarcinoma among 4,570 cases of ERCP from 1995 to 1998. RESULTS: Recent or previous attacks of biliary pain or acute cholangitis were elicited in most of the patients. CT showed diffuse intra- and extra-hepatic duct dilatation in all patients and suspicious ill-defined mass shadow in 2 out of 8 patients. On cholangioscopic examination, a papillary mass or minute mucosal lesion was found in the dilated bile duct containing thick viscid mucin. Eight patients were recommended an operation and curative resection was performed in seven patients. Histologically, well-differentiated adenocarcinoma in the background of benign hyperplasia and adenoma was documented in all patients. CONCLUSIONS: Mucin- hypersecreting cholangiocarcinoma may be characterized by exceedingly similarity to IMPT of the pancreas in clinical, radiological and pathological features. Further investigation is needed for detailed information such as natural history and outcome.