Professional Documents
Culture Documents
Met Caz Clinic
Met Caz Clinic
Met Caz Clinic
Anca Moldovan-Pop
V.D., 47 y, woman (12-21.12. 2011):
Admitted for :
investigation of recurrent episodes of acute
pancreatitis
Personal history:
episodes of intense epigastric pain radiating in the
upper left quadrant and in the back since 2004
1-2 episodes/year
constant hyperamylasuria (3560U/l)
weight loss (8-10kg) and steatorrhea since 2011
No history of diabetes
Family history -insignificant
Working-proper
Behaviour-no alcohol intake, non-smoker, no medication
PHYSICAL EXAM
-underweight pacient (BMI=17,63kg/m²)
2. MECHANICAL
Choledocolithiasis
Obstruction-ampullary (e.g., diverticulum, cyst, polyp, tumor, stenosis)
-pancreatic ductal (e.g., tumor, mucinous ductal neoplasia,
nonneoplastic stricture-chronic pancreatitis)
Congenital malformations (e.g., annular pancreas)
Cystic lesion in the head of the pancreas Markedly dilated pancreatic duct with
parenchymal atrophy.
Imaging :MRCP
Important dilation of the Wirsung duct (11mm)
In the head of the pancreas there are multiple cystic
lesions , with the biggest measuring 25mm
communicating with the Wirsung duct.
Filiform aspect of the of the spleno-mesenteric
confluent
Dilation of the intra- and extrahepatic bile ducts
Talamini G, Zamboni G, Salvia R, Capelli P, Sartori N, Casetti L, Bovo P, Vaona B Falconi M, Bassi C,
Scarpa A, Vantini I, Pederzoli P. Intraductal papillary mucinous neoplasms and chronic pancreatitis.
Pancreatology 2006; 6: 626-634
Differential diagnosis
-IPMN -misdiagnosed as chronic pancreatitis because:
Talamini G, Zamboni G, Salvia R, Capelli P, Sartori N, Casetti L, Bovo P, Vaona B, Falconi M, Bassi C, Scarpa A, Vantini I,
Pederzoli P. Intraductal papillary mucinous neoplasms and chronic pancreatitis. Pancreatology 2006; 6: 626-634
Intraductal papillary mucinous neoplasm (IPMN) and chronic pancreatitis: overlapping pathological entities? Two case reports. Petrou A, Papalambros A,
Brennan N, Prassas E, Margariti T, Bramis K, Rozemberg T, Papalambros E. Source Department of Hepatobilary Surgery, Churchill Hospital, Oxford, United
Kingdom.
Differential diagnosis
2. Mucinous cystic tumors:
1. MAIN-DUCT IPMN
2. COMMON BILE DUCT STENOSIS
3. SUSPICION OF SPLENO-MESENTERIC INVASION
Treatment
SURGERY-total pancreatectomy (explained the life-
time diabetes mellitus with insulin)
Spinelli KS,et al. Ann Surg2004;239:651. Fernandez-del Castillo C,et al.SurgClinNorth Am1995;75:1001.
WarshawAL, et al. Ann Surg1990; 212:432
WHO Histological Classification of Neoplastic Pancreatic Cysts
1. Serous cystic tumors
Serous cystadenoma
Serous cystadenocarcinoma
Kloppel G SE, Longnecker DS, Capella C, Sobin LH. Histological typing of tumors of the exocrine pancreas. World Health
Organization International Histological Classification of Tumors. Berlin: Springer Verlag, 1996
Malignant potential
1. Mucinous cystic neoplasm (MCN)
2. Intraductal-papillary mucinous neoplasia (IPMN)
3. Solid pseudopapillary tumors (SPT)
Usually benign:
Serous cystadenomas
Intraductal papillary-mucinous neoplasm of the pancreas (IPMN)
Hruban, 2004;
IPMN
term IPMN -officially adopted in 1996 by WHO
Men = Women
Median age ~ 50 years
75% symptomatic:
- weight loss, abdominal pain
-acute pancreatitis (25%)
-recurrent pancreatitis (20%)
Jimenez R and Fernandez‐del Castillo C. Tumors of The Pancreas. In: Feldman M et al. Sleisenger&Fordtran's Gastrointestinal and
Liver Disease. 9th Edition. Philadelphia: Saunders, 2010
Levy PJ., Clin Gastroenterol Hepatol2006;4:460–468.
IPMN-2 types
Main-Duct IPMN
A.IPMN-adenoma
B.IPMN-borderline
C.IPMN-carcinoma in situ
D.IPMN-invasive carcinoma
adenoma
1. Chronic pancreatitis
2. Mucinous cystic tumors
Positive diagnosis
-tumor locations,
-relationship to surrounding structures
-lymph node involvement,
-metastatic disease
Waters JA, Schmidt CM, Pinchot JW et al. CT vs MRCP: Optimal classification of IPMN type and extent J Gastrointest Surg
2008;12:101–109.
EUS
Identifies dilation of the pancreatic
duct in the absence of chronic pancreatitis
or obstructing mass
Sugiyama M, Atomi Y, Saito M. Intraductal papillary tumors of the pancreas: evaluation with endoscopic
ultrasonography. Gastrointest Endosc 1998; 48:164.)
EUS-differentiating between benign and malignant IPMN
Accuracy 86%
Sensitivity 77%
Specificity 89%
Hiroaki K, Ioshiharo C. et al, Intraductal-papillary mucinous tumors of the pancreas. Differential diagnosis between
benign and malignant tumors by endoscopic ultrasonography. The American Journal of Gastroenetrology
(2001) 96; 1429-1434
ERCP
Patulous ampulla of Vater
extruding mucus (20% –50%)
Fritz S, Hackert T, Hinz U, et al. Role of serum carbohydrate antigen 19-9 and carcinoembryonic antigen in
distinguishing between benign and invasive intraductal papillary mucinous neoplasm of the pancreas.
Br J Surg 2011; 98:104.
Treatment
Prediction of malignancy:
-main-duct IPMN (60% of resected IPMN harbor cancer)
-age (6,4 y diff between be-ma)
-symptoms ( jaundice and/or worsening of diabetes)
(Salvia R, Fernández-del Castillo C, Bassi C Thayer SP, Falconi M, Mantovani W, Pederzol P, Warshaw AL: Main duct
intraductal papillary mucinous neoplasms of the pancreas: clinical predictors of malignancy and longterm survival
following resection. Ann Surg 2004; 239: 678–687.
Sendai consensus guideline
Most if not all benign lesions of main-duct IPMN
may progress to invasive cancer (60-92%)
Thompson LD, Becker RC, Przygodzki RM, Adair CF, Heffess CS: Mucinous cystic neoplasm of lowgrade
malignant potential) of the pancreas: a clinicopathologic study of 130 cases. Am J Surg
Pathol 1999; 23: 1–16.
partial/total pancreatectomy?
Surgery
The most common operation is pancreaticoduodenectomy (70%)
because most tumors are in the head of the pancreas.
Paye F, Sauvanet A, Terris B, et al. Intraductal papillary mucinous tumors of the pancreas: pancreatic resections guided by
preoperative morphological assessment and intraoperative frozen section examination. Surgery 2000; 127:536.
Salvia R, Fernández-del Castillo C, Bassi C Thayer SP, Falconi M, Mantovani W, Pederzol P, Warshaw AL: Main duct
intraductal papillary mucinous neoplasms of the pancreas
Surgery
if multiple lesions (multifocality/”field defects”) or
concerning radiologic or endoscopic features, total
pancreatectomy may be considered
Salvia R,et al. Clinical Ann Surg2004;239:678. D'AngelicaM,et al. Ann Surg2004;239:400.
Evolution of the case
Returns in 1.03.2012 (after 2 and ½ month) with
cholangitis
Gastric mild
atypia
Intestinal
(coloid carcinoma)
Pancreato-biliary
(tubular carcinoma)
Oncocytic severe
atypia