review of literature on clinical pancreatology - The Pancreapedia

Growth rateOne study reported the growth rate in two cases <strong>of</strong> main duct pancreatic intraductal papillarymucinousneoplasms (MD-IPMNs) demonstrating significant changes over several years'observation. The first patient was a 74-year-old woman with an incidental finding <strong>of</strong> diffusedilatation <strong>of</strong> the main pancreatic duct (MPD). Endoscopic retrograde pancreatography (ERP)identified a 5 mm filling defect. Three years later computed tomography (CT) revealed a 20mm mass occupying the MPD. The second patient was a 67-year-old woman who presentedwith back pain. Abdominal CT revealed a 5 mm mass in the dilated MPD. Five years later,CT and ERP showed a 20 mm mass occupying the markedly dilated MPD. Both patientssubsequently underwent pancreatectomy. Histologically, the tumors showed an intraductalpapillary growth occupying the dilated main pancreatic duct and comprised <strong>of</strong> mucincontainingcolumnar epithelial cells. The tumor volume doubling time <strong>of</strong> these MD-IPMNswas 141 and 304 days in patient 1 and 2, respectively, with a mean <strong>of</strong> 223 days. The presentreports demonstrate the ability <strong>of</strong> benign MD-IPMNs to grow at a significant rate, supportingthe current consensus guidelines that MD-IPMNs require surgical resection [576].Ways <strong>of</strong> detectionTo define how patients with pancreatic cysts are being diagnosed and treated 401 patientswere evaluated between 2004 and 2007. Pancreatic cysts were incidentally discovered in 71percent (284 <strong>of</strong> 401) <strong>of</strong> patients. There was no statistically significant difference in age (60 vs63 years), cyst size (31 vs 27 mm), or histological diagnosis between symptomatic patientsand patients with incidentally discovered cysts. Whereas the majority <strong>of</strong> symptomatic patientshad their cystic neoplasms resected on diagnosis, 50 percent (142 <strong>of</strong> 284) <strong>of</strong> incidentallydiscovered cysts were initially managed nonoperatively. Of the patients who were managedwith surveillance, 13 (8 %) subsequently underwent resection after a median <strong>of</strong> 2.1 yearsbecause <strong>of</strong> an increase in cyst size, development <strong>of</strong> symptoms, increasing tumor markers,worrisome endoscopic ultrasonography findings, or patient anxiety. The most commondiagnosis among resected lesions was either main-duct intraductal papillary mucinousneoplasm (25 %) or branch-duct intraductal papillary mucinous neoplasm (23 %). Invasivecancer was found in 29 <strong>of</strong> 256 (11 %) resected cystic neoplasms, 9 <strong>of</strong> which wereincidentally discovered, and in 7 percent (1 <strong>of</strong> 13) <strong>of</strong> patients who underwent watchful waitingprior to resection. Incidentally discovered pancreatic cystic neoplasms composed 71 percent<strong>of</strong> our series, <strong>of</strong> which 50 percent were immediately resected. Subsequent morphologicchanges or development <strong>of</strong> symptoms prompted an operation in 8 percent <strong>of</strong> patients after aperiod <strong>of</strong> surveillance. Invasive malignancy was present in 11 percent <strong>of</strong> all resectedspecimens but in 38 percent <strong>of</strong> main-duct intraductal papillary mucinous neoplasms [577].Intraductal papillary mucinous neoplasms have gained recognition in recent years aspremalignant precursors to pancreatic cancer that enable early detection and <strong>of</strong>ten are foundincidentally at imaging. Accurate diagnosis and optimal, finely tuned management <strong>of</strong> theselesions are important and require collaboration across various disciplines, includingradiology, endoscopy, surgery, and pathology. Several imaging modalities can visualizethese lesions adequately, each with specific advantages and disadvantages. Multidetectorcomputed tomography and magnetic resonance cholangiopancreatography are generally thefirst-line imaging modalities; endoscopic imaging such as endoscopic ultrasound andendoscopic retrograde cholangiopancreatography are beneficial when the former 2modalities are equivocal. Surgical candidates generally include patients with main ductlesions or branch duct lesions greater than 3 cm or any possessing a solid component. Amanagement algorithm indicating when surgery should be pursued was proposed. Fornonsurgical and postsurgical patients, follow-up management is important to monitor growthand recurrence, and risks from repeated radiation exposure should be taken into account.Furthermore, issues <strong>of</strong> multifocality and increased predisposition <strong>of</strong> the pancreas to ductal