Presentation on theme: "Joint Hospital Grand Round"— Presentation transcript:
1Joint Hospital Grand Round Topic: Intraductal papillary mucinous neoplasm (IPMN) of PancreasDr. Chui Lap BunPrince of Wales Hospital16th January, 2010
2Introduction More pancreatic cystic lesions are being detected . Evolution from small benign cystic neoplasms may be very slow and some had high malignant potential and therefore allow selective treatment according to morphological characteristics.
4Intraductal papillary mucinous neoplasm (IPMN) First described in 1982, it is characterized by papillary proliferation of mucin-producing epithelial cells with excessive mucus production and cystic dilatation of main or branch pancreatic ducts.Two-third of IPMN are men.Peak age :Main duct – characterised by marked dilatation of the MPD, diffuse or segmental. Together with atrophy of the pancreas.Branch duct – Multi focal cyst in clusters with mild or no dilatation of MPD
5Intraductal papillary mucinous neoplasm (IPMN) Main duct type: – characterised by marked dilatation of the MPD, diffuse or segmental. Together with atrophy of the pancreas.Branch duct type – Multi- focal cysts in clusters with mild or no dilatation of MPD.
8Main duct IPMN The retire pancreas is replaced by mltiple cysts The pain pancreatic duct appears markedly dilated measuring up to 15.7mm in the pancreatic head.The overall features are suggestive of IPMN, though other cystic pancreatic neoplasms cannot be entirely excluded
10Investigation CT scan MRI + MRCP ERCP- mucin protruding from a widely open papilla.EUS- Detect communication with pancreatic duct and detect mural nodules. Sample cystic fluid and biopsyCyst fluid for cytology, amylase, mucin and CEA
11Malignancy in main duct IPMNs (including mixed type IPMN) Reference (author)Year publishedPatientsMalignant including CIS (%)Invasive malignancy (%)Kobari19991392%23%Terris20003057%37%Doi20021283%-Mastsumoto20032763%Choi3485%Kitagawa3765%54%Sugiyama70%Sohn20046945%Salvia14060%42%Mean43%
12Malignancy in branch duct IPMNs Reference (author)Year publishedPatientsMalignant including CIS (%)Invasive malignancy (%)Kobari19991331%6%Terris20003015%0%Doi20021246%-Mastsumoto200327Choi3425%Kitagawa3735%Sugiyama40%9%Sohn20046930%Mean
13Indication for surgery International Consensus guideline for Management of IPMN and MCN of Pancreas [Pancreatology 2006; 6: 17-32]Main duct and mixed variant IPMNResectionBranch-duct IPMN1. symptomatic (30% malignancy),2. > 3cm in size3. mural nodules
14Extent of surgeryFor invasive IPMN, recurrence after partial pancreatectomy vs total pancreatectomy 67% vs 62% suggested no oncologic advantage of total pancreatecomy.[ Study of recurrence after surgical resection of IPMN of the pancreas. Gastroenterology Nov; 123(5): ]The extent of pancreatic resection remain controversial.
15Extent of surgeryRisk of recurrence Vs. the morbidity of total pancreatectomy.Routine total pancreatectomy for IPMN is not recommended.Total pancreatectomy should only be reserved for patients with resectable but extensive IPMN which involves the whole pancreas.
16Frozen sectionMicroscopic extension of neoplastic cells beyond visible boundaries of the main lesion is common.IPMNs can be multifocal and the margin frequently involved at the time of resectionPositive Margin (LD, MD, HD, invasive) Resect more??
17Frozen sectionClinical Significance of Frozen Section Analysis During Resection of Intraductal Papillary Mucinous Neoplasm: Should a Positive Pancreatic Margin for Adenoma or Borderline Lesion Be Resected Additionally? [J. Am Coll Surg 2009; 209:IPMN with CIS or invasive carcinoma: complete resection if possible.IPM adenoma or borderline lesion: might not need further resectionNegative margin should be the goal of operation when achievable with partial pancreatectomy, but the risk of local recurrence is not high enough to mandate total pancreatectomy for microscopic positive margin. Although some patients may need total pancreatectomy, the benefits of such an aggressive treatment must be balanced against severe permanent endocrine and exocrine pancreatic insufficiency as IPMN is a slow growing disease of elderly with relatively good prognosis.
18Clinical Significance of Frozen Section Analysis During Resection of Intraductal Papillary Mucinous Neoplasm: Should a Positive Pancreatic Margin for Adenoma or Borderline Lesion Be Resected Additionally? [J. Am Coll Surg 2009; 209:DiagnosisInitial IOFSAAdditional resectionRecurrenceNegative8317LD or MD26121HD (CIS)10Invasive cancer6
19Follow up plan Slow growing Residual tumour may develop into carcinoma New IPMN arise from ramnantTime of recurrence ranged from 8-62 monthsNeed regular FU imaging
20Synchronous and metachronous malignancy 23.6 – 32% IPMNs associated with extrapancreatic malignant neoplasm, including gastric, biliary, colorectal and lung malignancy.[ Yamaguchi et, al. Osanai et al., Augiyama et al.]Mayo clinic: IPMN patients with more benign and malignant neoplasms compared with controls– screening colonoscopy should be considered in all patients with IPMN. [Ann Surg 2010; 251: 64-69]
21ConclusionIPMN of the pancreas is uncommon but important because it is slow growing with significant malignant potential.Main duct type should be resected.Branch duct type with tumour > 3cm, mural nodule or positive symptoms warrants surgical resection.High incidence of extrapancreatic malignancies and pancreatic ductal carcinoma.
23Frequency of Extrapancreatic Neoplasms in Intraductal Papillary Mucinous Neoplasm of the Pancreas: Implications for Management.Reid-Lombardo, Kaye; Mathis, Kellie; Wood, Christina; Harmsen, William; Sarr, MichaelAnnals of Surgery. 251(1):64-69, January 2010.DOI: /SLA.0b013e3181b5ad1e2