BACKGROUND:Surgical resection for intraductal papillary mucinous neoplasm (IPMN) of the pancreas has increased over the last decade. While IPMN with main duct communication are generally recommended for resection, indications for resection of side-branch IPMN (SDIPMN) have been less clear. We reviewed our single institutional experience with SDIPMN and indications for resection.
METHODS:Patients who underwent resection for IPMN were identified from a prospectively maintained IRB-approved database. Patients with main pancreatic duct communication were excluded. Outcome, clinical and pathologic characteristics were correlated with endoscopic ultrasound (EUS) findings.
RESULTS:From 2000 to 2010, 105 patients who underwent preoperative EUS evaluation and resection for SDIPMN were identified. The mean age was within the sixth decade of life, and there was a slight female predominance (55 vs. 45 %). The most common presenting symptom was abdominal pain (N = 47, 45 %), followed by jaundice (N = 24, 23 %) and weight loss (N = 24, 23 %). Only ten patients (10 %) were asymptomatic at presentation; seven (70 %) had suspicious features on EUS. Of the total cohort, few patients had intracystic septations (N = 27, 26 %) or presence of mural nodules (N = 2, 2 %) on EUS. Of 39 patients who had invasive pancreatic ductal adenocarcinoma (PDAC) on final pathology, EUS-fine needle aspiration (EUS-FNA) demonstrated malignancy in only 21 (54 %). An additional seven (18 %) had EUS-FNA findings of atypia or concern for mucinous neoplasm. EUS evaluation of cyst size was correlated with final pathology. Of 70 patients with EUS cyst size <3 cm, 12 (17 %) had a preoperative EUS diagnosis of malignancy. Final pathology revealed 24 (34 %) to have PDAC: 1 of 7 (14 %) patients with cyst size <1 cm, 2 of 19 (11 %) with cyst size 1-2 cm, and 21of 44 (48 %) with cyst size 2-3 cm. Fifteen of 35 (43 %) patients with cyst size >3 cm had PDAC on final pathology. Of the patients with cyst size <3 cm, 16 (23 %) had high-grade dysplasia on final pathology: 3 of 7 (43 %) with cyst size <1 cm, 3 of 19 (16 %) with cyst size 1-2 cm, and 10 of 44 (23 %) with cyst size 2-3 cm. Seven of 35 (20 %) patients with cyst size >3 cm had high-grade dysplasia on final pathology. Although overall survival (OS) at 48 months stratified by EUS cyst size did not significantly differ between groups, patients with PDAC on final pathology had significantly worse OS compared to noninvasive pathology. A total of eight patients (8 %) developed recurrent disease, all of whom had PDAC on final pathology.
CONCLUSION:EUS is a helpful modality for the diagnostic evaluation of SDIPMN. Considering the high incidence of malignancy as well as high-grade dysplasia in SDIPMN greater than 2 cm, EUS features should be used in conjunction with other clinical criteria to guide management decisions. Patients with SDIPMN greater than 2 cm that do not undergo surgical resection may benefit from more intensive surveillance.
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【High-grade dysplasia and adenocarcinoma are frequent in side-branch intraductal papillary mucinous neoplasm measuring less than 3 cm on endoscopic ultrasound.].
【内镜超声检查不到3 cm的侧支导管内乳头状黏液性肿瘤常发生高度不典型增生和腺癌。】
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DOI：10.1007/s11605-012-2017-0文章类型：杂志文章
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背景：过去十年来，胰腺导管内乳头状粘液性肿瘤（IPMN）的手术切除有所增加。虽然通常建议使用IPMN与主导管通信进行切除，但对于旁支IPMN（SDIPMN）切除的指征尚不明确。我们回顾了我们在SDIPMN方面的单一机构经验以及切除的适应症。
方法：从经过前瞻性维护的IRB批准的数据库中鉴定接受IPMN切除的患者。排除主要胰管沟通的患者。结果，临床和病理特征与内镜超声检查（EUS）相关。
结果：从2000年至2010年，确定了105例接受了术前EUS评估并切除SDIPMN的患者。平均年龄在生命的第六十年以内，女性占主导地位（55％对45％）。最常见的症状是腹痛（N = 47，45％），其次是黄疸（N = 24，23％）和体重减轻（N = 24，23％）。就诊时仅10例（10％）无症状;七分（70％）的EUS具有可疑特征。在整个队列中，很少有患者在超声内镜下出现囊内分隔（N = 27，26％）或有壁结节（N = 2，2％）。在39例最终病理诊断为浸润性胰腺导管腺癌（PDAC）的患者中，EUS细针穿刺术（EUS-FNA）仅显示21例恶性肿瘤（54％）。 EUS-FNA发现另外7例（18％）为非典型性或粘液性肿瘤。 EUS对囊肿大小的评估与最终病理相关。 EUS囊肿大小<3 cm的70例患者中，有12例（17％）术前经EUS诊断为恶性。最终病理结果显示24（34％）患有PDAC：囊肿尺寸<1 cm的患者中有7（14％）1例，囊肿尺寸1-2 cm的患者中有19（11％）中的2人，囊肿尺寸为1-2 cm的患者中有21（44％）囊肿大小2-3厘米在35例（43％）囊肿尺寸大于3厘米的患者中，其最终病理结果为PDAC。囊肿大小<3 cm的患者中，最终病理表现为高度不典型增生：7例囊肿中的3个（43％）囊肿大小<1 cm，19例囊肿中的3例（16％）囊肿大小为1- 2厘米，44个中的10个（23％），囊肿大小2-3厘米。 35例囊肿大小> 3 cm的患者中有7例（20％）在最终病理上表现为高度不典型增生。尽管各组之间按EUS囊肿大小分层的48个月总生存率（OS）没有显着差异，但与无创病理学相比，具有最终病理学特征的PDAC患者的OS明显较差。共有8例患者（8％）患有复发性疾病，所有患者均在最终病理学上患有PDAC。
结论：超声内镜对SDIPMN的诊断评价有帮助。考虑到SDIPMN中恶性肿瘤的高发率以及高度不典型增生大于2 cm，应将EUS功能与其他临床标准结合使用以指导管理决策。 SDIPMN大于2厘米且未进行手术切除的患者可受益于更深入的监测。
方法：从经过前瞻性维护的IRB批准的数据库中鉴定接受IPMN切除的患者。排除主要胰管沟通的患者。结果，临床和病理特征与内镜超声检查（EUS）相关。
结果：从2000年至2010年，确定了105例接受了术前EUS评估并切除SDIPMN的患者。平均年龄在生命的第六十年以内，女性占主导地位（55％对45％）。最常见的症状是腹痛（N = 47，45％），其次是黄疸（N = 24，23％）和体重减轻（N = 24，23％）。就诊时仅10例（10％）无症状;七分（70％）的EUS具有可疑特征。在整个队列中，很少有患者在超声内镜下出现囊内分隔（N = 27，26％）或有壁结节（N = 2，2％）。在39例最终病理诊断为浸润性胰腺导管腺癌（PDAC）的患者中，EUS细针穿刺术（EUS-FNA）仅显示21例恶性肿瘤（54％）。 EUS-FNA发现另外7例（18％）为非典型性或粘液性肿瘤。 EUS对囊肿大小的评估与最终病理相关。 EUS囊肿大小<3 cm的70例患者中，有12例（17％）术前经EUS诊断为恶性。最终病理结果显示24（34％）患有PDAC：囊肿尺寸<1 cm的患者中有7（14％）1例，囊肿尺寸1-2 cm的患者中有19（11％）中的2人，囊肿尺寸为1-2 cm的患者中有21（44％）囊肿大小2-3厘米在35例（43％）囊肿尺寸大于3厘米的患者中，其最终病理结果为PDAC。囊肿大小<3 cm的患者中，最终病理表现为高度不典型增生：7例囊肿中的3个（43％）囊肿大小<1 cm，19例囊肿中的3例（16％）囊肿大小为1- 2厘米，44个中的10个（23％），囊肿大小2-3厘米。 35例囊肿大小> 3 cm的患者中有7例（20％）在最终病理上表现为高度不典型增生。尽管各组之间按EUS囊肿大小分层的48个月总生存率（OS）没有显着差异，但与无创病理学相比，具有最终病理学特征的PDAC患者的OS明显较差。共有8例患者（8％）患有复发性疾病，所有患者均在最终病理学上患有PDAC。
结论：超声内镜对SDIPMN的诊断评价有帮助。考虑到SDIPMN中恶性肿瘤的高发率以及高度不典型增生大于2 cm，应将EUS功能与其他临床标准结合使用以指导管理决策。 SDIPMN大于2厘米且未进行手术切除的患者可受益于更深入的监测。
