Clinical Features and Natural History of Serous Cystic Neoplasm of the Pancreas

Aims: To clarify the clinical features and the natural history of serous cystic neoplasm (SCN) of the pancreas. Methods: We retrospectively analyzed data from 30 patients affected by SCN. SCNs were classified as (1) microcystic type, (2) micro- and macrocystic type, and (3) macrocystic type according to the modified WHO classification. Eighteen patients who underwent serial radiographic imaging were identified, and tumor growth rate in these patients was evaluated. Results: The median age was 62 years, and the female:male ratio was 2:1. Twenty-five patients (83%) were asymptomatic and 5 (17%) were symptomatic. The median tumor size was 2.6 cm. Fifteen cases (50%) had the microcystic type, 7 (23%) the micro- and macrocystic type, and 8 (27%) the macrocystic type. Age, gender, symptoms, location or tumor size did not differ significantly among the three subtypes. Eighteen patients were followed up for a median of 58 months. Morphological changes were observed in 3 patients (17%) and enlargement of tumor size in 9 patients (50%) during the follow-up. The growth rate was 0.29 cm per year and doubling time was 3.5 years; these rates did not differ among morphological subtypes or size of tumors. Conclusions: In asymptomatic patients with a clear imaging diagnosis of SCN, non-operative management with a careful follow-up should be recommended. Surgery should be suggested in only symptomatic patients, those with giant tumors (110 cm), rapid growing or when the presence of a potentially malignant tumor cannot be excluded.     

Serous Cystadenoma of the Pancreas: Clinical and Pathological Features in 33 Patients

Aim: To report the clinicopathological features of patients with serous cystadenomas of the pancreas. Methods: Thirty-three cases of serous cystadenoma diagnosed between 1977 and 2006 were retrieved from the files of the Ohio State University Medical Center. Clinical data and microscopic slides were reviewed. Results: The patients included 27 women and 6 men with an age range of 38–83 (mean 64.3) years. The clinical presentation included 13 patients with abdominal pain and 8 patients with abdominal mass; 9 tumors were found incidentally. Abdominal CT scans in 25 patients were interpreted as suspicious for carcinoma in 8 (32%), suspicious for serous cystadenoma in 8, neoplasm not otherwise specified in 8, and suspicious for a pseudocyst in 1.Only 7 patients underwent a preoperative biopsy, and 5 of these were diagnosed as having a serous cystadenoma. All but 2 of the patients underwent surgical resection of the tumor. The serous cystadenomas varied in size from 1.0 to up to 13 cm in maximum dimension, and all but one had a multicystic appearance. Of the 33 serous cystadenomas, 20 (61%) were located in the pancreatic tail, 4 (12%) in the pancreatic body, 4 in the pancreatic body and tail, and 5 (15%) in the head of the pancreas. Follow-up in 17 patients (median 3 years, range from 1 month to 11 years) showed no recurrence of serous cystadenomas. One patient had von Hippel-Lindau syndrome, 4 patients had diabetes mellitus, 3 patients had metastatic cancer, and 2 patients had ovarian tumors. Conclusions: Serous cystadenoma is an uncommon neoplasm that can be confused with malignancy both clinically and radiologically; a correct diagnosis is important in order to provide an accurate prognosis.     

Pancreatoblastoma in Adults: A Review of the Literature

Background: Pancreatoblastoma is a very uncommon neoplasm in adults and its management represents a great challenge with regards to different treatment options. Given the rarity of the disease, the aim of this study was to review our personal experience with adult pancreatoblastoma as well as the cases reported in the literature in order to support clinicians observing this entity. Methods: Adult patients with histologically proven pancreatoblastoma were identified from our prospective database of pancreatic resections. After a search on the Medline database, a review of all cases was performed as well, focusing on clinical, radiological and hystopathological features and treatment options. Results: At our Institution, 2 adult males, 26 and 69 years old, underwent successful pancreatic resection for pancreatoblastoma. The diagnosis of pancreatoblastoma mainly depends on the pathological findings characterized by squamoid corpuscles at histopathology. Only 21 cases of adult pancreatoblastoma have been identified in the literature. In general, despite aggressive treatment, pancreatoblastoma in adults is associated with poorer outcome than in children, with a median survival time of 18.5 months. Both our patients are disease free after 15 months (case 2) and 51 months (case 1). The latter represents the most successful result in long-term disease-free survival. Conclusion: Pancreatoblastoma is a rare neoplasm in adults. The differential diagnosis includes nonfunctional pancreatic endocrine tumor, acinar cell carcinoma, solid pseudopapillary tumor and adenocarcinoma. Surgical resection is the only treatment associated with long-term survival. Chemotherapy may play a role as palliative treatment in advanced disease.     

Frequency of Intraductal Papillary Mucinous Neoplasm in Patients with and without Pancreas Cancer

Purpose: To determine the frequency of intraductal papillary mucinous neoplasm (IPMN) in patients with and without invasive ductal adenocarcinoma (IDAC). Methods: 82 patients underwent pancreatectomy for pancreas adenocarcinoma. 68/82 subjects underwent at least one preoperative imaging study including CT (n = 43), MRI (n = 25), or both (n = 12). Imaging studies were retrospectively evaluated to determine if IPMN was present in the gland at a location distant from IDAC. In 183 different adult patients undergoing MRI for renal mass, images were evaluated to determine the frequency of IPMN. Fisher's exact test was used to test whether the prevalence of IPMN was greater among patients with pancreas cancer than those without. Results: Five of 68 (7.3%) patients who underwent pancreatic resection for IDAC had IPMN at a site distant from the cancer. Two of 182 (1.1%) patients undergoing MRI for renal cancer had imaging evidence of IPMN. There was a significant difference (p = 0.017) in the prevalence of IPMN between patients with and without IDAC. The odds ratio for IPMN as a predictor of pancreas cancer was estimated as 7.18. Conclusion: IPMN occurs with increased frequency in patients with pancreas cancer as opposed to those without pancreas cancer.     

Update on the Molecular Pathogenesis of Pancreatic Tumors Other than Common Ductal Adenocarcinoma

Purpose: Although ductal adenocarcinoma is the most common and well known pancreatic tumor type, other distinct epithelial neoplasms affecting the pancreas that show different symptoms, biological behaviors and outcomes are becoming more frequently recognized and documented. Pancreatic epithelial tumors may be separated into ductal and nonductal neoplasms. The former group includes pancreatic ductal adenocarcinoma, intraductal papillary-mucinous tumor, mucinous cystic tumor and serous cystic tumor. The latter group includes pancreatic endocrine tumor, pancreatic acinar cell carcinoma, pancreatoblastoma and solid-pseudopapillary tumor. The aim of this review is to summarize recently acquired knowledge regarding the molecular characterization of these uncommon pancreatic epithelial neoplasms. Recent Findings: Molecular studies of uncommon pancreatic epithelial tumors suggest that the different morphological entities are associated with distinct molecular profiles, highlighting the involvement of different molecular pathways leading to the development of each subtype of pancreatic neoplasm. Conclusion: The correct classification of rare pancreatic epithelial tumors and the identification of their characteristic molecular aspects is the fundamental starting point in identifying novel diagnostic molecular tools and new targets for innovative therapeutic Strategies.     

Intraductal papillary-mucinous tumor of the pancreas concomitant with ductal carcinoma of the pancreas

Background: Despite the recent progress of diagnostic and therapeutic modalities, the clinical course of patients with ductal carcinoma (DC) of the pancreas remains dismal. Intraductal papillary-mucinous tumor of the pancreas (IPMT) is sometimes accompanied by malignant diseases of the other organs and pancreatic adenocarcinoma. Thus, IPMT may be a potential diagnostic clue to DC of the pancreas at early phase. Methods: Clinico-pathologic findings of 7 Japanese patients with IPMT of the pancreas concomitant with independent DC were examined and compared with those of 69 patients with IPMT alone and of 70 with DC alone. Results: The seven patients corresponded to 9.2% of 76 patients with IPMT and 9.1 % of 77 patients with DC. The seven male patients ranged from 55 to 75 years with a mean of 64.3. DC was synchronous with IPMT in five patients, metachronous to IPMT (4 years after IPMT) in one, and synchronous with IPMT and metachronous to IPMT and DC (7 years after IPMT) in the other. In 4 patients, the presence of IPMT led to the diagnosis of DC. All the 7 IPMTs were of branch type with a mean diameter of 3.0 cm. The IPMT was located in the head of the pancreas in 3, body in 2 and tail in the other 2. All the 7 IPMTs were adenoma with mild dysplasia. Two of the 7 patients with DC had in situ carcinoma, 1 minimally invasive carcinoma and the remaining 4 invasive carcinoma. The mean diameter of seven DCs (3.0 cm) with IPMT were smaller than that of 70 DCs (3.6 cm) (8P = 0.0295). Stage (stage I/II/III/IV = 3/0/3/1) of the seven DCs concomitant with IPMT were significantly earlier than that (stage I/II/III/IV = 5/6/28/31) of the other 70 (p = 0.0203). The survival curve of the 7 patients with IPMT and DC was significantly better than that of the 70 with DC alone (p = 0.0460). Conclusions: Clinicians should pay attention to the possible presence of DC of the pancreas in male patients with intraductal papillary-mucinous adenoma of the pancreas of branch type in their 6th to 8th decades.     

Serum Adenosine Deaminase Levels in Pancreatic Diseases

Background: Adenosine deaminase (ADA) is found in most tissues including the pancreas. Its role in inflammation and malignancy has been studied experimentally. To date, serum ADA levels in pancreatic diseases have not been studied before. Aim: To assess the levels of ADA in patients with pancreatitis and cancer of the pancreas. Methodology: Serum levels of ADA were investigated in 14 cases with acute pancreatitis (mean age 46 years; male/female 5/9), 38 with chronic pancreatitis (mean age 46 years; male/female 25/13), 21 with cancer of the pancreas (mean age 67 years; male/female 11/10), and 21 healthy controls (mean age 40 years; male/female 11/10). The ADA levels were also compared among patients with pancreatic cancer with regard to tumor size and localization and the presence of métastases. Correlation analysis between ADA and CA 19.9 was also performed. Results: Serum ADA levels were 12.66 (9.54–20.72), 12.51 (8.88–26.64), 15.36 (10.20–21.05) and 9.39 (6.58–11.84) U/l in patients with acute pancreatitis, chronic pancreatitis, pancreatic cancer, and healthy controls, respectively. Serum ADA levels were significantly higher in acute and chronic pancreatitis, and pancreatic cancer patients compared to the control group (p < 0.05). Pancreatic cancer patients had significantly higher serum ADA levels when compared with acute and chronic pancreatitis cases (p < 0.05). The serum ADA levels were comparable according to tumor size and location and the presence of metastases. There was a linear correlation between serum ADA and CA 19-9 levels (p = 0.027, r = 0.552). Conclusions: Our data suggest that the ADA enzyme may play a role in inflammatory diseases of the pancreas. Serum ADA levels increase in pancreatic disorders especially in pancreatic cancer. It may be a serum marker for the diagnosis of pancreatic cancer.     

Stenting is unnecessary in duct-to-mucosa pancreaticojejunostomy even in the normal pancreas

Background: There is a high risk of anastomotic leakage after pancreaticojejunostomy after pancreaticoduodenectomy (PD) in patients with a normal pancreas because of the high degree of exocrine function. These PD are therefore generally performed using a stenting tube (stented method). In recent years, we have performed pancreaticojejunostomy with duct-to-mucosa anastomosis without a stenting tube (nonstented method) and obtained good results. Methods: The point of this technique is to preserve adequate patency of the pancreatic duct by carefully picking up the pancreatic duct wall with a fine atraumatic needle and monofilament thread. The results of end-to-side pancreaticojejunostomy of the normal pancreas were compared between the nonstented method (n = 109) and the stented method (n = 39). Results: There were no differences in background characteristics between the groups, including age, gender and disease. The mean duration to complete pancreati-cojejunostomy was 26.6 min in the nonstented group and 29.2 min in the stented group. The mean durations of surgical procedure and intraoperative blood loss were also similar in the groups. Morbidity rates due to early postoperative complications were 20.2 and 23.1%, with pancreatic leakage occurring in 7.3 and 7.7% of patients, respectively. These differences were not statistically significant. One patient in the stented group died of sepsis following leakage of pancreaticojejunostomy. There were also no significant differences in the mean time to initiation of solid food intake or postoperative hospital stay. Conclusion: We conclude that a stenting tube is unnecessary if the duct-to-mucosa anastomosis is completely performed. This operative technique can be considered a basic procedure for pancreaticojejunostomy because of the low risk.     

Incidental Pancreatic Cysts: Do We Really Know What We Are Watching?

Background: Most cystic neoplasms of the pancreas (CNPs) are incidentally discovered. Their management continues to be debated and preoperative diagnosis is often inaccurate. Methods: Retrospective review of 330 patients with inciden-tallydiscovered CNPs. Preoperative and final histological diagnoses were correlated. Results: 41% (136/330) of patients were operated on at diagnosis. 50 patients underwent resection for a presumed branch-duct (Bd) intraductal papillary mucinous neoplasm (IPMN), which was confirmed in only 64% (32/50); of the remaining patients, 20% had main-duct involvement. Mucinous cystic neoplasm was the preoperative diagnosis in 30/136 patients, histologic examination was confirmatory in only 60% (18/30). Most lesions presumed to be main-duct or combined IPMNs or serous cystadenomas were confirmed as such after resection (15/16 and 11/12, respectively). Multifocality was not only associated with Bd-IPMN, and 5% of all cysts were non-neoplastic. Overall, in only 68% of cases did the preoperative and histological diagnoses match. Conclusions: In an experienced, high-volume center, preoperative diagnosis was incorrect in one-third of incidentally discovered CNPs who underwent resection. Of particular concern, 20% of presumed Bd-IPMN had a main-duct component. Conversely, 5% of resected cysts were not even neoplastic. Clearly, better diagnostic methods are needed to aid in formulating appropriate treatment strategies.     

Possible Oncogenesis of Mucinous Cystic Tumors of the Pancreas Lacking Ovarian-Like Stroma

Background/Aims: Clinicopathological features and postoperative results from mucinous cystic tumors of the pancreas (MCTs) were reviewed. MCTs with ovarianlike stroma (MCTs-OLS+; n = 6) and those lacking ovarianlike stroma (MCTs-OLS–; n = 4) were compared to elucidate the oncogenesis of MCT without OLS. Patients and Methods: Ten patients with MCT were studied. Results: The 6 MCTs-OLS+ cases occurred in females and were located in the body and tail of the pancreas. The mean tumor size was 6.5 cm (range 2–11 cm). The majority (5/6) of MCTs-OLS+ were multilocular and exhibited tiny loculi on the cyst wall and septum characteristic of MCTs-OLS+. Pathological classifications were adenoma in 4 patients and noninvasive adenocarcinoma in 2 patients. All 6 patients were alive without tumor recurrence 6–124 months after tumor resection. Of the 4 MCTs-OLS– cases, 2 were males and 2 females; MCTsOLS– were located in the tail of the pancreas. The mean tumor size was 6.9 cm (range 4–8.4 cm). Invasive cancer in the pancreatic parenchyma or extrapancreatic tissue was recognized in all 4 patients, and the pathological classification of epithelia of the cyst wall were adenocarcinomas. These findings were also compatible with common invasive ductal carcinomas of the pancreas with secondary retention cyst on pseudocyst. All patients died of the disease (15, 27, 31 and 80 months after resection, respectively). Whether or not OLS is specific for MCTs of the pancreas should be clarified in future studies. Conclusion: The results of our study led to three hypotheses regarding the oncogenesis of MCTs-OLS–: (1) MCTs in which OLS disappears during the development of invasive carcinoma; (2) advanced cancer derived from intraductal papillary mucinous tumor of the pancreas, and (3) invasive ductal carcinoma of the pancreas with secondary cyst.     

Cancer Risk among the Relatives of Patients with Pancreatic Ductal Adenocarcinoma

Background/Aims: Pancreatic cancer is a leading cause of cancer-related death; the most consistently identified risk factors are smoking and family history. Our aims were to examine familial aggregations of pancreas and other cancers, and to determine the relative risk of the family members. Methods: We prospectively collected data on the families of patients presenting with pancreatic ductal adenocarcinoma. Smoking habits and alcohol consumption of the probands were compared with the available statistics on the Italian population. Mortality from cancer was investigated in first-degree relatives, and age-dependent risks of dying from pancreatic cancer and other tumors were compared with background population levels. Results: Data for 570 families were collected, including 9,204 relatives. Probands were 3- to 5-fold more often heavy smokers than the general population, and 9.3% of them reported a positive family history of pancreatic cancer. In first-degree relatives, only mortality from pancreatic cancer was significantly increased (relative risk at age 85 years = 2.7). Lifetime risk of dying of pancreas cancer was 4.1% for the relatives of all probands, and was 7.2% for the relatives of probands who developed disease before 60 years of age. Conclusions: The data suggest that genetic susceptibility to pancreatic cancer may be attributable, in addition to BRCA2,to moderate-to low-penetrance gene(s).     

FOXP3+ Regulatory T Cells and Tumoral Indoleamine 2,3-Dioxygenase Expression Predicts the Carcinogenesis of Intraductal Papillary Mucinous Neoplasms of the Pancreas

Background and Aims: FOXP3+ regulatory T cells (Tregs) play a central role in self-tolerance and suppress the effective antitumor immune response. A recent study revealed that indoleamine 2,3-dioxygenase (IDO)-mediated tryptophan depletion was able to affect local tumor-infiltrating lymphocytes. The aim of this study was to investigate the clinical significance of the tumor-infiltrating Tregs and tumoral IDO expression during the progression of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. Methods: We investigated the prevalence and localization of FOXP3+ Tregs, CD8+ lymphocytes, and IDO expression in IPMNs by immunohistochemistry. We recruited 39 cases with IPMNs (IPMA; adenoma, n = 11; IPMB; borderline malignancy, n = 9; IPMC; noninvasive carcinoma, n = 7; I-IPMC; invasive IPMC, n = 12). Results: The prevalence of Tregs increased step by step during the carcinogenesis of IPMNs (Kruskal-Wallis test: p < 0.0001). IDO expression in the tumor was observed in 5 cases with IPMNs (IPMC, n = 1; I-IPMC, n = 4). IDO expression in the tumor was positively correlated with the prevalence of Tregs in IPMNs. Conclusions: FOXP3+ Tregs play a role in controlling the immune surveillance against IPMNs at the premalignant stage. IDO expression in the tumor is one of the late-stage phenomena of multistage Carcinogenesis Of IPMNS.     

Long-term follow-up of hepatic hemangiomas by ultrasonography: with emphasis on the growth rate of the tumor

BACKGROUND/AIMS: It is not rare to find hepatic hemangiomas in people in Taiwan where hepatitis B is endemic during ultrasonographic examinations for the screening of hepatocellular carcinoma, and we can therefore monitor these hemangiomas longitudinally since detected. METHODOLOGY: Totally 180 hepatic hemangiomas in 130 adult patients were followed up for more than 5 years with at least twice ultrasound examinations in our hospital. The diagnosis of hemangiomas was made by typical ultrasonographic findings as well as compatible findings in other imaging modalities. The largest diameter of the same tumor at various examinations was compared in each patient. The doubling time of tumor volume was calculated for the enlarging hepatic hemangiomas. RESULTS: The diameters of the 180 hemangiomas ranged from <8 cm - >4 cm in 11 (6.1%), < or =4 cm - >2 cm in 55 (30.6%), and < or =2 cm in 114 (63.3%). Among them, the diameter of 14 (7.7%) hemangiomas in 13 patients increased. The tumor volume doubling time of these hemangiomas ranged from 17.3 to 178.1 months. CONCLUSIONS: Although hepatic hemangiomas are benign, some of them indeed grow slowly. The growth rates of these hemangiomas varied and were definitely slower as compared with those of malignant hepatic tumors.     

Delayed Production of IL-18 in Lungs and Pancreas of Rats with Acute Pancreatitis

Background/Aims: During acute pancreatitis, tumor necrosisfactor(TNF)-α, interleukin (IL)-1 and IL-6 play a pivotal role in promoting injury in the pancreas and remote organs. IL-18 is a more recently discovered proinflammatory cytokine whose expression is also increased in serum. However, the profile of IL-18 expression in the pancreas and lung is unknown, and the aim of our study was to investigate such expression in rats with pancreatitis. Methods: Acute pancreatitis was induced by taurocholic acid and endotoxin. Pulmonary and pancreatic injury was measured by biological and histological parameters. Lung injury was also evaluated in ex vivo lung preparations. Results: Pancreatic and pulmonary injury appeared within 2 h after pancreatitis induction and persisted until the end of the protocol (18 h). TNF-α, IL-1 and IL-6 expression increased early in the lungs and pancreas, with a partial recovery by the end of the study. In contrast, IL-18 increased mostly by the end of the protocol (18 h after pancreatitis induction). Conclusion: IL-18 may serve as an additional marker to monitor the severity of inflammation during pancreatitis since its tissue production is delayed and appears after that of more commonly investigated cytokines.     

Curative reoperations for locally recurrent rectal cancer

PURPOSE: Our aims were to determine the morbidity, survival and its influencing factors, and patterns of failure for patients who underwent further surgery with the hope of cure for locally recurrent rectal cancer. METHODS: Between January 1981 and December 1988, 224 patients with a preoperative diagnosis of recurrent rectal cancer underwent additional surgery at Mayo Medical Center in Rochester, Minnesota. Of these, 65 underwent further surgery with the hope of cure,i.e.,no gross/microscopic residual disease at tumor margins after reoperation. Factors assessed included type of original operation, time interval between operation for primary tumor and initial operation for recurrence, symptom status, degree of fixation, types of reoperations for recurrence, and adjuvant therapy. RESULTS: None of the patients died within 30 days of reoperation. Seventeen complications requiring hospitalization and/or surgical procedure were observed in 14 patients. Extended operations (involving partial or complete removal of surrounding organs/structures) required more time to perform, a greater number of transfusions, and a longer hospital stay than more limited operations. Three-year, five-year, and median survival were 57, 34, and 44.7 months, respectively. Survival was greater after curative than after palliative resection (P <0.001). Survival tended to be greater in females (P <0.075) and in patients without pain (P <0.065). Cumulative probability of local failure was 24, 41, and 47 percent at 1, 3, and 5 years, respectively. Cumulative risk of distant metastasis was 30, 51, and 62 percent at 1, 3, and 5 years, respectively. CONCLUSIONS: Our results indicate that complete excision of locally recurrent rectal cancer can provide a significant number of patients with long-term survival and can be accomplished safely in select patients.     

Is Serous Cystadenoma of the Pancreas a Model of Clear-Cell-Associated Angiogenesis and Tumorigenesis?

Background: Similar to the other von Hippel-Lindau (VHL)-related tumors such as renal cell carcinomas and capillary hemangioblastomas, serous cystadenomas (SCAs) of the pancreas are also characterized by clear cells. Over the years, we have also noticed that the tumor epithelium shows a prominent capillary network. Methods: Eighteen cases of SCA were reviewed histologically, and immunohistochemical analysis was performed for CD31 and vascular endothelial growth factor (VEGF) as well as the molecules implicated in clear-cell tumorigenesis: GLUT-1, hypoxia-inducible factor-1 (HIF-1α), and carbonic anhydrase IX (CA IX). Results: There was an extensively rich capillary networkthat appears almost intraepithelially in all cases of SCA, which was confirmed by CD31 stain that showed, on average, 26 capillaries per every 100 epithelial cells. VEGF expression was identified in 10/18 cases. Among the clear-cell tumorigenesis markers, CA IX was detected in all cases, GLUT-1 and HIF-1α in most cases. Conclusion: As in other VHL-related clear-cell tumors, there is a prominent capillary network immediately adjacent to the epithelium of SCA, confirming that the clear-cell-angiogenesis association is also valid for this tumor type. Molecules implicated in clear-cell tumorigenesis are also consistently expressed in SCA. This may have biologic and therapeutic implications, especially considering the rapidly evolving drugs against these pathways. More importantly, SCA may also serve as a model of clear-cell-associated angiogenesis and tumorigenesis, and the information gained from this tumor type may also be applicable to other clear-cell tumors.     

Laparoscopic distal pancreas resection of an intrapancreatic accessory spleen – Case report

Introduction: Prognosis of patients with pancreas cancer is very poor.Aims: The aim of the study was to test the significance of laboratory parameters in the prognosis of patients with pancreas cancer.Patients and methods: The studied group included 57 patients (31 men, 26 women, mean age 65±9 years). Blood was collected at the time of diagnosis of pancreas cancer and basic laboratory parameters, including nutritional and inflammatory markers and tumour markers were measured. Patients were     

Cystic Lesions of the Pancreas: A Diagnostic and Management Dilemma

Background/Aims: Due to enhanced imaging modalities, pancreatic cysts are being increasingly detected, often as an incidental finding. They comprise a wide range of differing underlying pathologies from completely benign through premalignant to frankly malignant. The exact diagnostic and management pathway of these cysts remains problematic and this review attempts to provide an overview of the pathology underlying pancreatic cystic lesions and suggests appropriate methods of management. Methods: A search was undertaken with a Pubmed database to identify all English articles using the keywords ‘pancreatic cysts’, ‘serous cystadenoma’, ‘intraductal papillary mucinous tumour’, ‘pseudocysts’, ‘mucinous cystic neoplasm’ and ‘solid pseudopapillary tumour’. Results: The mainstay of assessment of pancreatic cysts is cross-sectional imaging incorporating CT and MRI. Fine-needle aspiration (FNA) (often with endoscopic ultrasound) may provide valuable additional information but can lack sensitivity. Symptomatic cysts, increasing age and multilocular cysts (with a solid component and thick walls) are predictors of malignancy. A raised cyst aspirate CEA, CA 19-9 and mucin content (including abnormal cytology), if present, can accurately distinguish premalignant and malignant cysts from benign ones. Conclusion: In summary, all patients with pancreatic cystic lesions, whether asymptomatic or symptomatic, must be thoroughly investigated to ascertain the underlying nature of the cyst. Small asymptomatic cysts (<3 cm) with no suspicious features on imaging or FNA may be safely followed up. Follow-up should continue for at least 4 years, with a repeat FNA if needed. An algorithm for the management of pancreatic cystic tumours is also suggested.     

Surgical outcome of solid pseudopapillary tumor of the pancreas

Background/Purpose

The best surgical treatment for solid pseudopapillary tumor of the pancreas is a matter of debate.

Methods

Fourteen patients with solid pseudopapillary tumor of the pancreas who underwent surgical resection, including enucleation, between June 1996 and January 2007 were retrospectively analyzed to evaluate the effect of the treatment.

Results

The mean age of the patients was 39 years (range, 15 to 59 years). The mean size of the tumor was 4.4 cm (range, 2.0 to 12 cm). Ten tumors (71%) had a well-defined capsule, and 6 tumors (43%) extended beyond the pancreas. Eight of the 14 tumors (57%) had a cystic component, and calcification was observed in 6 tumors (43%). The frequency of microscopic venous invasion, lymphatic invasion, and nerve invasion was 29% (4 of 14), 0%, and 21% (3 of 14), respectively. No lymph node involvement or liver metastasis was observed. Six patients underwent positron emission tomography with 2-deoxy-2-[¹⁸F] fluoro-D-glucose (FDG), and stronger FDG accumulation compared with the surrounding pancreatic parenchyma was observed in 5 of the 6 patients. The median standardized uptake value (SUV) was 6.3 (range, 0.9 to 42.8). Distal pancreatectomy (n = 5), subtotal stomach-preserving pancreatoduodenectomy (n = 3), local resection (n = 3), enucleation (n = 2), and duodenum-preserving pancreatic head resection (n = 1) were performed. Overall morbidity and mortality rates were 43% and 0%, respectively. All patients were still alive without recurrent disease after a median follow-up of 46 months.

Conclusions

Patients with solid pseudopapillary tumor of the pancreas had a favorable outcome after surgical treatment, including enucleation.