胰腺导管内乳头状黏液性肿瘤的研究进展

胰腺导管内乳头状黏液性肿瘤（IPMNS）在所有类型胰腺肿瘤中,其预后相对较好,具有与一般胰腺肿瘤不同的分子及临床病理特征,深入研究IPMNS,能更好地了解IPMNs在临床、影像学以及病理学表现方面的特点。     

胰腺导管内乳头状黏液性肿瘤的临床病理学分析

胰腺导管内乳头状黏液性肿瘤（IPMN）是近几年才被逐渐认识的一类胰腺囊性肿瘤，约占临床诊断胰腺肿瘤的7．5％和手术切除胰腺肿瘤的16．3％，具有产生大量黏液蛋白、胰腺导管囊性扩张和伴有导管内乳头生成的特点。本文总结我院近年来诊治的24例IPMN患者的临床病理学资料，报告如下。[第一段]     

组织病理学分型在胰腺导管内乳头状黏液性肿瘤中的临床意义

胰腺导管内乳头状黏液性肿瘤(IPMN)是一类少见的胰腺囊性肿瘤,以胰腺导管上皮细胞乳头状异常增生合并大量黏液产生为特点。IPMN根据累及胰管不同,可以分为主胰管型、分支胰管型及混合型,病理学上表现为腺瘤至浸润癌多种类型。根据细胞形态及表达黏蛋白不同,可以分为胃型、肠型、胰胆管型及嗜酸细胞型。笔者结合既往文献及团队实践经验,分析组织病理学分型在胰腺IPMN中的临床意义,旨在提高外科医师对胰腺IPMN不同组织病理学类型的认识。     

胰腺导管内乳头状黏液性肿瘤的临床病理学分析(附29例报告)

目的：回顾性分析胰腺导管内乳头状黏液性肿瘤（IPMT）的诊治经验及预后,以期提高对该病的治疗水平。方法：1993年5月至2006年8月,共29例IPMT病人在我院接受手术治疗,男17例,女12例。现回顾性分析其临床表现、病理学分类以及术后随访情况。结果：术后病理证实,本组共有11例是类腺瘤,2例交界性肿瘤,16例腺癌。其中,主胰管型11例,分支胰管型16例,混合型2例。2例病人由于病变累及全胰而施行全胰切除术,其余病人分别施行胰十二指肠切除术（16例）、胰体尾切除术（7例）及局部切除术（4例）。在腺癌病例中,有37.5%（6/16）发生淋巴结转移。结论：IPMT有独特的临床病理学特征。对主胰管直径≥10mm、肿瘤直径〉40mm以及主胰管型病例,应高度怀疑恶性病变的可能性。如术前考虑IPMT有恶性可能,则应施行合并淋巴结清扫的根治性切除术。     

胰腺导管内乳头状黏液性肿瘤的诊治策略

胰腺导管内乳头状黏液性肿瘤（intraductal papillary mucinous neoplasm,IPMN）分主胰管型、混合型和分支胰管型。主胰管型、混合型和有症状的分支胰管型IPMN建议行手术切除,对恶性IPMN,需行规则性胰腺切除。对良性和交界性IPMN,可行功能保留性胰腺手术。对暂时不行手术切除的IPMN病人,应定期随访。IPMN的治疗决策需综合考虑各方面因素,包括病人的预期寿命、身体状况、治疗意愿、依从性、随访的条件等加以综合评估,最后形成个体化的治疗方案。     

胰腺导管内乳头状黏液性肿瘤的诊断与治疗

目的提高对胰腺导管内乳头状黏液性肿瘤(IPMTs)的认识,以改善其诊治水平。方法对1993年5月至2003年12月收治的15例IPMTs病人的临床、影像学表现及病理资料作回顾性分析。结果15例中男性12例,女性3例。年龄33～76岁,平均58岁。上腹痛为最常见症状。B超和CT检查,均提示有不同程度的胰管扩张和囊实性占位。11例行ERCP检查,发现十二指肠乳头肿大和黏液溢出者7例。14例行手术治疗(胰十二指肠切除术12例,胰体尾切除1例,全胰切除1例)。术后病理诊断胰头导管内乳头状黏液性腺癌3例、导管内乳头状黏液性腺瘤伴局部癌变6例、胰头导管内乳头状黏液性腺瘤伴不典型增生3例、胰头导管内乳头状黏液性腺瘤2例,术后除1例因肝广泛转移而死亡外,其余病人均健在,存活期最长1例已13年。结论胰腺有囊实性占位伴胰管全程扩张的病人应考虑IPMTs,ERCP发现十二指肠乳头增大有黏液溢出者可确诊该疾病。手术切除是最有效的治疗,术后预后良好。     

胰腺导管内乳头状黏液性肿瘤研究进展

随着CT和MRI等影像技术的应用和发展,临床上越来越多的胰腺囊性疾病得到诊断。胰腺导管内乳头状黏液性肿瘤(intraductal papillary mucinous neoplasm,IPMN)作为肿瘤性胰腺囊性疾病的重要病理分支,在近年来成为研究热点。在有的医疗中心,IPMN已经成为胰腺切除术的第二常     

58例胰腺导管内乳头状黏液性肿瘤临床分析

目的探讨胰腺导管内乳头状黏液性肿瘤(intraducta[papillary mucinous neoplasm,IPMN)的诊断和治疗。方法回顾性分析2004年12月至2014年12月10年间收治58例IPMNs病人的临床资料、病理分型、治疗方式。男性36例,女性22例,男女比例为1.6:1,年龄39~82岁,中位年龄67岁。58例IPMNs病人均行手术治疗。其中行胰十二指肠切除术31例(53.45%),胰头部局部切除术9例(15.52%),胰体尾切除术7例(12.07%),胰体部局部切除术4例(6.90%),胰尾切除术4例(6.90%),胰尾联合脾切除1例(1.72%),全胰腺切除2例(3.44%)。结果58例IPMNs病人中主胰管型26例;分支胰管型9例;混合型23例;术后病理:腺瘤26例,交界瘤13例,非浸润癌10例,浸润性癌9例;全组的中位生存期为42.6个月;1、2和5年的生存率分别为94.5%、79.3%和65.5%。其中病理类型为浸润性癌的病人1、2、5年生存率分别为62.5%、47.5%、12.5%。结论IPMN是一种比较罕见的肿瘤,手术治疗是目前比较好的治疗方式。     

胰腺导管内乳头状黏液性肿瘤的诊断与治疗

[摘 要] 目的 提高对胰腺导管内乳头状黏液性肿瘤（intraductal papillary mucinous neoplasm,IPMN）的认识和诊治水平。方法 对2005年7月至2017年3月洛阳市第二中医院普外科收治的19例IPMN患者的临床资料进行回顾性分析。结果 19例胰腺PIMN患者主胰管型6例（31.6%）,分支胰管型9例（47.4%）,混合型4例（21.1%）;12例胰腺IPMN行胰十二指肠切除术,其中1例行胰十二指肠并门静脉切除术;3例行胰体尾切除术;4例行胰腺局部切除术。结论 胰腺导管内乳头状黏液性肿瘤是一种预后较好的胰腺肿瘤,早期手术切除疗效满意,预后良好。     

Prognosis of invasive intraductal papillary mucinous neoplasms of the pancreas

Intraductal papillary mucinous neoplasms (IPMN) are mucin producing cystic neoplasms of the pancreas histologically classified as having non-invasive and invasive components. The five-year survival rates for non-invasive and associated invasive carcinoma are 90% and 40%, respectively in resected IPMN lesions. Invasive carcinoma within IPMN lesions can be further classified by histological subtype into colloid carcinoma and tubular carcinoma. Estimated five-year survival rates following resection of colloid carcinoma range from 57%-83% and estimated five-year survival following resection of tubular carcinoma range from 24%-55%. The difference in survival outcome between invasive colloid and tubular IPMN appears to be a function of disease biology, as patients with the tubular subtype tend to have larger tumors with a propensity for metastasis to regional lymph nodes. When matched to resected conventional pancreatic adenocarcinoma lesions by the Memorial Sloan Kettering Cancer Center pancreatic adenocarcinoma nomogram, the colloid carcinoma histological subtype has an improved estimated five-year survival outcome compared to conventional pancreatic adenocarcinoma, 87% and 23% (P = 0.0001), respectively. Resected lesions with the tubular carcinoma subtype overall have a similar five-year survival outcome compared to conventional pancreatic adenocarcinoma. However, when these groups were stratified by regional lymph node status patients with negative regional lymph nodes and the tubular subtype experienced significantly better survival than patients with a similar nodal status and ductal adenocarcinoma with estimated five-year survival rates of 73% and 27% (P = 0.01), respectively.     

76例胰腺导管内乳头状黏液性肿瘤的外科治疗及预后分析

目的 分析胰腺导管内乳头状黏液性肿瘤患者的临床特征及手术疗效.方法 收集1999年1月至2008年12月复旦大学附属中山医院手术切除的76例胰腺导管内乳头状黏液性肿瘤的病史资料,并进行随访,分析其临床特征及手术疗效.结果 76例患者中,男性49例,女性27例;肿瘤位于胰头者63例,胰体尾10例,全胰3例;32例为非浸润性肿瘤(腺瘤16例,交界性肿瘤6例,原位癌10例),44例为浸润癌,两者在发病年龄及黄疸、消瘦、无症状患者、CA199升高等方面差异有统计学意义(P＜0.05);胰十二指肠切除59例,联合门静脉切除重建4例,胰体尾切除6例,局部切除2例,节段性胰腺切除2例,全胰切除3例;总体并发症发生率为28.9%,无手术相关死亡病例;非浸润性及浸润性肿瘤患者5年生存率分别为100%及35%;非浸润性肿瘤患者7例切缘阳性,其中1例术后67个月复发转移;多因素分析显示肿瘤直径及淋巴结状况是影响浸润性癌患者预后的独立因素.结论 非浸润性胰腺导管内乳头状黏液性肿瘤手术疗效极佳,而浸润癌患者的预后较差;及早手术是防止病变进展及改善预后的关键;术后必须进行长期随访.

Abstract：

Objective To investigate the outcome of intraductual papillary mucious neoplasms (IPMN) of the pancreas after surgical resection. Method Clinical data of 76 patients with intraductal papillary neoplasms of the pancreas undergoing surgical resection at Zhongshan Hospital, Fudan University between January 1999 and December 2008 were retrospectively analyzed. Results Among the 76 patients,49 were male, 37 were female. 32 had noninvasive IPMNs, including adenomas( n = 16), borderline tumors (n =6 ), carcinomas in situ (n = 10 ). 44 had invasive IPMNs. Lesions were present in the head in 63 cases, in the body or tail in 10, in the whole pancreas in 3. There were significant difference in age,jaundice, weight loss, asymptomatic cases and CA199 value between noninvasive and invasive IPMNs.Three patients underwent total pancreatectomy, 59 patients underwent pancreaticoduodenectomy, 4 patients underwent pancreaticoduodenectomy with portal vein resection and reconstruction, six patients underwent distal pancreatectomy, two patients each underwent central pancreatectomy or enucleation. The overall postoperative morbidity rate were 28.9%, there was no operative mortality. Positive pancreatic margin was identified in seven patients of noninvasive neoplasms, among thoee one developed recurrence after 67 months. The five-year survival rate for patients with noninvasive and invasive neolpasms was 100% and 35% ,respectively. Size and lymph node metastasis were significant prognostic factors after surgical resection of the invasive IPMNs. Conclusions Surgical resection provides a favorable outcome for patients with noninvasive IPMNs. In contrast, invasive IPMNs was associated with a poor survival. Early resection is essential for improving survival. Long-term follow-up is necessary for all patients with IPMNs after resection.     

Differentiating intraductal papillary mucinous neoplasms from other pancreatic cystic lesions

Intraductal papillary mucinous neoplasms (IPMN) can be difficult to distinguish from other cystic lesions of the pancreas. To understand better and discuss the current knowledge on this topic, the literature and the institutional experience at a large pancreatic disease center have been reviewed. A combination of preoperative demographic, historical, radiographic, laboratory data, as well as postoperative pathologic analyses can often distinguish IPMN from other lesions in the differential diagnosis.     

Imaging considerations in intraductal papillary mucinous neoplasms of the pancreas

With the widespread use of cross-sectional imaging, particularly computed tomography (CT) and magnetic resonance imaging (MRI), and the continuous improvement in the image quality of these techniques, the diagnosis of incidental pancreatic cysts has increased dramatically in the last decades. While the vast majority of these cysts are not clinically relevant, a small percentage of them will evolve into an invasive malignant tumor making their management challenging. Mucinous cystic neoplasms and intraductal papillary mucinous neoplasms (IPMN) are the most common pancreatic cystic lesions with malignant potential. Imaging findings on CT and MRI correlate tightly with the presence of malignant degeneration in these neoplasms. IPMN can be classified based on their distribution as main duct, branch duct or mixed type lesions. MRI is superior to CT in demonstrating the communication of a branch duct IPMN with the main pancreatic duct (MPD). Most branch duct lesions are benign whereas tumors involving the MPD are frequently associated with malignancy. The presence of solid nodules, thick enhancing walls and/or septae, a wide (> 1 cm) connection of a side-branch lesion with the MPD and the size of the tumor > 3 cm are indicative of malignancy in a branch and mixed type IPMN. A main pancreatic duct > 6 mm, a mural nodule > 3 mm and an abnormal attenuating area in the adjacent pancreatic parenchyma on CT correlates with malignant disease in main duct and mixed type IPMN. An accurate characterization of these neoplasms by imaging is thus crucial for selecting the best management options. In this article, we review the imaging findings of IPMN including imaging predictors of malignancy and surgical resectability. We also discuss follow-up strategies for patients with surgically resected IPMN and patients with incidental pancreatic cysts.     

Diagnostic and therapeutic endoscopic approaches to intraductal papillary mucinous neoplasm

Pancreatic cystic lesions are increasingly identified on routine imaging. One specific lesion, known as intraductal papillary mucinous neoplasm (IPMN), is a mucinous, pancreatic lesion characterized by papillary cells projecting from the pancreatic ductal epithelium. The finding of mucin extruding from the ampulla is essentially pathognomonic for diagnosing these lesions. IPMNs are of particular interest due to their malignant potential. Lesions range from benign, adenomatous growths to high-grade dysplasia and invasive cancer. These mucinous lesions therefore require immediate attention to determine the probability of malignancy and whether observation or resection is the best management choice. Unresected lesions need long-term surveillance monitoring for malignant transformation. The accurate diagnosis of these lesions is particularly challenging due to the substantial similarities in morphology of pancreatic cystic lesions and limitations in current imaging technologies. Endoscopic evaluation of these lesions provides additional imaging, molecular, and histologic data to aid in the identification of IPMN and to determine treatment course. The aim of this article is to focus on the diagnostic and therapeutic endoscopic approaches to IPMN.     

Endoscopic diagnosis and staging of mucinous cystic neoplasms and intraductal papillary-mucinous tumors

Background/Purpose. The number of patients with cystic neoplasms of the pancreas as detected using various types of imaging techniques has been steadily increasing. Among the cystic neoplasms, mucinous cystic neoplasms (MCNs) and intraductal papillary-mucinous tumors (IPMTs) were comparatively more frequently encountered. We used imaging techniques to focus on the differential diagnosis of MCNs and IPMTs, and tumor staging.Methods. Fifteen patients with MCNs with ovarian-like stroma and 109 patients with IPMTs were experienced. We examined the image findings for the differential diagnosis and stage diagnosis of these two types of cystic neoplasms.Results. Endoscopic ultrasonography could reveal detailed images of internal structure and was effective for the diagnosis of MCNs. Other endoscopic imaging modalities could not give specific findings for MCNs. Endoscopic retrograde cholangiopancreatography (ERCP; including duodenoscopic findings and pancreatogram) and pancreatoscopy showed the characteristic and specific findings of IPMTs. Also, endoscopic ultrasonography and intraductal ultrasonography were found to have high sensitivity and diagnostic accuracy for their differential diagnosis of neoplastic/nonneoplastic and invasive/noninvasive lesions in IPMTs.Conclusions. Endoscopic imaging techniques are capable of revealing the detailed structure of pancreatic cystic lesions. They are effective for differential diagnosis, for assessing the degree of malignancy, and for deciding upon an appropriate treatment in patients with IPMTs.     

Multifocal branch-duct pancreatic intraductal papillary mucinous neoplasms

The appropriate management for patients with multifocal branch-duct intraductal papillary mucinous neoplasms (IPMNs) of the pancreas involving the entire pancreatic gland remains unclear. We present a 66-year-old woman who underwent pylorus-preserving pancreaticoduodenectomy for a branch-duct intraductal papillary mucinous carcinoma demonstrating a grape-like multilocular cyst, 35 mm in diameter, in the head of the pancreas along with numerous number of small branch-duct IPMNs in the whole pancreas. Histologically, the multifocal cystic lesions were lined by a single row of columnar mucin-containing epithelial cells without atypia. The patient has been doing well without any recurrence during 9-year follow-up after surgery. Surgical removal of the prominent lesions suspicious of malignancy and a close observation of the remaining lesions in the remnant pancreas may be a reasonable treatment plan for patients with multifocal branch-duct IPMNs involving the entire pancreatic gland.     

胰腺导管内乳头状黏液性肿瘤临床特征汇集分析

目的 探索胰腺导管内乳头状黏液性肿瘤(IPMN)的临床特征,为该疾病的临床诊断提供参考依据.方法 以PubMed为检索数据库,对2006年7月1日至2011年6月30日已发表的关于胰腺IPMN文献中经病理学证实的临床病例进行汇集分析,主要内容包括病例的人口统计学信息、主要临床表现、主要相关伴随疾病、肿瘤的形态学类型、解剖学分布特征、病理学类型等.结果 共汇集文献123篇,病例6548例.胰腺IPMN多发于老年人,男性较女性略多.胰腺IPMN可发生于胰腺的各个部位,以胰头部多见,其次为胰体尾部以及弥漫性分布.在其三种形态学类型中,支胰管型最为多见.胰腺IPMN主要临床表现缺乏特异性,以上腹部疼痛、体重减轻及黄疸最为多见.在汇集的病例中,恶性肿瘤病例达半数.结论 胰腺IPMN的临床表现缺乏特异性.在临床工作中应警惕胰腺IPMN的存在.应在对其临床特征进行综合分析后,结合患者的自身状况进一步制定治疗方案.