Saturday, May 1, 2010
Robert R. Selby, MD
Robert R. Selby, MD
Background:
Dr. Selby is a Professor of Surgery at the USC School of Medicine, as well as Director of the Liver Transplantation Program and Chief of the Division of Hepatobiliary and Pancreas Surgery. Dr. Selby graduated cum laude from the University of Missouri School of Medicine at Columbia, Missouri. Before joining USC, Dr. Selby served on the faculty at the University of Pittsburgh where he participated in 700 liver transplantations, 200 of which he performed personally. He has extensive experience in hepatobiliary and pancreatic surgery. As Director of the Multiorgan Transplantation Fellowship at the University of Pittsburgh, Dr. Selby trained more than 25 transplant surgeons who are now participating in transplant programs throughout the world. Dr. Selby is board certified in general surgery and general surgical critical care. His research interests include general surgery and small intestinal transplantation, xenotransplantation, cellular transplantation, fulminant hepatic failure and transplantation for pediatric metabolic disease.
Education:
Doctor of Medicine, Medicine, University of Missouri, 1979
Internships:
Good Samaritan Hospital, Phoenix, Arizona, 2000
Phoenix Intergrated Surgical Residency, Phoenix, Arizona, General Surgery, 2000
Residencies:
Phoenix Intergrated Surgical Residency - General Surgery, 1982 - 1986
Good Samaritan, Phoenix, Arizona Internal Medicine, 1980 - 1981
Fellowships:
University of Pittsburgh Medical Center (Presbyterian University Hospital and Childrens Hospital of Pittsburgh), Multiorgan Abdominal Transplant, 1987 - 1989
Background:
Dr. Selby is a Professor of Surgery at the USC School of Medicine, as well as Director of the Liver Transplantation Program and Chief of the Division of Hepatobiliary and Pancreas Surgery. Dr. Selby graduated cum laude from the University of Missouri School of Medicine at Columbia, Missouri. Before joining USC, Dr. Selby served on the faculty at the University of Pittsburgh where he participated in 700 liver transplantations, 200 of which he performed personally. He has extensive experience in hepatobiliary and pancreatic surgery. As Director of the Multiorgan Transplantation Fellowship at the University of Pittsburgh, Dr. Selby trained more than 25 transplant surgeons who are now participating in transplant programs throughout the world. Dr. Selby is board certified in general surgery and general surgical critical care. His research interests include general surgery and small intestinal transplantation, xenotransplantation, cellular transplantation, fulminant hepatic failure and transplantation for pediatric metabolic disease.
Education:
Doctor of Medicine, Medicine, University of Missouri, 1979
Internships:
Good Samaritan Hospital, Phoenix, Arizona, 2000
Phoenix Intergrated Surgical Residency, Phoenix, Arizona, General Surgery, 2000
Residencies:
Phoenix Intergrated Surgical Residency - General Surgery, 1982 - 1986
Good Samaritan, Phoenix, Arizona Internal Medicine, 1980 - 1981
Fellowships:
University of Pittsburgh Medical Center (Presbyterian University Hospital and Childrens Hospital of Pittsburgh), Multiorgan Abdominal Transplant, 1987 - 1989
Through the Keyhole
Through the Keyhole
That is, until earlier this year, when a local woman decided to seek help from her physician to uncover the cause of her jaundice, Parekh says. On examining her with a scope, physicians discovered an early stage cancerous tumor of the ampulla at the opening of her bile and pancreatic ducts. Her best option: a Whipple operation.
That is, until earlier this year, when a local woman decided to seek help from her physician to uncover the cause of her jaundice, Parekh says. On examining her with a scope, physicians discovered an early stage cancerous tumor of the ampulla at the opening of her bile and pancreatic ducts. Her best option: a Whipple operation.
Dr. Dilip Parekh M.D
FACULTY
The Whipple operation was first described in the 1930’s by Allan Whipple. In the 1960’s and 1970’s the mortality rate for the Whipple operation was very high. Up to 25% of patients died from the surgery. This experience of the 1970’s is still remembered by some physicians who are reluctant to recommend the Whipple operation.
Today the Whipple operation has become an extremely safe operation in the USA. At tertiary care centers where a large numbers of these procedures are performed by a selected few surgeons, the mortality rate from the operation is less than 4%. Studies have shown that for good outcomes from the Whipple surgery, the experience of the center and the surgeon is important. At USC, Dilip Parekh M.D. has performed more than 100 consecutive Whipple type of procedures over the past 9 years with good outcomes.
What is a Whipple operation?
In the Whipple operation the head of the pancreas, a portion of the bile duct, the gallbladder and the duodenum is removed. Occasionally a portion of the stomach may also be removed. After removal of these structures the remaining pancreas, bile duct and the intestine is sutured back into the intestine to direct the gastrointestinal secretions back into the gut.
The Whipple operation was first described in the 1930’s by Allan Whipple. In the 1960’s and 1970’s the mortality rate for the Whipple operation was very high. Up to 25% of patients died from the surgery. This experience of the 1970’s is still remembered by some physicians who are reluctant to recommend the Whipple operation.
Today the Whipple operation has become an extremely safe operation in the USA. At tertiary care centers where a large numbers of these procedures are performed by a selected few surgeons, the mortality rate from the operation is less than 4%. Studies have shown that for good outcomes from the Whipple surgery, the experience of the center and the surgeon is important. At USC, Dilip Parekh M.D. has performed more than 100 consecutive Whipple type of procedures over the past 9 years with good outcomes.
What is a Whipple operation?
In the Whipple operation the head of the pancreas, a portion of the bile duct, the gallbladder and the duodenum is removed. Occasionally a portion of the stomach may also be removed. After removal of these structures the remaining pancreas, bile duct and the intestine is sutured back into the intestine to direct the gastrointestinal secretions back into the gut.
What to do next - IPMN Johns Hoplins University
- accurated diagnostic
- be referred to Dr. Dilip Prekh or Dr. Robert Selby
- referral though:
GI doctor Beblawi or Stubin
Dr. Rao
Family Doctor
Through USC doctor Tylor or Dr. Starnes
- it is on the branch duct
- over 30mm
- is associated with main duct dilatation
- therefore according to the Management Guidelines it is possible a Whipple is required.
How are main duct type intraductal papillary mucinous neoplasms treated?
As many as 70% of main duct type intraductal papillary mucinous neoplasms harbor high-grade dysplasia (the step right before an invasive cancer develops) or an invasive cancer. Main duct type IPMNs are therefore significant lesions, and, in general, most main duct intraductal papillary mucinous neoplasms should be surgically resected if the patient can safely tolerate surgery (see reference 5). It is important that this surgery is carried out by surgeons with ample experience with pancreatic surgery (see reference 5).
Intraductal papillary mucinous neoplasms in the tail of the pancreas are usually resected using a procedure called a “distal pancreatectomy.” Surgeons at Johns Hopkins, including Drs. Martin Makary and Barish Edil, perform some distal pancreatectomies using minimally invasive procedures (laproscopic pancreatectomy). IPMNs in the head or uncinate process of the pancreas are usually resected using a Whipple procedure (pancreaticoduodenectomy). A total pancreatectomy (removal of the entire gland) may be indicated in the rare instances in which the intraductal papillary mucinous neoplasm involves the entire length of the pancreas.
How are branch duct type intraductal papillary mucinous neoplasms treated?
The management of branch duct IPMNs is more complicated than is the management of main duct type IPMNs. It is likely that many, if not most, branch duct IPMNs are harmless and the risks associated with surgery may outweigh the benefits of resecting small branch duct IPMNs. International consensus guidelines for the treatment of branch duct IPMNs were established in 2006. These guidelines try to balance the risks and benefits of treating patients with a branch duct type IPMN (see reference 5).
The guidelines suggest that asymptomatic patients with a branch duct IPMN that a) is less than 3 cm in size, b) not associated with dilatation (ballooning) of the main pancreatic duct, and c) does not contain a solid mass (mural nodule), can be followed safely without surgery. By contrast, the guidelines recommend the surgical resection of branch duct type IPMNs that cause symptoms, that are larger than 3 cm, that contain a mass (mural nodule), OR which are associated with dilatation of the main pancreatic duct. These guidelines have been supported by a number of recent papers (see reference 6-10). Unfortunately, some resected branch duct IPMNs that are less than 3 cm have been found to have cancer, so the guidelines do not perfectly distinguish patients with benign or malignant disease. Additionally, the size cutoff of 3 cm will either be further validated or changed based upon ongoing studies. Depending on the circumstances, sometimes branch duct IPMNs less than 3 cm are resected because of their rate of growth and or preferences of the patient and surgeon. As was true for main duct IPMNs, intraductal papillary mucinous neoplasms should be surgically resected only if the patient can safely tolerate surgery.
Branch duct IPMNs that are not surgically resected should be monitored radiographically to make sure that they do not grow. Growth of a branch duct IPMN or the development of a mass (mural nodule) may be an indication to surgically remove the IPMN.
Several imaging technologies can be used to monitor branch duct IPMNs for growth. These include computerized tomography (CT), endoscopic ultrasound (EUS), and magnetic resonance cholangiopancreatography (MRCP). In general, smaller branch duct IPMNs less than 1 cm in diameter can be followed with an annual exam. Patients with larger IPMNs should have an examination more frequently, some as frequently as every three months. If you have an IPMN, you should consult with a physician to determine the the most suitable methodology to follow your IPMN as well as the frequency of follow-up.
If I had an IPMN surgically removed, am I cured?
While patients who undergo resection of an IPMN not associated with an invasive cancer are “cured” of that lesion, IPMNs can be multiple and these patients remain at risk for developing a second lesion (see references 11,12). Your doctor may therefore recommend routine follow-up visits. Should you develop a second IPMN, management will depend on it’s characteristics.
- be referred to Dr. Dilip Prekh or Dr. Robert Selby
- referral though:
GI doctor Beblawi or Stubin
Dr. Rao
Family Doctor
Through USC doctor Tylor or Dr. Starnes
- it is on the branch duct
- over 30mm
- is associated with main duct dilatation
- therefore according to the Management Guidelines it is possible a Whipple is required.
How are main duct type intraductal papillary mucinous neoplasms treated?
As many as 70% of main duct type intraductal papillary mucinous neoplasms harbor high-grade dysplasia (the step right before an invasive cancer develops) or an invasive cancer. Main duct type IPMNs are therefore significant lesions, and, in general, most main duct intraductal papillary mucinous neoplasms should be surgically resected if the patient can safely tolerate surgery (see reference 5). It is important that this surgery is carried out by surgeons with ample experience with pancreatic surgery (see reference 5).
Intraductal papillary mucinous neoplasms in the tail of the pancreas are usually resected using a procedure called a “distal pancreatectomy.” Surgeons at Johns Hopkins, including Drs. Martin Makary and Barish Edil, perform some distal pancreatectomies using minimally invasive procedures (laproscopic pancreatectomy). IPMNs in the head or uncinate process of the pancreas are usually resected using a Whipple procedure (pancreaticoduodenectomy). A total pancreatectomy (removal of the entire gland) may be indicated in the rare instances in which the intraductal papillary mucinous neoplasm involves the entire length of the pancreas.
How are branch duct type intraductal papillary mucinous neoplasms treated?
The management of branch duct IPMNs is more complicated than is the management of main duct type IPMNs. It is likely that many, if not most, branch duct IPMNs are harmless and the risks associated with surgery may outweigh the benefits of resecting small branch duct IPMNs. International consensus guidelines for the treatment of branch duct IPMNs were established in 2006. These guidelines try to balance the risks and benefits of treating patients with a branch duct type IPMN (see reference 5).
The guidelines suggest that asymptomatic patients with a branch duct IPMN that a) is less than 3 cm in size, b) not associated with dilatation (ballooning) of the main pancreatic duct, and c) does not contain a solid mass (mural nodule), can be followed safely without surgery. By contrast, the guidelines recommend the surgical resection of branch duct type IPMNs that cause symptoms, that are larger than 3 cm, that contain a mass (mural nodule), OR which are associated with dilatation of the main pancreatic duct. These guidelines have been supported by a number of recent papers (see reference 6-10). Unfortunately, some resected branch duct IPMNs that are less than 3 cm have been found to have cancer, so the guidelines do not perfectly distinguish patients with benign or malignant disease. Additionally, the size cutoff of 3 cm will either be further validated or changed based upon ongoing studies. Depending on the circumstances, sometimes branch duct IPMNs less than 3 cm are resected because of their rate of growth and or preferences of the patient and surgeon. As was true for main duct IPMNs, intraductal papillary mucinous neoplasms should be surgically resected only if the patient can safely tolerate surgery.
Branch duct IPMNs that are not surgically resected should be monitored radiographically to make sure that they do not grow. Growth of a branch duct IPMN or the development of a mass (mural nodule) may be an indication to surgically remove the IPMN.
Several imaging technologies can be used to monitor branch duct IPMNs for growth. These include computerized tomography (CT), endoscopic ultrasound (EUS), and magnetic resonance cholangiopancreatography (MRCP). In general, smaller branch duct IPMNs less than 1 cm in diameter can be followed with an annual exam. Patients with larger IPMNs should have an examination more frequently, some as frequently as every three months. If you have an IPMN, you should consult with a physician to determine the the most suitable methodology to follow your IPMN as well as the frequency of follow-up.
If I had an IPMN surgically removed, am I cured?
While patients who undergo resection of an IPMN not associated with an invasive cancer are “cured” of that lesion, IPMNs can be multiple and these patients remain at risk for developing a second lesion (see references 11,12). Your doctor may therefore recommend routine follow-up visits. Should you develop a second IPMN, management will depend on it’s characteristics.
Friday, April 30, 2010
Thursday, April 29, 2010
Wednesday, April 28, 2010
Monday, April 26, 2010
Arch Surg -- Intraductal Papillary-Mucinous Tumors of the Pancreas: Predictive Criteria of Malignancy According to Pathological Examination of 53 Cases, November 2002, Bernard et al. 137 (11): 1274
The IPMTs were classified as invasive carcinoma in 22 cases (41%), noninvasive carcinoma (carcinoma in situ or severe dysplasia) in 11 cases (21%), borderline (moderate dysplasia) in 9 cases (17%), and adenoma (mild dysplasia) in 11 cases (21%). A malignant form was found in 73% of cases (24/33) in patients aged 60 years or older and in 45% (9/20) of the remaining patients (P = .04).
There were 6 cases of main duct type (11%), 12 cases of branch duct type (23%), and 35 cases of combined duct type (66%). The numbers of malignant or invasive forms were similar according to right or left location of the tumor. In fact, a malignant form was noted in 61% (22/36) of cases with a right location and in 55% (6/11) in cases with a left location. Furthermore, an invasive form was found in 44% (16/36) with right location and in 27% (3/11) with left location (middle and total pancreatectomies were excluded).
The correlations between the histologic grade and the classification used by Sugiyama and Atomi2 are shown in Table 1. The rate of malignant tumors was significantly higher in the main duct type (83%; P = .02) and in the combined type (74%; P = .002) compared with the branch duct type (17%). Among the malignant forms, the rate of invasive carcinomas was significantly higher in the main duct type (83%; P = .004) and in the combined duct type (46%; P = .04) compared with the branch duct type (8%). The rate of carcinoma ranged from 17% to 76% according to the absence or presence of main pancreatic duct lesions (P<.001), and the rate of invasive carcinoma ranged from 8% to 51% according to the absence or presence of main pancreatic duct lesions (P = .009). A benign form (adenoma and borderline) was more frequent in the branch duct type (83%) than in the main duct type (17%; P = .02) or the combined type (26%; P = .002).
Arch Surg -- Intraductal Papillary-Mucinous Tumors of the Pancreas: Predictive Criteria of Malignancy According to Pathological Examination of 53 Cases, November 2002, Bernard et al. 137 (11): 1274
There were 6 cases of main duct type (11%), 12 cases of branch duct type (23%), and 35 cases of combined duct type (66%). The numbers of malignant or invasive forms were similar according to right or left location of the tumor. In fact, a malignant form was noted in 61% (22/36) of cases with a right location and in 55% (6/11) in cases with a left location. Furthermore, an invasive form was found in 44% (16/36) with right location and in 27% (3/11) with left location (middle and total pancreatectomies were excluded).
The correlations between the histologic grade and the classification used by Sugiyama and Atomi2 are shown in Table 1. The rate of malignant tumors was significantly higher in the main duct type (83%; P = .02) and in the combined type (74%; P = .002) compared with the branch duct type (17%). Among the malignant forms, the rate of invasive carcinomas was significantly higher in the main duct type (83%; P = .004) and in the combined duct type (46%; P = .04) compared with the branch duct type (8%). The rate of carcinoma ranged from 17% to 76% according to the absence or presence of main pancreatic duct lesions (P<.001), and the rate of invasive carcinoma ranged from 8% to 51% according to the absence or presence of main pancreatic duct lesions (P = .009). A benign form (adenoma and borderline) was more frequent in the branch duct type (83%) than in the main duct type (17%; P = .02) or the combined type (26%; P = .002).
Arch Surg -- Intraductal Papillary-Mucinous Tumors of the Pancreas: Predictive Criteria of Malignancy According to Pathological Examination of 53 Cases, November 2002, Bernard et al. 137 (11): 1274
Arch Surg -- Intraductal Papillary-Mucinous Tumors of the Pancreas: Predictive Criteria of Malignancy According to Pathological Examination of 53 Cases, November 2002, Bernard et al. 137 (11): 1274
Patients Fifty-three consecutive patients who underwent pancreatic resection for intraductal papillary-mucinous tumors between January 1, 1985, and December 31, 2000.
Results Macroscopic analyses of tumors showed 6 main duct lesions, 12 branch duct lesions, and 35 combined lesions. A carcinoma was present in 33 cases (62%): 22 (41%) were invasive and 11 (21%) were noninvasive; 9 (17%) were borderline tumors and 11 (21%) were benign. Carcinoma and invasive carcinoma forms were less frequent in branch duct lesions (P<.001 and P = .009, respectively). Mural nodules were more frequent in carcinomas (P = .006) and invasive carcinomas (P<.001), with a positive predictive value of malignancy of 81%. The diameter of lesions (branch duct lesion =" src="http://archsurg.ama-assn.org/math/ge.gif" border=0>30 mm) or main duct (main pancreatic duct =" src="http://archsurg.ama-assn.org/math/ge.gif" border=0>15 mm in combined or main pancreatic duct lesions) did not correlate with malignancy.
Conclusions No carcinoma occurred in branch duct types smaller than 30 mm without mural nodules. Limited resection may be appropriate only in this type of tumor.
Arch Surg -- Intraductal Papillary-Mucinous Tumors of the Pancreas: Predictive Criteria of Malignancy According to Pathological Examination of 53 Cases, November 2002, Bernard et al. 137 (11): 1274
Results Macroscopic analyses of tumors showed 6 main duct lesions, 12 branch duct lesions, and 35 combined lesions. A carcinoma was present in 33 cases (62%): 22 (41%) were invasive and 11 (21%) were noninvasive; 9 (17%) were borderline tumors and 11 (21%) were benign. Carcinoma and invasive carcinoma forms were less frequent in branch duct lesions (P<.001 and P = .009, respectively). Mural nodules were more frequent in carcinomas (P = .006) and invasive carcinomas (P<.001), with a positive predictive value of malignancy of 81%. The diameter of lesions (branch duct lesion =" src="http://archsurg.ama-assn.org/math/ge.gif" border=0>30 mm) or main duct (main pancreatic duct =" src="http://archsurg.ama-assn.org/math/ge.gif" border=0>15 mm in combined or main pancreatic duct lesions) did not correlate with malignancy.
Conclusions No carcinoma occurred in branch duct types smaller than 30 mm without mural nodules. Limited resection may be appropriate only in this type of tumor.
Arch Surg -- Intraductal Papillary-Mucinous Tumors of the Pancreas: Predictive Criteria of Malignancy According to Pathological Examination of 53 Cases, November 2002, Bernard et al. 137 (11): 1274
Precursor Lesions of Pancreatic Cancer: Molecular Pathology and Clinical Implications
Conclusions: Precursor lesions of pancreatic adenocarcinomas represent a unique opportunity for diagnosis and intervention for a malignancy with near uniform lethality. Further studies on these precursors will enable the development of rational early detection and therapeutic strategies in order to ameliorate pancreatic cancer survival.
Precursor Lesions of Pancreatic Cancer: Molecular Pathology and Clinical Implications
Precursor Lesions of Pancreatic Cancer: Molecular Pathology and Clinical Implications
Basics of Pancreatic Cancer
What is the difference between a main duct and a branch duct intraductal papillary mucinous neoplasm? Intraductal papillary mucinous neoplasms, as mentioned earlier, form in the main pancreatic duct or in one of the branches off of the main pancreatic duct. Intraductal papillary mucinous neoplasms that arise in the main pancreatic duct are called, as one might expect, “main duct type” IPMNs. Intraductal papillary mucinous neoplasms that arise in one of the branches of the main duct are called “branch duct type” IPMNs. The distinction between main duct type and branch duct type IPMNs is important because several studies have shown that, for each given size, branch duct IPMNs are less aggressive (less likely to have an invasive cancer) than are main duct IPMNs (see references 2,3).
Basics of Pancreatic Cancer
Basics of Pancreatic Cancer
Basics of Pancreatic Cancer
Pathologists classify intraductal papillary mucinous neoplasms (IPMNs) into two broad groups - those that are associated with an invasive cancer and those that are not associated with an invasive cancer. This separation has critical prognostic significance. Patients with a surgically resected intraductal papillary mucinous neoplasm without an associated invasive cancer have an excellent prognosis (>95% will be cured), while patients with a surgically resected intraductal papillary mucinous neoplasm with an associated invasive cancer have a worse prognosis.
Basics of Pancreatic Cancer
Basics of Pancreatic Cancer
Pancreatic Cancer Causes, Symptoms, Diagnosis, Treatment, and Prognosis Information on eMedicineHealth.com
Intraductal papillary mucinous neoplasia (IPMN) is a type of pancreatic cancer that is beginning to be recognized more frequently. This pancreatic cancer has a better prognosis than other types of pancreatic cancer. Intraductal papillary mucinous neoplasia is usually diagnosed endoscopically (see Exams and Tests).
Pancreatic Cancer Causes, Symptoms, Diagnosis, Treatment, and Prognosis Information on eMedicineHealth.com
Pancreatic Cancer Causes, Symptoms, Diagnosis, Treatment, and Prognosis Information on eMedicineHealth.com
Sunday, April 25, 2010
Pancreatic Neoplasms: Intraductal Papillary Mucinous Neoplasms
Pancreatic Neoplasms: Intraductal Papillary Mucinous Neoplasms
Now encountered more and more commonly in major centers around the world, intraductal papillary mucinous neoplasms (IPMNs) have become a popular subject of investigation. Bernard et al. [20] reviewed their experience with 53 consecutive resections of IPMN from 1985 to 2000. Carcinoma was present in 62% (33/53) of tumors and was significantly less common (both intramucosal and invasive forms) in lesions isolated within branch ducts. IPMNs containing carcinoma were more likely to exhibit mural nodules. The authors concluded that lesions >30 mm, located solely in branch ducts and lacking mural nodules, had a very low chance of harboring in situ or invasive carcinoma (none found in lesions meeting these criteria). Thus, such patients could be considered for limited resection. IPMNs involving the main duct or having associated mural nodules have a greater chance of housing carcinoma and warrant more aggressive treatment.
Adenocarcinoma arising within an IPMN (Fig. 5) is associated with a more favorable prognosis than ordinary ductal adenocarcinoma. In a multi-institutional review, Maire et al. [21] analyzed the long-term outcomes in 73 patients who underwent pancreatic resection for IPMN with in situ (n = 22) or invasive carcinoma (n = 51). The overall median survival was 47 months, and the 5-year survival rates for IPMN-affiliated in situ or invasive carcinoma were 88% and 36%, respectively. Multivariate analysis showed that lymph node metastases were the only significant factor that independently worsened the prognosis. Disease recurred only in patients with invasive adenocarcinoma (28 patients [38%]), with 16 occurring in the pancreatic remnant, 7 in regional lymph nodes, and 21 in various distant sites. A comparison of survival rates for resected IPMN-carcinoma vs resected ductal adenocarcinoma revealed a better 5-year prognosis for IPMN-carcinoma (36% vs 21%, respectively, P = 0.03).
Now encountered more and more commonly in major centers around the world, intraductal papillary mucinous neoplasms (IPMNs) have become a popular subject of investigation. Bernard et al. [20] reviewed their experience with 53 consecutive resections of IPMN from 1985 to 2000. Carcinoma was present in 62% (33/53) of tumors and was significantly less common (both intramucosal and invasive forms) in lesions isolated within branch ducts. IPMNs containing carcinoma were more likely to exhibit mural nodules. The authors concluded that lesions >30 mm, located solely in branch ducts and lacking mural nodules, had a very low chance of harboring in situ or invasive carcinoma (none found in lesions meeting these criteria). Thus, such patients could be considered for limited resection. IPMNs involving the main duct or having associated mural nodules have a greater chance of housing carcinoma and warrant more aggressive treatment.
Adenocarcinoma arising within an IPMN (Fig. 5) is associated with a more favorable prognosis than ordinary ductal adenocarcinoma. In a multi-institutional review, Maire et al. [21] analyzed the long-term outcomes in 73 patients who underwent pancreatic resection for IPMN with in situ (n = 22) or invasive carcinoma (n = 51). The overall median survival was 47 months, and the 5-year survival rates for IPMN-affiliated in situ or invasive carcinoma were 88% and 36%, respectively. Multivariate analysis showed that lymph node metastases were the only significant factor that independently worsened the prognosis. Disease recurred only in patients with invasive adenocarcinoma (28 patients [38%]), with 16 occurring in the pancreatic remnant, 7 in regional lymph nodes, and 21 in various distant sites. A comparison of survival rates for resected IPMN-carcinoma vs resected ductal adenocarcinoma revealed a better 5-year prognosis for IPMN-carcinoma (36% vs 21%, respectively, P = 0.03).
World Journal of Gastroenterology-Baishideng Publishing
World Journal of Gastroenterology-Baishideng Publishing
INTRODUCTION
Intraductal papillary mucinous neoplasm of the pancreas (IPMN) shows a wide spectrum of histological presentations, ranging from adenoma with mild atypia to adenocarcinoma, and was first described by Ohashi et al[1] in 1980. IPMN is divided into two types, the main duct type and the branch duct type. In general, branch duct IPMN develops slowly and has a comparatively good prognosis. However, in several studies, it became evident that IPMN is a disease that very frequently coexists with cancer. Therefore, the prognosis of IPMN is more closely related to the coexisting disease than to IPMN per se[2-8]. In the present study, the prognostic significance of the coexistence of metachronous and synchronous cancer in branch duct IPMN was investigated.
INTRODUCTION
Intraductal papillary mucinous neoplasm of the pancreas (IPMN) shows a wide spectrum of histological presentations, ranging from adenoma with mild atypia to adenocarcinoma, and was first described by Ohashi et al[1] in 1980. IPMN is divided into two types, the main duct type and the branch duct type. In general, branch duct IPMN develops slowly and has a comparatively good prognosis. However, in several studies, it became evident that IPMN is a disease that very frequently coexists with cancer. Therefore, the prognosis of IPMN is more closely related to the coexisting disease than to IPMN per se[2-8]. In the present study, the prognostic significance of the coexistence of metachronous and synchronous cancer in branch duct IPMN was investigated.
Prognosis for intraductal papillary mucinous neoplasms
Prognosis for intraductal papillary mucinous neoplasms
Prognosis for intraductal papillary mucinous neoplasms
Intraductal papillary mucinous neoplasm of the pancreas (IPMN) shows a wide spectrum of histological presentations, ranging from adenoma with mild atypia to adenocarcinoma. In general, branch duct IPMN develops slowly and has a comparatively good prognosis. However, in several studies, it became evident that IPMN is a disease that very frequently coexists with cancer. Several investigators have suggested that the prognosis of the IPMN is more closely related to coexisting diseases than IPMN per se.
A research article to be published on April 21, 2010 in the World Journal of Gastroenterology addresses this question. The research team led by PhD Takao Itoi, from Department of Gastroenterology and Hepatology, Tokyo Medical University, reviewed the records of 145 patients with branch duct IPMN between January 1991 and April 2008 and assessed the relationship between IPMN and intra- or extra-pancreatic carcinoma and the outcome of IPMN.
Their results showed the prognosis for IPMN depends not on the IPMN per se, but on the presence of intra- or extra-pancreatic cancer. It appears to be important to determine the presence of intra- or extrapancreatic cancer when examining the patients with IPMN.
Prognosis for intraductal papillary mucinous neoplasms
Intraductal papillary mucinous neoplasm of the pancreas (IPMN) shows a wide spectrum of histological presentations, ranging from adenoma with mild atypia to adenocarcinoma. In general, branch duct IPMN develops slowly and has a comparatively good prognosis. However, in several studies, it became evident that IPMN is a disease that very frequently coexists with cancer. Several investigators have suggested that the prognosis of the IPMN is more closely related to coexisting diseases than IPMN per se.
A research article to be published on April 21, 2010 in the World Journal of Gastroenterology addresses this question. The research team led by PhD Takao Itoi, from Department of Gastroenterology and Hepatology, Tokyo Medical University, reviewed the records of 145 patients with branch duct IPMN between January 1991 and April 2008 and assessed the relationship between IPMN and intra- or extra-pancreatic carcinoma and the outcome of IPMN.
Their results showed the prognosis for IPMN depends not on the IPMN per se, but on the presence of intra- or extra-pancreatic cancer. It appears to be important to determine the presence of intra- or extrapancreatic cancer when examining the patients with IPMN.
5 helpful hints for diagnosis Pancreas Cysts
Johns Hopkins
http://pathology2.jhu.edu/pancreascyst/index.cfm
1. What is the patient's gender?Some cystic neoplasms, including mucinous cystic neoplasms and solid-pseudopapillary neoplasms, are much more common in women. Pseudocysts, because of there association with alcoholism, tend to be more common in men.
2. Do the cysts communicate with the large pancreatic ducts?This feature can help distinguish intraductal papillary mucinous neoplasms, which do communicate with the ducts, from mucinous cystic neoplasms, which do not.
3. What are the cyst contents?The cysts of mucinous cystic neoplasms and intraductal papillary neoplasms contain thick tenacious mucoid material. The cysts of serous cystic neoplasms, as the name suggests, contain thin straw colored fluid. Pseudocysts and solid-pseudopapillary neoplasms can contain necrotic/hemorrhagic debris.
4. What type of cells, if any, line the cysts?Pseudocysts lack an epithelial lining. Mucinous cystic neoplasms and intraductal papillary neoplasms are lined by tall columnar mucin-producing cells. Serous cystic neoplasms are lined by low cuboidal glycogen-rich cells.
5. What is the character of the stroma?Mucinous cystic neoplasms have a distinctive "ovarian-type" of dense stroma. The often cystic lesions do not.
Pancreas Cysts
http://pathology2.jhu.edu/pancreascyst/index.cfm
http://pathology2.jhu.edu/pancreascyst/index.cfm
1. What is the patient's gender?Some cystic neoplasms, including mucinous cystic neoplasms and solid-pseudopapillary neoplasms, are much more common in women. Pseudocysts, because of there association with alcoholism, tend to be more common in men.
2. Do the cysts communicate with the large pancreatic ducts?This feature can help distinguish intraductal papillary mucinous neoplasms, which do communicate with the ducts, from mucinous cystic neoplasms, which do not.
3. What are the cyst contents?The cysts of mucinous cystic neoplasms and intraductal papillary neoplasms contain thick tenacious mucoid material. The cysts of serous cystic neoplasms, as the name suggests, contain thin straw colored fluid. Pseudocysts and solid-pseudopapillary neoplasms can contain necrotic/hemorrhagic debris.
4. What type of cells, if any, line the cysts?Pseudocysts lack an epithelial lining. Mucinous cystic neoplasms and intraductal papillary neoplasms are lined by tall columnar mucin-producing cells. Serous cystic neoplasms are lined by low cuboidal glycogen-rich cells.
5. What is the character of the stroma?Mucinous cystic neoplasms have a distinctive "ovarian-type" of dense stroma. The often cystic lesions do not.
Pancreas Cysts
http://pathology2.jhu.edu/pancreascyst/index.cfm
masses can be solid and cyctic
mass can be sold or cystic
Masses can be described based on their physical characteristics, as defined by imaging studies, as:
1. solid (consisting of solid abnormal tissue) or
2. cystic (filled with mucus or fluid).
Masses can also further be described based on their aggressiveness usually based on imaging and examination of their cells under the microscope as:
1. benign (no potential for turning into cancer)
2. premalignant (some potential to turning into cancer) and
3. malignant (cancer).
Masses can be described based on their physical characteristics, as defined by imaging studies, as:
1. solid (consisting of solid abnormal tissue) or
2. cystic (filled with mucus or fluid).
Masses can also further be described based on their aggressiveness usually based on imaging and examination of their cells under the microscope as:
1. benign (no potential for turning into cancer)
2. premalignant (some potential to turning into cancer) and
3. malignant (cancer).
Two kinds of pancres tumors (masses or neoplasms)
Masses can be described based on their physical characteristics, as defined by imaging studies, as:
1. solid (consisting of solid abnormal tissue) or
2. cystic (filled with mucus or fluid).
Masses can also further be described based on their aggressiveness usually based on imaging and examination of their cells under the microscope as:
1. benign (no potential for turning into cancer)
2. premalignant (some potential to turning into cancer) and
3. malignant (cancer).
Surgery: All of the information obtained in the medical history, imaging and pathological analyses are considered in determining the best management of a pancreatic mass. In general, most solid pancreatic masses are either malignant or have malignant potential. Therefore, most solid tumors are removed surgically. Exceptions to removal of solid tumors exist but are rare. The management of pancreatic cyst is often much more complex since the majority of these types of tumors are benign and therefore do not require surgery. The key in management of pancreatic cystic lesions is to avoid an operation in people who have “innocent” cysts while on the other hand not choosing to observe individuals with cysts that may harbor malignancy. This concept may seem simple, but in practice differentiating between these two groups requires experienced physicians. In fact, here at Johns Hopkins we have an entire clinic dedicated to the management of pancreatic cysts (the phone number of our pancreatic cyst clinic is 410-933-PANC). Very specific criteria have been developed to guide the management of pancreatic cystic lesions and are used to predict the need for surgical resection. These criteria rely on accurate imaging and pathological data. If surgery is to be performed for a mass this surgery should be done in a center with experienced pancreatic surgeons who perform many of these types of operations on a regular basis.
1. solid (consisting of solid abnormal tissue) or
2. cystic (filled with mucus or fluid).
Masses can also further be described based on their aggressiveness usually based on imaging and examination of their cells under the microscope as:
1. benign (no potential for turning into cancer)
2. premalignant (some potential to turning into cancer) and
3. malignant (cancer).
Surgery: All of the information obtained in the medical history, imaging and pathological analyses are considered in determining the best management of a pancreatic mass. In general, most solid pancreatic masses are either malignant or have malignant potential. Therefore, most solid tumors are removed surgically. Exceptions to removal of solid tumors exist but are rare. The management of pancreatic cyst is often much more complex since the majority of these types of tumors are benign and therefore do not require surgery. The key in management of pancreatic cystic lesions is to avoid an operation in people who have “innocent” cysts while on the other hand not choosing to observe individuals with cysts that may harbor malignancy. This concept may seem simple, but in practice differentiating between these two groups requires experienced physicians. In fact, here at Johns Hopkins we have an entire clinic dedicated to the management of pancreatic cysts (the phone number of our pancreatic cyst clinic is 410-933-PANC). Very specific criteria have been developed to guide the management of pancreatic cystic lesions and are used to predict the need for surgical resection. These criteria rely on accurate imaging and pathological data. If surgery is to be performed for a mass this surgery should be done in a center with experienced pancreatic surgeons who perform many of these types of operations on a regular basis.
Parts of the Pancreas
Parts of the Pancreas
The pancreas is made up of glandular tissue and a system of ducts. The main duct is the pancreatic duct which runs the length of the pancreas. It drains the pancreatic fluid from the gland and carries it to the duodenum. The main duct is about one-sixteenth of an inch in diameter and has many small side branches. The pancreatic duct merges with the bile duct to form the ampulla of Vater (a widening of the duct just before it enters the duodenum
1. uncinate process-The part of the gland that bends backwards and underneath the body of the pancreas. Two very important blood vessels, the superior mesenteric artery and vein cross in front of the uncinate process.
2. head-The widest part of the gland. It is found in the right part of abdomen, nestled in the curve of the duodenum which forms an impression in the side of the gland.
3. neck-The thin section between the head and the body of the gland.
4. body-The middle part of gland between the neck and the tail. The superior mesenteric blood vessels run behind this part of the gland.
5. tail-The thin tip of gland in the left part of abdomen in close proximity with the spleen.
The pancreas is made up of glandular tissue and a system of ducts. The main duct is the pancreatic duct which runs the length of the pancreas. It drains the pancreatic fluid from the gland and carries it to the duodenum. The main duct is about one-sixteenth of an inch in diameter and has many small side branches. The pancreatic duct merges with the bile duct to form the ampulla of Vater (a widening of the duct just before it enters the duodenum
1. uncinate process-The part of the gland that bends backwards and underneath the body of the pancreas. Two very important blood vessels, the superior mesenteric artery and vein cross in front of the uncinate process.
2. head-The widest part of the gland. It is found in the right part of abdomen, nestled in the curve of the duodenum which forms an impression in the side of the gland.
3. neck-The thin section between the head and the body of the gland.
4. body-The middle part of gland between the neck and the tail. The superior mesenteric blood vessels run behind this part of the gland.
5. tail-The thin tip of gland in the left part of abdomen in close proximity with the spleen.
My tumor can be surgically removed
Is the cancer growing into any of the major blood vessels running by the pancreas that would make the removal of the tumor dangerous or impossible?
Typically we use our high definition three-dimensional CT scan to determine whether the cancer is growing into any of the major blood vessels running by the pancreas. In many cases, it is extremely important that these images are obtained on 64 or 32 detector CT machines. These cutting-edge imaging machines are available at Johns Hopkins. Images obtained on 16 or 8 detector machines are significantly inferior in quality.
Specifically, the major blood vessels we examine are:
1. the portal vein/superior mesenteric vein (drains blood from the intestines to the liver),
2. superior mesenteric artery (supplies blood from the heart to the intestines), and
3. the hepatic artery (supplies blood from the heart to the liver).
If there is significant involvement of any of these major blood vessels, the pancreas cancer may not be surgically removable (unresectable). In these instances the cancer is best treated medically.
My tumor can be surgically removed
Typically we use our high definition three-dimensional CT scan to determine whether the cancer is growing into any of the major blood vessels running by the pancreas. In many cases, it is extremely important that these images are obtained on 64 or 32 detector CT machines. These cutting-edge imaging machines are available at Johns Hopkins. Images obtained on 16 or 8 detector machines are significantly inferior in quality.
Specifically, the major blood vessels we examine are:
1. the portal vein/superior mesenteric vein (drains blood from the intestines to the liver),
2. superior mesenteric artery (supplies blood from the heart to the intestines), and
3. the hepatic artery (supplies blood from the heart to the liver).
If there is significant involvement of any of these major blood vessels, the pancreas cancer may not be surgically removable (unresectable). In these instances the cancer is best treated medically.
My tumor can be surgically removed
Masses and Tumors Involving the Pancreas
Masses can be described based on their physical characteristics, as defined by imaging studies, as:
1. solid (consisting of solid abnormal tissue) or
2. cystic (filled with mucus or fluid).
Masses can also further be described based on their aggressiveness usually based on imaging and examination of their cells under the microscope as:
1. benign (no potential for turning into cancer)
2. premalignant (some potential to turning into cancer) and
3. malignant (cancer).
Pancreatic Cancer Blog » Blog Archive » Masses and Tumors Involving the Pancreas
1. solid (consisting of solid abnormal tissue) or
2. cystic (filled with mucus or fluid).
Masses can also further be described based on their aggressiveness usually based on imaging and examination of their cells under the microscope as:
1. benign (no potential for turning into cancer)
2. premalignant (some potential to turning into cancer) and
3. malignant (cancer).
Pancreatic Cancer Blog » Blog Archive » Masses and Tumors Involving the Pancreas
Pancreatic surgery - Organ preservation
Preservation of pancreatic tissue is an important goal during surgery for pancreatic and biliary diseases to reduce the risks of loss of pancreatic tissue. During the Whipple operation, organs that play a vital role in digestive function are often removed. The organs removed include part of the pancreas and bile duct, and all of the duodenum. The duodenum appears to play an important role in regulating the motility of the stomach and the upper gastrointestinal tract. It is thought that partial or complete loss of the duodenum is responsible for the delay in emptying of the stomach that often occurs after the Whipple operation.
Pancreatic surgery for pancreatic tumors
Pancreatic surgery for pancreatic tumors
Surgical operations on the pancreas
For malignant tumors affecting the duodenum, head of pancreas, and the distal (bottom end) of the bile duct, the Whipple operation is the standard of care and the procedure of choice. The Whipple operation is also frequently performed for benign (non-cancerous) disorders that affect the bottom end of the bile duct, duodenum, or head of pancreas. While in some patients the extent or nature of disease may require a Whipple operation, alternate procedures that preserve some of the organs removed during the standard whipple operation may be an option in other patients.
Surgical operations on the pancreas
Surgical operations on the pancreas
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