INTRADUCTAL NEOPLASMS OF THE PANCREAS

BACKGROUND: Since 1980 a group of pancreatic tumors have been termed i ntraductal papillary mucinous tumors (IPMT). Because these tumors occu py an intraductal position they are demonstrated by pancreatography to reside in the main pancreatic duct (MPD) or side branch ducts (SBD). Lesions of IPMT result in abdominal pain or pancreatitis symptoms beca use mucin production or papillary growth results in ductal obstruction . Only 104 cases had been reported in the literature by 1996 but more are being presented in abstract form. We reviewed our own 33 cases to assist defining operative decision-making criteria. METHODS: All cases of IPMT between 1989 and 1997 were reviewed for clinical presentation , anatomy by endoscopic retrograde cholangiopancreatography and comput ed tomography, histologic findings, and long-term outcomes. RESULTS: O ur cases,were older (65 years) and presented with disease centered mai nly in the head of the gland. Clinical presentation was epigastric pai n (82%), pancreatitis (56%), weight loss (36%), diabetes (27%), and ja undice (9%). Operations were pancreatectomy in 31 (Whipple n = 15, tot al n = 5, distal n = 10, local n = 1), bypass only (n = 1), and no ope ration (n = 1). Malignancy was found in 14 of 33 (42%). Factors signif icantly associated (P <0.05 Fisher exact test) with malignancy were hi story of alcohol abuse or death from disease. Jaundice or presence in both MPD and SBD approached a significant association with malignancy but not abdominal pain, weight loss, diabetes, preoperative serum elev ations of amylase, SOOT, CA-19-9, or CEA; diffuse MPD dilation, gland region, gross mucus in ducts or filling defects, cytology, calcificati ons, or a pancreatic mass. In 31 resected patients after a follow-up o f 37 months (1 to 103) death had occurred in 6 of 13 malignant cases a nd 0 of 18 with benign disease. Three-year actuarial survival was 82% tall) and 56% (malignant). Symptom recurrence after resection was foun d in 6 of 31 at a mean of 13 months postoperatively and was associated with death from disease (P <0.05) or presence of pain preoperatively. CONCLUSION: Malignancy is common with IPMT and is more likely to be p resent with the clinical history of alcohol abuse or jaundice and if t he tumor involves both the MPD and the SBD. The prognosis after resect ion is better than pancreatic cancer but the 19% recurrence of symptom s was equally seen with benign or malignant cases owing to residual di sease in pancreatic remnants. The amount of resection should be extens ive in patients likely to have malignancy (alcohol, jaundice, MPD+SBD) . In those likely to redevelop symptoms, ie, those with preoperative p ain, a careful assessment should be made via imaging studies for exten t of disease. (C) 1998 by Excerpta Medica, Inc.