Hruban RH, Pitman MB, Klimstra DS:Tumor of the Pancreas. Fourth Series, Fascicle 6. Armed Forces Institute of Pathology, 2007.
Mohammad Al-Haddad, Max C Schmidt, Kumar Sandrasegaran, John Dewitt
Diagnosis and treatment of cystic pancreatic tumors.
Clin Gastroenterol Hepatol. 2011 Aug;9(8):635-48. doi: 10.1016/j.cgh.2011.03.005. Epub 2011 Mar 11.
Abstract/Text
Cystic pancreatic tumors (CPTs) have more frequently been identified in the last decade because of increased use of cross-sectional abdominal imaging. Although serous CPTs follow an indolent course and do not necessarily require surgical resection or long-term follow-up, mucinous CPTs (mucinous cystic neoplasms and intraductal papillary mucinous neoplasms) have a greater risk for malignancy. Although most CPTs are initially detected with imaging modalities such as computed tomography or magnetic resonance imaging, these tests alone rarely permit an accurate clinical diagnosis. Endoscopic ultrasound and endoscopic ultrasound-guided, fine-needle aspiration allow real-time examination and biopsy analysis of CPTs, which increases diagnostic accuracy because cytopathology features and tumor markers in cyst fluid can be analyzed. Management of patients with mucinous CPTs by surgery or imaging surveillance is controversial, partially because of limited information about disease progression and the complexities of surgical resection. We review approaches to diagnosis and management of common CPTs.
Copyright © 2011 AGA Institute. Published by Elsevier Inc. All rights reserved.
Josefin Björk Werner, Anna Bartosch-Härlid, Roland Andersson
Cystic pancreatic lesions: current evidence for diagnosis and treatment.
Scand J Gastroenterol. 2011 Jul;46(7-8):773-88. doi: 10.3109/00365521.2011.551892. Epub 2011 Feb 3.
Abstract/Text
Pancreatic cystic neoplasms are detected at an increasing frequency due to an increased use and quality of abdominal imaging. There are well known differential diagnostic difficulties concerning these lesions. The aim is to review current literature on the diagnostic options and the following treatment for cystic lesions in the pancreas focusing on serous cystadenomas, primary mucinous neoplasm of the pancreas and mucinous cystadenocarcinomas, as well as intraductal papillary mucinous neoplasms, starting with excluding pseudocysts. A conservative approach is feasible in patients with a clinical presentation suggestive of an asymptomatic serous cystadenoma. Surgical management, as well as follow-up, is discussed for each of the types of neoplastic lesions, including an uncharacterized cyst, based on patient data, symptoms, serum analysis, cyst fluid analysis and morphological features. Aspects for future diagnostics and management of these neoplasia are commented upon.
G Garcea, S L Ong, A Rajesh, C P Neal, C A Pollard, D P Berry, A R Dennison
Cystic lesions of the pancreas. A diagnostic and management dilemma.
Pancreatology. 2008;8(3):236-51. doi: 10.1159/000134279. Epub 2008 May 23.
Abstract/Text
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. and IAP.
Copyright 2008 S. Karger AG, Basel.
Hiroyuki Maguchi, Manabu Osanai, Akio Katanuma, Kuniyuki Takahashi
[Pancreatic tumor: progress in diagnosis and treatment. Topics: II. Intraductal papillary mucinous neoplasm of the pancreas (IPMN)/mucinous cystic neoplasm (MCN): 6. Other cystic neoplasms of the pancreas].
Nihon Naika Gakkai Zasshi. 2012 Jan 10;101(1):93-9.
Abstract/Text
Peter A Banks, Thomas L Bollen, Christos Dervenis, Hein G Gooszen, Colin D Johnson, Michael G Sarr, Gregory G Tsiotos, Santhi Swaroop Vege, Acute Pancreatitis Classification Working Group
Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus.
Gut. 2013 Jan;62(1):102-11. doi: 10.1136/gutjnl-2012-302779. Epub 2012 Oct 25.
Abstract/Text
BACKGROUND AND OBJECTIVE: The Atlanta classification of acute pancreatitis enabled standardised reporting of research and aided communication between clinicians. Deficiencies identified and improved understanding of the disease make a revision necessary.
METHODS: A web-based consultation was undertaken in 2007 to ensure wide participation of pancreatologists. After an initial meeting, the Working Group sent a draft document to 11 national and international pancreatic associations. This working draft was forwarded to all members. Revisions were made in response to comments, and the web-based consultation was repeated three times. The final consensus was reviewed, and only statements based on published evidence were retained.
RESULTS: The revised classification of acute pancreatitis identified two phases of the disease: early and late. Severity is classified as mild, moderate or severe. Mild acute pancreatitis, the most common form, has no organ failure, local or systemic complications and usually resolves in the first week. Moderately severe acute pancreatitis is defined by the presence of transient organ failure, local complications or exacerbation of co-morbid disease. Severe acute pancreatitis is defined by persistent organ failure, that is, organ failure >48 h. Local complications are peripancreatic fluid collections, pancreatic and peripancreatic necrosis (sterile or infected), pseudocyst and walled-off necrosis (sterile or infected). We present a standardised template for reporting CT images.
CONCLUSIONS: This international, web-based consensus provides clear definitions to classify acute pancreatitis using easily identified clinical and radiologic criteria. The wide consultation among pancreatologists to reach this consensus should encourage widespread adoption.
厚生労働省難治性膵疾患に関する調査研究班，日本膵臓学会編：膵仮性嚢胞の内視鏡治療ガイドライン2009．膵臓2009; 24(5):571-593.
Atsushi Irisawa, Ai Sato, Masaki Sato, Tsunehiko Ikeda, Rei Suzuki, Hiromasa Ohira
Early diagnosis of small pancreatic cancer: role of endoscopic ultrasonography.
Dig Endosc. 2009 Jul;21 Suppl 1:S92-6. doi: 10.1111/j.1443-1661.2009.00866.x.
Abstract/Text
Advanced pancreatic cancer is a major cause of cancer-related death. However, if surgery achieves clear margins and negative lymph nodes, the prognosis for survival can be prolonged. Therefore, early diagnosis - as early as possible - is important for improving overall survival and quality of life in patients with pancreatic cancer. Because of higher imaging resolution near the pancreas through the gastroduodenal wall, endoscopic ultrasonography enables detection of subtle pancreatic abnormalities. In fact, many investigators have reported the high ability of EUS not only for detection of small lesions but also recognition of chronic pancreatitis, which is the risky status of pancreatic cancer. As a tool for early diagnosis of pancreatic cancer, EUS is a highly anticipated modality.
Ken Kamata, Masayuki Kitano, Masatoshi Kudo, Hiroki Sakamoto, Kumpei Kadosaka, Takeshi Miyata, Hajime Imai, Kiyoshi Maekawa, Takaaki Chikugo, Masashi Kumano, Tomoko Hyodo, Takamichi Murakami, Yasutaka Chiba, Yoshifumi Takeyama
Value of EUS in early detection of pancreatic ductal adenocarcinomas in patients with intraductal papillary mucinous neoplasms.
Endoscopy. 2014 Jan;46(1):22-9. doi: 10.1055/s-0033-1353603. Epub 2013 Nov 11.
Abstract/Text
BACKGROUND AND STUDY AIMS: Pancreatic ductal adenocarcinomas (PDAC) sometimes arise in patients with intraductal papillary mucinous neoplasms (IPMNs). This study examined the incidence of PDACs concomitant to or derived from branch duct IPMNs. The usefulness of endoscopic ultrasonography (EUS) relative to other imaging methods for detecting these tumors was also assessed.
PATIENTS AND METHODS: This retrospective study used data from clinical records and imaging studies that were collected prospectively. During 2001-2009, 167 consecutive patients with IPMNs underwent EUS, ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI). The 102 patients whose branch duct IPMNs lacked mural nodules/symptoms and thus did not qualify for resection were followed up by semiannual EUS and annual ultrasonography, CT, and MRI. The sensitivity and specificity with which the four modalities detected IPMN-derived and -concomitant PDACs at the first examination and throughout the study period were evaluated. The rate of PDAC development during follow-up was analyzed by the Kaplan-Meier method.
RESULTS: A total of 17 IPMN-derived and 11 IPMN-concomitant PDACs were diagnosed at the first examination. Lesions that did not qualify for resection or chemotherapy were followed up for a median of 42 months. Seven IPMN-concomitant PDACs and no IPMN-derived PDACs were detected during follow-up. The 3- and 5-year rates of IPMN-concomitant PDAC development were 4.0% and 8.8%, respectively. At the first examination, EUS was superior to other imaging modalities in terms of IPMN-derived and -concomitant PDAC detection. Throughout the study period, including follow-up, EUS was significantly better at detecting IPMN-concomitant PDACs than the other modalities.
CONCLUSIONS: IPMN-concomitant PDACs are quite often found at diagnosis and during follow-up. EUS examination of the whole pancreas plays an important role in the management of IPMNs as it allows the early detection of these small invasive carcinomas.
© Georg Thieme Verlag KG Stuttgart · New York.
Masao Tanaka, Carlos Fernández-Del Castillo, Terumi Kamisawa, Jin Young Jang, Philippe Levy, Takao Ohtsuka, Roberto Salvia, Yasuhiro Shimizu, Minoru Tada, Christopher L Wolfgang
Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas.
Pancreatology. 2017 Sep - Oct;17(5):738-753. doi: 10.1016/j.pan.2017.07.007. Epub 2017 Jul 13.
Abstract/Text
The management of intraductal papillary mucinous neoplasm (IPMN) continues to evolve. In particular, the indications for resection of branch duct IPMN have changed from early resection to more deliberate observation as proposed by the international consensus guidelines of 2006 and 2012. Another guideline proposed by the American Gastroenterological Association in 2015 restricted indications for surgery more stringently and recommended physicians to stop surveillance if no significant change had occurred in a pancreatic cyst after five years of surveillance, or if a patient underwent resection and a non-malignant IPMN was found. Whether or not it is safe to do so, as well as the method and interval of surveillance, has generated substantial debate. Based on a consensus symposium held during the meeting of the International Association of Pancreatology in Sendai, Japan, in 2016, the working group has revised the guidelines regarding prediction of invasive carcinoma and high-grade dysplasia, surveillance, and postoperative follow-up of IPMN. As the working group did not recognize the need for major revisions of the guidelines, we made only minor revisions and added most recent articles where appropriate. The present guidelines include updated information and recommendations based on our current understanding, and highlight issues that remain controversial or where further research is required.
Copyright © 2017 IAP and EPC. Published by Elsevier B.V. All rights reserved.
日本膵臓学会膵癌診療ガイドライン改訂委員会編：膵癌診療ガイドライン (2019年版)、金原出版、2019年.
Shigetaka Yoshinaga, Takao Itoi, Kenji Yamao, Ichiro Yasuda, Atsushi Irisawa, Hiroshi Imaoka, Takayoshi Tsuchiya, Shinpei Doi, Akane Yamabe, Yoshitaka Murakami, Hideki Ishikawa, Yutaka Saito
Safety and efficacy of endoscopic ultrasound-guided fine needle aspiration for pancreatic masses: A prospective multicenter study.
Dig Endosc. 2019 Jun 5;. doi: 10.1111/den.13457. Epub 2019 Jun 5.
Abstract/Text
OBJECTIVES: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for solid pancreatic lesions has high diagnostic yield. However, few prospective multicenter studies have been performed. We performed a prospective cohort study to evaluate the efficacy and safety of EUS-FNA for diagnosis of solid pancreatic lesions.
METHODS: This prospective cohort study involved five hospitals in Japan. The primary outcome was sensitivity of EUS-FNA for diagnosing malignant lesions. We also evaluated parameters of diagnostic sufficiency and the safety of EUS-FNA.
RESULTS: In total, 246 patients were enrolled. The absolute values of the parameters evaluated showed no significant differences; however, the percentage changes in the white blood cell counts and C-reactive protein levels after examination were significantly higher, and the percentage change in hemoglobin concentrations was significantly lower. The minor and major complication rates at the time of puncture, 24 h, 7 days and 28 days were 4.1%, 2.8%, 1.6%, and 0.0%, respectively. The true complication rate was 1.2%. The diagnostic sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 97.2%, 88.0%, 96.2%, 100%, and 81.4%, respectively.
CONCLUSIONS: EUS-FNA for solid pancreatic lesions has high diagnostic yield and is safe, consistent with previously studies.
© 2019 Japan Gastroenterological Endoscopy Society.
Atsushi Irisawa, Hironao Miyoshi, Takao Itoi, Shomei Ryozawa, Mitsuhiro Kida, Kazuo Inui
Recent innovations in therapeutic endoscopy for pancreatobiliary diseases.
Dig Endosc. 2019 Jun 26;. doi: 10.1111/den.13473. Epub 2019 Jun 26.
Abstract/Text
The development of endoscopic treatment for pancreatobiliary diseases in recent years is remarkable. In addition to conventional transpapillary treatments under endoscopic retrograde cholangiopancreatography (ERCP), new endoscopic ultrasound-guided therapy is being developed and implemented. On the other hand, due to the development/improvement of various devices such as new metal stents, a new therapeutic strategy under ERCP is also advocated. The present review focuses on recent advances in the endoscopic treatment of pancreatic pseudocysts, walled-off necrosis, malignant biliary strictures, and benign biliary/pancreatic duct strictures.
© 2019 Japan Gastroenterological Endoscopy Society.
Hiroyuki Maguchi, Satoshi Tanno, Nobumasa Mizuno, Keiji Hanada, Go Kobayashi, Takashi Hatori, Yoshihiko Sadakari, Taketo Yamaguchi, Kosuke Tobita, Ryuichiro Doi, Akio Yanagisawa, Masao Tanaka
Natural history of branch duct intraductal papillary mucinous neoplasms of the pancreas: a multicenter study in Japan.
Pancreas. 2011 Apr;40(3):364-70. doi: 10.1097/MPA.0b013e31820a5975.
Abstract/Text
OBJECTIVE: The aim of this study was to evaluate the long-term follow-up results of patients with branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) without mural nodules (MNs) at 10 representative institutions in Japan.
METHODS: We analyzed 349 follow-up BD-IPMN patients who had no MNs on endoscopic ultrasonography at initial diagnosis.
RESULTS: Observation periods ranged from 1 to 16.3 years (median, 3.7 years). Sixty-two (17.8%) patients exhibited disease progression during follow-up. Twenty-two underwent surgery, leading to a pathological diagnosis of carcinoma in 9 and adenoma in 13. Although the remaining 287 (82.2%) showed no changes, 7 underwent surgery because of symptoms (n = 2), choice (n = 2), or development of pancreatic ductal adenocarcinoma (n = 3); all of them were diagnosed pathologically as adenomas. Of the 29 patients undergoing surgery, all 9 with carcinoma exhibited signs of progression, such as increased main pancreatic duct diameter and/or appearance of MNs. Pancreatic ductal adenocarcinomas and additional BD-IPMNs developed in 7 (2.0%) and 13 (3.7%), respectively. Overall, 320 (91.7%) patients were followed without surgery.
CONCLUSIONS: Most BD-IPMN patients who had no MNs on endoscopic ultrasonography could be managed without surgery. However, careful attention should be paid to disease progression and the development of pancreatic ductal adenocarcinomas during follow-up.
Mitsuharu Fukasawa, Hiroyuki Maguchi, Kuniyuki Takahashi, Akio Katanuma, Manabu Osanai, Akira Kurita, Tamaki Ichiya, Takayoshi Tsuchiya, Toshifumi Kin
Clinical features and natural history of serous cystic neoplasm of the pancreas.
Pancreatology. 2010;10(6):695-701. doi: 10.1159/000320694. Epub 2011 Jan 18.
Abstract/Text
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, nonoperative management with a careful follow-up should be recommended. Surgery should be suggested in only symptomatic patients, those with giant tumors (>10 cm), rapid growing or when the presence of a potentially malignant tumor cannot be excluded. and IAP.
Copyright © 2011 S. Karger AG, Basel.
膵炎局所合併症（膵仮性嚢胞，感染性被包化壊死等）に対する診断・治療コンセンサス．膵臓 29：775-818，2014.
