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S1298 Clinicopathological Study of Solid Pseudopapillary Neoplasm of the Pancreas
AGA Abstracts
S1297
S1299
When to Operate or Observe Branch Duct Intraductal Papillary Mucinous Neoplasms (IPMN-Br): Evaluation of Consensus Guidelines Kanwar R. Gill, Daniela Scimeca, Laith H. Jamil, Justin H. Nguyen, John Stauffer, Timothy A. Woodward, Muhammad K. Hasan, Michael B. Wallace, Massimo Raimondo
Glycemic Control in Patients Post Total Pancreatectomy for Intraductal Papillary Mucinous Neoplasm (IPMN) Ana M. Chindris, Laith H. Jamil, John Stauffer, Kanwar R. Gill, Daniela Scimeca, Shon Meek, Justin H. Nguyen, Massimo Raimondo, Timothy A. Woodward, Michael B. Wallace
BACKGROUND: The current Consensus Guidelines for management of IPMN-Br recommend surgical resection of suspected IPMN-Br with cyst size >3 cm cysts irrespective of symptoms, and <3 cm with worrisome features (symptoms, intramural nodules, dilated main duct, positive cytology). AIMS: To evaluate the application of these guidelines retrospectively in pathologically confirmed cases of IPMN-Br. METHODS: The records of patients with pathologically confirmed IPMN lesions were reviewed at our institution. IPMN were classified into 2 types: main duct and branch duct. Histologically, the resected IPMN-Br were classified into low risk (adenoma, borderline) and high risk (carcinoma in situ or invasive cancer). Clinical data (symptoms, mural nodule, dilated pancreatic duct, and cyst size) were correlated with pathology. RESULTS: Between 2002 and 2008, there were 102 patients who underwent surgical resection for IPMN. 60 Patients had predominant IPMN-Br. There were 35% (21/ 60) IPMN-Br of size >3 cm, and 65% <3 cm in size. Among IPMN <3 cm, 72 % (28/39) had associated worrisome features. The prevalence of high-risk lesions in our study was 35% (21/60). A total of 82 % (49/60) of IPMN-Br met guidelines recommendation for surgical resection including 57% (18 of 26) of low-risk lesions and 100% (21/21) of highrisk lesions. All 11 cases of IPMN-Br that would have been recommended for conservative management were low-risk lesions. Sensitivity, specificity, positive predictive value, negative predictive value consensus guidelines for correctly defining high and low risk IPMN-Br was 100%, 28%, 43 %, 100%, respectively. CONCLUSIONS: Application of Consensus Guidelines to our patients would have recommended surgical resection to all histology proven high-risk IPMN-Br. All IPMN-Br which would have recommended for conservative management, were histologically low-risk lesions. The risk of high risk pathology among <3 cm IPMN without other worrisome features, is almost nonexistent and these lesions may selected for observation.
Introduction: Diabetes Mellitus (DM) induced by total pancreatectomy (TP) is often thought to be difficult to manage, and could adversely influence the decision to perform the procedure, which is otherwise the treatment of choice in patients with main duct or multifocal IPMN. It is unclear if this has changed with recent advances in therapies for DM, and if underlying pancreatic disease affects glycemic control after TP. Only one French study of 10 patients found that glycemic control can be achieved successfully after TP for mucinous pancreatic tumors. Methods and Aims: Retrospective chart review of patients who have undergone TP for IPMN in our institution, to evaluate their glycemic control. Results: We identified 29 patients (20 F, 9 M) who underwent TP for IPMN in our institution between 2004 and 2008. Follow up data regarding glycemic control was available in 19 (16 F, 3 M). Mean age 73.6 (60-82) and mean length of follow up 19.2 months (3-50). Mean BMI at the time of surgery was 25.5 kg/m2 (19-35.5) and approximately 1 year after TP was 21.39 kg/m2 (15.8-32.02, data on 14 patients). Mean BMI variation was 3.87 over 1 year (-0.1 - 10.9). Two of 19 patients had type 2DM prior TP and 2 had symptoms of pancreatic insufficiency. All patients were started on Insulin drip post surgery and were discharged on insulin sliding scale for meal coverage. In addition, 17 patients were given Lantus, 1 received Humulin 70/30, and another Levemir. Patients were also discharged on pancreatic enzyme supplements. Only 1 patient developed hypoglycemia that required admission to the emergency room treated with Dextrose 50% and discharged home. Other 9 patients mentioned occasional hypoglycemia noted during blood sugar monitoring with minimal or no symptoms. All these episodes were managed at home by the patients, none requiring glucagon or hospital admission. Current insulin regimens include: Lantus insulin (15 patients, mean dose 10.5U; 2-30 U/day), Humulin 70/30(1), Levemir (1) and insulin pimps (3). The mean of most recent Hgb A1C's was 6.8% (5.0-9.0, data for 19 patients), and overall mean Hgb A1C was 7.3% (5.0-9.0). Most (14/19) continued pancreatic enzyme supplements to avoid malabsorption and its potential negative effects on glycemic control. Two patients continued to complain of steatorrhea due to intolerance to medications (1) and inadequate dosing (1). One patient died 5 months after the surgery due to complications related to malnutrition. Conclusion: DM induced by TP for IPMN can be well managed and controlled with a variety of insulin therapy regimens. Fear of DM following TP for IPMN should not preclude surgery when indicated.
S1298 Clinicopathological Study of Solid Pseudopapillary Neoplasm of the Pancreas Eun Ju Cho, Youn Joo Kim, Ki Young Yang, Jeong Kyun Seo, Joo Kyung Park, Ji Kon Ryu, Yong-Tae Kim, Yong Bum Yoon, Min A Kim BACKGROUND:Solid pseudopapillary tumors(SPTs) are unusual neoplasms of the pancreas of uncertain histogenesis. Although most SPTs have good prognosis, some cases of locally infiltrating and metastatic variety, or recurrences after surgery, have been reported. Moreover, long term survival is described even for metastatic disease, suggesting a variable and not clearly elucidated biology of SPTs. This study aimed to delineate the clinicopathologic features predicting SPTs with malignant potential. METHODS:A retrospective analysis was done of 60 patients who underwent surgical resection with a definitive histological diagnosis of SPT. RESULTS:There were 55 female(91.7%) and five male(8.3%) with median age of 33.4 years(range, 2-74 years). Nine patients(15%) had SPTs with malignant potential. The deep parenchymal invasion into the surrounding tissue was the most frequent pathological feature suggesting malignancy(75%). There were no significant differences between benign and malignant SPT with respect to the age and gender of the patients, tumor size, location, internal composition, and pattern of calcification. Histopathologic features such as tumor necrosis, hemorrhage and immunohistochemical pattern were also similar in both groups. During the follow-up period, averaging 45.4 months, one patient developed recurrent disease following curative resection and none of 60 patients died. CONCLUSIONS:Although SPTs are low-grade tumors with good prognosis, the clinical behavior may be unpredictable and malignant potential can't be completely excluded even in case of histologic benign tumors. So careful long term follow-up is necessary and more studies are needed to provide insights into the behavior of SPTs. TABLE 1. Comparison of Clinical Features of Benign and Malignant SPTs
S1300 Quality of Life and Pancreatic Function After Resection of Pancreatic Cysts Niels Anthony Van Der Gaag, Olvert A. Berkhemer, Olivier R. Busch, Thomas M. Van Gulik, Dirk J. Gouma BACKGROUND/AIM: Cystic lesions in the pancreas are increasingly diagnosed. Radical resection is the accepted treatment for (pre)malignant cysts, but preoperative differentiation with benign lesions can be difficult. Evaluation of death due to recurrence, but in particular long term quality of life (QoL) and pancreatic function after resection is scarcely reported, which were the aims of the present study. METHODS: Records of 108 patients that underwent various surgical procedures between Jan/1992-June/2007 for a pancreatic cystic lesion (pathology proven serous cystic, mucinous cystic [MCN], intraductal papillary mucinous [IPMN] and solid pseudopapillary neoplasia) were reviewed. Latest follow-up was collected. Participating patients received generic (SF-36, QLQ-C30) and pancreatic (PAN26) QoL questionnaires, which were completed at home. Pancreatic function tests were performed [endocrine: HbA1c, fasting glucose; exocrine: faeces elastase] during a prospectively scheduled outpatient clinic visit. RESULTS: Death due to recurrence had occurred in 11 (10%) patients (6 IPMN, 5 MCN) at a median of 13 months. Two died in-hospital due to complications, 7 due to other causes. Sixty-five of 88 (74%) living patients agreed to participate; female gender was 69%, mean age 61 years. Median follow-up was 59 months. Thirty-one (48%) patients had undergone pancreatoduodenectomy, 26 (40%) tail resection, 4 (6%) central and 4 (6%) total pancreatectomy. Study population characteristics were not significantly different from non-participants. Reported global health status (QLQ-C30) was 83 (median; IQR 67-92) (max. possible: 100). Physical and mental QoL scores including all subdomains (SF36) were not different from a healthy reference population, except for a lower vitality score (61 vs 69, P <.05). In none of the 14 pancreatic symptom scales (PAN 26) median scores were above 50 (50-100: moderate/severe complaints). Endocrine insufficiency occurred in 24 (40%) of 60 patients available for analysis; 19 were already diagnosed and received antidiabetics, only 5 appeared to be adequately treated (HbA1c <6%). Exocrine insufficiency was present in 32 (59%) of 54 available patients. CONCLUSION: Death due to recurrence after resection of a pancreatic cyst was 10% in the present series and occurred after a median of 13 months. After resection some deterioration of pancreatic function occurs, for which recognition and medical treatment should be improved. Patients report excellent long term QoL scores, equal to healthy individuals, which might lower the threshold to surgery in case differentiation between a benign and (pre)malignant lesion cannot be established in advance. S1301 Role of Repeat Endoscopic Ultrasonography with Fine Needle Aspiration in the Diagnosis of Indeterminant Pancreatic Cysts Tarun K. Narang, Neal J. Schamberg, Ketan Kulkarni, Savreet Sarkaria, Mark B. Pochapin, Felice Schnoll-Sussman Background: Endoscopic ultrasound with fine needle aspiration (EUS-FNA) is integral to the diagnosis and management of pancreatic cystic neoplasms. However, distinction between various types of pancreatic cysts is not always possible based on EUS-FNA findings alone. In these patients, follow up with repeat EUS-FNA or cross-sectional imaging may be undertaken. Aim: We sought to determine the yield of repeat EUS-FNA in the definitive diagnosis
AGA Abstracts
A-232
S1297
S1299
When to Operate or Observe Branch Duct Intraductal Papillary Mucinous Neoplasms (IPMN-Br): Evaluation of Consensus Guidelines Kanwar R. Gill, Daniela Scimeca, Laith H. Jamil, Justin H. Nguyen, John Stauffer, Timothy A. Woodward, Muhammad K. Hasan, Michael B. Wallace, Massimo Raimondo
Glycemic Control in Patients Post Total Pancreatectomy for Intraductal Papillary Mucinous Neoplasm (IPMN) Ana M. Chindris, Laith H. Jamil, John Stauffer, Kanwar R. Gill, Daniela Scimeca, Shon Meek, Justin H. Nguyen, Massimo Raimondo, Timothy A. Woodward, Michael B. Wallace
BACKGROUND: The current Consensus Guidelines for management of IPMN-Br recommend surgical resection of suspected IPMN-Br with cyst size >3 cm cysts irrespective of symptoms, and <3 cm with worrisome features (symptoms, intramural nodules, dilated main duct, positive cytology). AIMS: To evaluate the application of these guidelines retrospectively in pathologically confirmed cases of IPMN-Br. METHODS: The records of patients with pathologically confirmed IPMN lesions were reviewed at our institution. IPMN were classified into 2 types: main duct and branch duct. Histologically, the resected IPMN-Br were classified into low risk (adenoma, borderline) and high risk (carcinoma in situ or invasive cancer). Clinical data (symptoms, mural nodule, dilated pancreatic duct, and cyst size) were correlated with pathology. RESULTS: Between 2002 and 2008, there were 102 patients who underwent surgical resection for IPMN. 60 Patients had predominant IPMN-Br. There were 35% (21/ 60) IPMN-Br of size >3 cm, and 65% <3 cm in size. Among IPMN <3 cm, 72 % (28/39) had associated worrisome features. The prevalence of high-risk lesions in our study was 35% (21/60). A total of 82 % (49/60) of IPMN-Br met guidelines recommendation for surgical resection including 57% (18 of 26) of low-risk lesions and 100% (21/21) of highrisk lesions. All 11 cases of IPMN-Br that would have been recommended for conservative management were low-risk lesions. Sensitivity, specificity, positive predictive value, negative predictive value consensus guidelines for correctly defining high and low risk IPMN-Br was 100%, 28%, 43 %, 100%, respectively. CONCLUSIONS: Application of Consensus Guidelines to our patients would have recommended surgical resection to all histology proven high-risk IPMN-Br. All IPMN-Br which would have recommended for conservative management, were histologically low-risk lesions. The risk of high risk pathology among <3 cm IPMN without other worrisome features, is almost nonexistent and these lesions may selected for observation.
Introduction: Diabetes Mellitus (DM) induced by total pancreatectomy (TP) is often thought to be difficult to manage, and could adversely influence the decision to perform the procedure, which is otherwise the treatment of choice in patients with main duct or multifocal IPMN. It is unclear if this has changed with recent advances in therapies for DM, and if underlying pancreatic disease affects glycemic control after TP. Only one French study of 10 patients found that glycemic control can be achieved successfully after TP for mucinous pancreatic tumors. Methods and Aims: Retrospective chart review of patients who have undergone TP for IPMN in our institution, to evaluate their glycemic control. Results: We identified 29 patients (20 F, 9 M) who underwent TP for IPMN in our institution between 2004 and 2008. Follow up data regarding glycemic control was available in 19 (16 F, 3 M). Mean age 73.6 (60-82) and mean length of follow up 19.2 months (3-50). Mean BMI at the time of surgery was 25.5 kg/m2 (19-35.5) and approximately 1 year after TP was 21.39 kg/m2 (15.8-32.02, data on 14 patients). Mean BMI variation was 3.87 over 1 year (-0.1 - 10.9). Two of 19 patients had type 2DM prior TP and 2 had symptoms of pancreatic insufficiency. All patients were started on Insulin drip post surgery and were discharged on insulin sliding scale for meal coverage. In addition, 17 patients were given Lantus, 1 received Humulin 70/30, and another Levemir. Patients were also discharged on pancreatic enzyme supplements. Only 1 patient developed hypoglycemia that required admission to the emergency room treated with Dextrose 50% and discharged home. Other 9 patients mentioned occasional hypoglycemia noted during blood sugar monitoring with minimal or no symptoms. All these episodes were managed at home by the patients, none requiring glucagon or hospital admission. Current insulin regimens include: Lantus insulin (15 patients, mean dose 10.5U; 2-30 U/day), Humulin 70/30(1), Levemir (1) and insulin pimps (3). The mean of most recent Hgb A1C's was 6.8% (5.0-9.0, data for 19 patients), and overall mean Hgb A1C was 7.3% (5.0-9.0). Most (14/19) continued pancreatic enzyme supplements to avoid malabsorption and its potential negative effects on glycemic control. Two patients continued to complain of steatorrhea due to intolerance to medications (1) and inadequate dosing (1). One patient died 5 months after the surgery due to complications related to malnutrition. Conclusion: DM induced by TP for IPMN can be well managed and controlled with a variety of insulin therapy regimens. Fear of DM following TP for IPMN should not preclude surgery when indicated.
S1298 Clinicopathological Study of Solid Pseudopapillary Neoplasm of the Pancreas Eun Ju Cho, Youn Joo Kim, Ki Young Yang, Jeong Kyun Seo, Joo Kyung Park, Ji Kon Ryu, Yong-Tae Kim, Yong Bum Yoon, Min A Kim BACKGROUND:Solid pseudopapillary tumors(SPTs) are unusual neoplasms of the pancreas of uncertain histogenesis. Although most SPTs have good prognosis, some cases of locally infiltrating and metastatic variety, or recurrences after surgery, have been reported. Moreover, long term survival is described even for metastatic disease, suggesting a variable and not clearly elucidated biology of SPTs. This study aimed to delineate the clinicopathologic features predicting SPTs with malignant potential. METHODS:A retrospective analysis was done of 60 patients who underwent surgical resection with a definitive histological diagnosis of SPT. RESULTS:There were 55 female(91.7%) and five male(8.3%) with median age of 33.4 years(range, 2-74 years). Nine patients(15%) had SPTs with malignant potential. The deep parenchymal invasion into the surrounding tissue was the most frequent pathological feature suggesting malignancy(75%). There were no significant differences between benign and malignant SPT with respect to the age and gender of the patients, tumor size, location, internal composition, and pattern of calcification. Histopathologic features such as tumor necrosis, hemorrhage and immunohistochemical pattern were also similar in both groups. During the follow-up period, averaging 45.4 months, one patient developed recurrent disease following curative resection and none of 60 patients died. CONCLUSIONS:Although SPTs are low-grade tumors with good prognosis, the clinical behavior may be unpredictable and malignant potential can't be completely excluded even in case of histologic benign tumors. So careful long term follow-up is necessary and more studies are needed to provide insights into the behavior of SPTs. TABLE 1. Comparison of Clinical Features of Benign and Malignant SPTs
S1300 Quality of Life and Pancreatic Function After Resection of Pancreatic Cysts Niels Anthony Van Der Gaag, Olvert A. Berkhemer, Olivier R. Busch, Thomas M. Van Gulik, Dirk J. Gouma BACKGROUND/AIM: Cystic lesions in the pancreas are increasingly diagnosed. Radical resection is the accepted treatment for (pre)malignant cysts, but preoperative differentiation with benign lesions can be difficult. Evaluation of death due to recurrence, but in particular long term quality of life (QoL) and pancreatic function after resection is scarcely reported, which were the aims of the present study. METHODS: Records of 108 patients that underwent various surgical procedures between Jan/1992-June/2007 for a pancreatic cystic lesion (pathology proven serous cystic, mucinous cystic [MCN], intraductal papillary mucinous [IPMN] and solid pseudopapillary neoplasia) were reviewed. Latest follow-up was collected. Participating patients received generic (SF-36, QLQ-C30) and pancreatic (PAN26) QoL questionnaires, which were completed at home. Pancreatic function tests were performed [endocrine: HbA1c, fasting glucose; exocrine: faeces elastase] during a prospectively scheduled outpatient clinic visit. RESULTS: Death due to recurrence had occurred in 11 (10%) patients (6 IPMN, 5 MCN) at a median of 13 months. Two died in-hospital due to complications, 7 due to other causes. Sixty-five of 88 (74%) living patients agreed to participate; female gender was 69%, mean age 61 years. Median follow-up was 59 months. Thirty-one (48%) patients had undergone pancreatoduodenectomy, 26 (40%) tail resection, 4 (6%) central and 4 (6%) total pancreatectomy. Study population characteristics were not significantly different from non-participants. Reported global health status (QLQ-C30) was 83 (median; IQR 67-92) (max. possible: 100). Physical and mental QoL scores including all subdomains (SF36) were not different from a healthy reference population, except for a lower vitality score (61 vs 69, P <.05). In none of the 14 pancreatic symptom scales (PAN 26) median scores were above 50 (50-100: moderate/severe complaints). Endocrine insufficiency occurred in 24 (40%) of 60 patients available for analysis; 19 were already diagnosed and received antidiabetics, only 5 appeared to be adequately treated (HbA1c <6%). Exocrine insufficiency was present in 32 (59%) of 54 available patients. CONCLUSION: Death due to recurrence after resection of a pancreatic cyst was 10% in the present series and occurred after a median of 13 months. After resection some deterioration of pancreatic function occurs, for which recognition and medical treatment should be improved. Patients report excellent long term QoL scores, equal to healthy individuals, which might lower the threshold to surgery in case differentiation between a benign and (pre)malignant lesion cannot be established in advance. S1301 Role of Repeat Endoscopic Ultrasonography with Fine Needle Aspiration in the Diagnosis of Indeterminant Pancreatic Cysts Tarun K. Narang, Neal J. Schamberg, Ketan Kulkarni, Savreet Sarkaria, Mark B. Pochapin, Felice Schnoll-Sussman Background: Endoscopic ultrasound with fine needle aspiration (EUS-FNA) is integral to the diagnosis and management of pancreatic cystic neoplasms. However, distinction between various types of pancreatic cysts is not always possible based on EUS-FNA findings alone. In these patients, follow up with repeat EUS-FNA or cross-sectional imaging may be undertaken. Aim: We sought to determine the yield of repeat EUS-FNA in the definitive diagnosis
AGA Abstracts
A-232