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A unifying concept for periampullary adenocarcinomas
Abstracts / Pancreatology 13 (2013) S2–S98 1 Surgical and Emergency Unit, Department of Internal Medicine and Surgery, S.Orsola-Malpighi Hospital, University of Bologna, Italy 2 Internal Medicine Unit, Department of Internal Medicine and Surgery, S.Orsola-Malpighi Hospital, University of Bologna, Italy 3 Pathological Unit, Department of Hematology, Oncology and Pathology, S.Orsola-Malpighi Hospital, University of Bologna, Italy
Introduction: In 2012 the IPMNs International Consensus Guidelines changed the criteria for surgery and the definition of “malignancy”, reserving this term only for invasive carcinoma Aims: To evaluate the accuracy of surgical criteria to predict malignancy. Patients & methods: From 2003 to 2012, data regarding 184 patients with IPMNs, were recorded. Forty-two (22.8 %) patients, undergoing surgery, were evaluated according to the new guidelines. Criteria for surgery (cyst size, Wirsung dilatation, symptoms and presence of solid endocystic component) were studied to assess the malignancy in patients affected by IPMNs. Multivariate analysis was carried out comparing the new (only invasive carcinoma) and old definition of malignancy (invasive carcinoma and high grade dysplasia). Results: All operated patients presented criteria for surgery. Malignancy was recorded in 21 (50%) and 17 (40.5%) patients, according to the Sendai and Fukuoka definitions. At multivariate analysis no factors predicted malignancy according to Fukuoka definition, while presence of ESC (RR 14.2; C.I. 95% 1.8-113.5; P¼0.012) and cystic size (RR 1.1; CI 95% 1.021.20; P¼0.019) were related to malignancy according to Sendai definition. A dimensional cut-off of the cystic lesion of 26 mm was obtained with a ROC curve (AUC¼ 0.724; P¼0.013). At the multivariate analysis, this cut-off resulted the strongest indipendent factor predicting malignancy according to Sendai definition (RR 8.0; CI 95% 1.13-56.95; P¼0.037). Conclusion: In our experience, surgical criteria seem to be inefficacy to predict presence of invasive carcinoma. ESC and cystic size were the only factors able to detect patients with high grade dysplasia or invasive carcinoma and to suggest the surgical approach.
PII-110 Abstract id: 331. A unifying concept for periampullary adenocarcinomas Peter Bronsert 1, Ilona Kohler 1, Martin Werner 1, Frank Makowiec 1, Dirk Bausch 2, Ulrich Theodor Hopt 1, Tobias Keck 2, Ulrich Friedrich Wellner 2. 1 2
University of Freiburg, Germany € beck, Germany UKSH Campus Lu
Introduction: Periampullary adenocarcinomas comprise pancreatic, distal bile duct, ampullary and duodenal adenocarcinoma. The epithelia of these anatomical structures share a common embryologic origin from the foregut. With steadily increasing numbers of pancreatoduodenectomies over the last decades, pathologists, surgeons and oncologists are more often confronted with the diagnosis of “other than pancreatic” periampullary cancers. The intestinal subtype of ampullary cancer has been shown to correlate with better prognosis. Aims: clinical and histopathological evaluation of intestinal vs pancreatobiliary differentiation in duodenal, ampullary, bile duct and pancreatic adenocarcinoma Patients & methods: From n¼198 cases of periampullary carcinoma with clinical follow-up, evaluation of histological subtype and immunohistochemical staining pattern for CK7, CK20 and CDX2 was done by two experienced pathologists. Routine pathological parameters were included in survival analysis performed with SPSS 20. Results: In univariate analysis, intestinal subtype was associated with better survival in ampullary, pancreatic ductal and duodenal adenocarcinoma. Intestinal differentiation and lymph node ratio, but not tumor location were independent predictors of survival when all significant predictor variables from univariate analysis (grade, TNM stage, presence of precursor lesions, surgical margin status, perineural, vascular and lymphatic vessel invasion, CK7 and CDX2 staining pattern) were included in a Cox proportional hazards model.
S85
Conclusion: Intestinal type differentiation of periampullary carcinomas and lymph node ratio are independent prognostic factors not only in ampullary, but also in other periampullary adenocarcinomas like pancreatic ductal adenocarcinoma. Differentiation is more important than tumor location for prognostic stratification in periampullary carcinomas.
PII-111 Abstract id: 114. Diagnostic accuracy of contrast-enhanced computed tomography in assessing extra-regional lymphadenopathy in pancreatic and periampullary cancer: A systematic review Dorine S.J. Tseng 1, Hjalmar C. van Santvoort 1, Samira Fegrachi 1, Marc G.H. Besselink 2, Inne H.M. Borel Rinkes 1, Maarten S. van Leeuwen 1, I. Quintus Molenaar 1. 1 2
University Medical Center Utrecht, Netherlands Academic Medical Center Amsterdam, Netherlands
Introduction: Computed tomography (CT) is the most widely used method for assessing resectability of pancreatic and peri-ampullary cancer. One of the contra-indications for curative resection is extra-regional lymph node (ELN) metastases. Aims: The aim of this study was to determine the diagnostic accuracy of CT in assessing ELN metastases in pancreatic and peri-ampullary cancer. Patients & methods: We systematically reviewed the literature published up to November 29th 2012, according to the PRISMA guidelines. Studies reporting on CT and histopathological assessment of ELN in patients undergoing pancreatoduodenectomy were included. We excluded studies were data on CT and ELN were not reported. Data on baseline characteristics, CT-investigations and histopathological outcomes were extracted. Diagnostic accuracy, positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity were calculated for individual studies and pooled data. Results: After screening, 4 cohort studies reporting on CT-findings and histopathological outcome in 157 patients with pancreatic or periampullary cancer were included. Histopathologically proven ELN metastases were present in 28/157(18%) patients, which had been diagnosed on CT in 7(25%) patients. CT falsely suggested presence of ELN metastases in 18/129(14%) patients. Overall, diagnostic accuracy, specificity and NPV varied from 63-81, 80-100% and 67-90% respectively. However, PPV and sensitivity ranged from 0-100% and 0-38%. Pooled accuracy, sensitivity, specificity, PPV and NPV were 75%, 25%, 86%, 28% and 84% respectively. Conclusion: CT has a low diagnostic accuracy in assessing ELN metastases in patient with pancreatic or peri-ampullary cancer. Therefore the suspicion of ELN metastases on CT should not be a contra-indication for explorative laparotomy and, when possible, pancreatoduodenectomy.
PII-112 Abstract id: 121. Clinical behavior in 63 patients with branch duct type of intraductal papillary mucinous neoplasm Arichika Hoshino 1, Hiroyuki Suzuki 1, Takayuki Aimoto 2, Satoshi Mizutani 1, Eiji Uchida 2. 1 2
Nippon Medical School Musashikosugi Hospital, Japan Nippon Medical School, Japan
Introduction: An international consensus conference has recommended close follow-up in patients with branch duct type of intraductal papillary mucinous neoplasm (BD-IPMN), even if no symptoms, smaller than 30 mm in diameter and no mural nodules. Aims: This study investigated whether the recommendation could be appropriate in a single-centre experience. Patients & methods: Sixty-three patients who were diagnosed with BD-IPMN at our institute between 2000 and 2012 were enrolled in this study. At the first presentation, all patients were asymptomatic and had a
Introduction: In 2012 the IPMNs International Consensus Guidelines changed the criteria for surgery and the definition of “malignancy”, reserving this term only for invasive carcinoma Aims: To evaluate the accuracy of surgical criteria to predict malignancy. Patients & methods: From 2003 to 2012, data regarding 184 patients with IPMNs, were recorded. Forty-two (22.8 %) patients, undergoing surgery, were evaluated according to the new guidelines. Criteria for surgery (cyst size, Wirsung dilatation, symptoms and presence of solid endocystic component) were studied to assess the malignancy in patients affected by IPMNs. Multivariate analysis was carried out comparing the new (only invasive carcinoma) and old definition of malignancy (invasive carcinoma and high grade dysplasia). Results: All operated patients presented criteria for surgery. Malignancy was recorded in 21 (50%) and 17 (40.5%) patients, according to the Sendai and Fukuoka definitions. At multivariate analysis no factors predicted malignancy according to Fukuoka definition, while presence of ESC (RR 14.2; C.I. 95% 1.8-113.5; P¼0.012) and cystic size (RR 1.1; CI 95% 1.021.20; P¼0.019) were related to malignancy according to Sendai definition. A dimensional cut-off of the cystic lesion of 26 mm was obtained with a ROC curve (AUC¼ 0.724; P¼0.013). At the multivariate analysis, this cut-off resulted the strongest indipendent factor predicting malignancy according to Sendai definition (RR 8.0; CI 95% 1.13-56.95; P¼0.037). Conclusion: In our experience, surgical criteria seem to be inefficacy to predict presence of invasive carcinoma. ESC and cystic size were the only factors able to detect patients with high grade dysplasia or invasive carcinoma and to suggest the surgical approach.
PII-110 Abstract id: 331. A unifying concept for periampullary adenocarcinomas Peter Bronsert 1, Ilona Kohler 1, Martin Werner 1, Frank Makowiec 1, Dirk Bausch 2, Ulrich Theodor Hopt 1, Tobias Keck 2, Ulrich Friedrich Wellner 2. 1 2
University of Freiburg, Germany € beck, Germany UKSH Campus Lu
Introduction: Periampullary adenocarcinomas comprise pancreatic, distal bile duct, ampullary and duodenal adenocarcinoma. The epithelia of these anatomical structures share a common embryologic origin from the foregut. With steadily increasing numbers of pancreatoduodenectomies over the last decades, pathologists, surgeons and oncologists are more often confronted with the diagnosis of “other than pancreatic” periampullary cancers. The intestinal subtype of ampullary cancer has been shown to correlate with better prognosis. Aims: clinical and histopathological evaluation of intestinal vs pancreatobiliary differentiation in duodenal, ampullary, bile duct and pancreatic adenocarcinoma Patients & methods: From n¼198 cases of periampullary carcinoma with clinical follow-up, evaluation of histological subtype and immunohistochemical staining pattern for CK7, CK20 and CDX2 was done by two experienced pathologists. Routine pathological parameters were included in survival analysis performed with SPSS 20. Results: In univariate analysis, intestinal subtype was associated with better survival in ampullary, pancreatic ductal and duodenal adenocarcinoma. Intestinal differentiation and lymph node ratio, but not tumor location were independent predictors of survival when all significant predictor variables from univariate analysis (grade, TNM stage, presence of precursor lesions, surgical margin status, perineural, vascular and lymphatic vessel invasion, CK7 and CDX2 staining pattern) were included in a Cox proportional hazards model.
S85
Conclusion: Intestinal type differentiation of periampullary carcinomas and lymph node ratio are independent prognostic factors not only in ampullary, but also in other periampullary adenocarcinomas like pancreatic ductal adenocarcinoma. Differentiation is more important than tumor location for prognostic stratification in periampullary carcinomas.
PII-111 Abstract id: 114. Diagnostic accuracy of contrast-enhanced computed tomography in assessing extra-regional lymphadenopathy in pancreatic and periampullary cancer: A systematic review Dorine S.J. Tseng 1, Hjalmar C. van Santvoort 1, Samira Fegrachi 1, Marc G.H. Besselink 2, Inne H.M. Borel Rinkes 1, Maarten S. van Leeuwen 1, I. Quintus Molenaar 1. 1 2
University Medical Center Utrecht, Netherlands Academic Medical Center Amsterdam, Netherlands
Introduction: Computed tomography (CT) is the most widely used method for assessing resectability of pancreatic and peri-ampullary cancer. One of the contra-indications for curative resection is extra-regional lymph node (ELN) metastases. Aims: The aim of this study was to determine the diagnostic accuracy of CT in assessing ELN metastases in pancreatic and peri-ampullary cancer. Patients & methods: We systematically reviewed the literature published up to November 29th 2012, according to the PRISMA guidelines. Studies reporting on CT and histopathological assessment of ELN in patients undergoing pancreatoduodenectomy were included. We excluded studies were data on CT and ELN were not reported. Data on baseline characteristics, CT-investigations and histopathological outcomes were extracted. Diagnostic accuracy, positive predictive value (PPV), negative predictive value (NPV), sensitivity and specificity were calculated for individual studies and pooled data. Results: After screening, 4 cohort studies reporting on CT-findings and histopathological outcome in 157 patients with pancreatic or periampullary cancer were included. Histopathologically proven ELN metastases were present in 28/157(18%) patients, which had been diagnosed on CT in 7(25%) patients. CT falsely suggested presence of ELN metastases in 18/129(14%) patients. Overall, diagnostic accuracy, specificity and NPV varied from 63-81, 80-100% and 67-90% respectively. However, PPV and sensitivity ranged from 0-100% and 0-38%. Pooled accuracy, sensitivity, specificity, PPV and NPV were 75%, 25%, 86%, 28% and 84% respectively. Conclusion: CT has a low diagnostic accuracy in assessing ELN metastases in patient with pancreatic or peri-ampullary cancer. Therefore the suspicion of ELN metastases on CT should not be a contra-indication for explorative laparotomy and, when possible, pancreatoduodenectomy.
PII-112 Abstract id: 121. Clinical behavior in 63 patients with branch duct type of intraductal papillary mucinous neoplasm Arichika Hoshino 1, Hiroyuki Suzuki 1, Takayuki Aimoto 2, Satoshi Mizutani 1, Eiji Uchida 2. 1 2
Nippon Medical School Musashikosugi Hospital, Japan Nippon Medical School, Japan
Introduction: An international consensus conference has recommended close follow-up in patients with branch duct type of intraductal papillary mucinous neoplasm (BD-IPMN), even if no symptoms, smaller than 30 mm in diameter and no mural nodules. Aims: This study investigated whether the recommendation could be appropriate in a single-centre experience. Patients & methods: Sixty-three patients who were diagnosed with BD-IPMN at our institute between 2000 and 2012 were enrolled in this study. At the first presentation, all patients were asymptomatic and had a