Intraductal papillary and mucinous tumors of the pancreas: accuracy of preoperative computed tomography, endoscopic retrograde pancreatography and endoscopic ultrasonography, and long-term outcome in a large surgical series☆,☆☆,★

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Abstract

Background: Few data are available on the accuracy of preoperative imaging or on long-term outcome after surgery for intraductal papillary and mucinous tumors of the pancreas. The aims of this study were to assess the following: (1) the accuracy of preoperative computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography for determination of tumor invasion and pancreatic extension as compared with surgical findings; (2) the long-term outcome after surgery. Methods: Forty-seven patients who underwent surgery between 1980 and 1995 for pathologically diagnosed intraductal papillary and mucinous tumors were included in this study. The findings of available computed tomography (n = 25), endoscopic retrograde pancreatography (n = 29), and endoscopic ultrasonography (n = 21) were reviewed by experienced clinicians blinded to pathologic diagnosis to assess tumor invasion and pancreatic extension. Pathologic specimens were reviewed by experienced pathologists. Postoperative follow-up data were analyzed. Results: Histologic features of invasive carcinoma were found in 43% of patients, severe dysplasia in 21%, and mild or moderate dysplasia in 36%. The overall accuracy of computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography in distinguishing between invasive and noninvasive tumors were, respectively, 76%, 79%, and 76%. The overall 3-year disease-free survival rate was 63%, but it was 21% among patients with invasive carcinoma at surgery (p < 0.001). Conclusions: This study emphasizes the need for early surgical resection in patients with suspected intraductal papillary and mucinous tumors of the pancreas because of the high frequency of invasive carcinoma and the inadequacy of preoperative imaging for assessing malignancy. (Gastrointestinal Endosc 1998;47:42-9.)

Section snippets

Selection of patients

Patients were selected from the files of three referring endoscopic centers specialized in pancreatic diseases. Sixty-six patients from three endoscopic centers (Brussels, Belgium; Lyons and Paris, France) were seen between 1980 and 1995 with a diagnosis of IPMT of the pancreas initially suggested by ERP or EUS findings (Figs. 1 and 2).

. Endoscopic retrograde pancreatography: diffuse main pancreatic duct dilatation and intraductal filling defects. Benign IPMT located in the head of the pancreas.

Clinical characteristics and tumor marker levels

There were 34 men and 13 women with a mean age of 63 years (range 35 to 81 years). The time between onset of symptoms and diagnosis was 46 months (range 0 to 348 months). Presenting manifestations and tumor marker levels are summarized in Table 2.

. Presenting manifestations and tumor markers level in the 47 patients operated on for intraductal papillary mucinous tumors of the pancreas

Presenting manifestationsn* (%)
Acute pancreatitis18 (39)
Weight loss6 (13)
Diarrhea and steatorrhea6 (13)
Incidental

Discussion

This study demonstrates an unexpected high frequency (43%) of invasive carcinoma in patients operated on for IPMT of the pancreas and a poor outcome after surgery for patients with this finding.

IPMT of the pancreas has attracted much attention.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30 These tumors have mainly been reported in elderly men with an average age between 60 and 70 years, as in our series. One of the main presenting

Acknowledgements

We thank the following doctors and professors: Bailly (Sens), Berger (Lyon), Bouillot (Paris), Breil (Paris), Boudinet (Saint-Cloud), Carnot (Paris), Chapuis (Paris), Degoy (Alençon), Denis (Corbeil), Dupuy (Chartres), Florent (Paris), Gayet (Paris), Hofman (Paris), Julien (Créteil), Legou (Orléans), Lemoine (Nevers), Levy (Paris), Louvel (Paris), Marteau (Paris), Martin (Montreuil), Mosnier (Suresnes), Sinico (Créteil), Tran Van Nhien (Créteil), Valette (Lyon), Van de Stadt (Bruxelles), and

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    ☆

    From the Departments of Gastroenterology, Surgery and Radiology,Laennec Hospital, Paris; Departments of Gastroenterology and Surgery,Edouard Herriot Hospital, Lyon; Departments of Gastroenterology and Pathology, Beaujon Hospital, Clichy, France; and Departments of Gastroenterology, Radiology and Pathology, Erasme Hospital, Brussels, Belgium.

    ☆☆

    Reprint requests: Christophe Cellier, MD, Service de Gastro-entérologie, Hôpital Laennec, 42 rue de Sèvres 75007 Paris, France.

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