Although there are still controversies over the efficiency and safety of minimally invasive radical surgery for pancreatic ductal adenocarcinoma (PDAC), most available studies have suggested a promising application of minimally invasive radical surgery. This consensus, referring to Chinese expert opinions and worldwide researches, aimed to discuss the related issues on minimally invasive radical surgery for PDAC to ensure the perioperative and oncological outcomes. Quality of evidence and strength of recommendations were evaluated based on the GRADE approach. The 15 recommendations covered 5 topics: oncological outcomes and patient safety of laparoscopic and robotic pancreatoduodenectomy, left-side pancreatectomy for PDAC, learning curve, safety of neoadjuvant therapy, and vascular resection in minimally invasive radical surgery for PDAC. This consensus gives reference and guidance to surgeons on the use of minimally invasive radical surgery for PDAC. Although this consensus is not sufficient to answer all the questions about minimally invasive radical surgery for PDAC, it represents the current consensus on the application of the techniques in the treatment of PDAC on the Chinese mainland.
Humans ; Carcinoma, Pancreatic Ductal/surgery* ; Consensus ; Laparoscopy/methods* ; Minimally Invasive Surgical Procedures/methods* ; Pancreatectomy/methods* ; Pancreatic Neoplasms/pathology* ; Treatment Outcome ; China

To investigate whether chemotherapy could prolong the postoperative survival time in patients with early stages pancreatic ductal adenocarcinoma (PDAC). A total of 5280 stage ⅠA -ⅡB PDAC patients diagnosed from 2010 to 2015 were selected from surveillance，epidemiology，and end results (SEER) database. Propensity score matching (PSM) analysis was adopted to reduce the baseline differences between the groups. Univariate survival analysis was conducted with the Kaplan-Meier method. Multivariate survival analysis was performed with the Cox proportional hazards model. Univariate and multivariate survival analyses showed that age, differentiation, stage, chemotherapy were independent risk factors for the survival of PDAC patients. After PSM, it is found that adjuvant chemotherapy could prolong the median overall survival time (mOS) for stage ⅠB, ⅡA and ⅡB patients. However, for stage ⅠA patients, there were no significant differences in 3-year survival rate and mOS between patients with chemotherapy (=283) and without chemotherapy (=229) (57.4% vs 55.6%, vs all >0.05). Further analyses show that among 101 patients with well differentiated PDAC and 294 patients with moderately differentiated PDAC, there were no significant differences in survival rate and mOS between patients with and without chemotherapy (all >0.05). Among 117 patients with low-differentiated + undifferentiated PDAC, 3-year survival rate and mOS in patients with chemotherapy were significantly better than those without chemotherapy (48.5% vs 34.1%, vs all <0.05). Chemotherapy regimen used currently is not beneficial for patients with moderately and well differentiated stage ⅠA PDAC, but it is an independent prognostic factor for low-differentiated + undifferentiated PDAC patients.
Adenocarcinoma/pathology* ; Carcinoma, Pancreatic Ductal/surgery* ; Chemotherapy, Adjuvant ; Humans ; Neoplasm Staging ; Pancreatic Neoplasms/drug therapy* ; Prognosis ; Propensity Score

Cystic neoplasms of the pancreas are found with increasing prevalence, especially in elderly asymptomatic individuals. Although the overall risk of malignancy is very low, the presence of these pancreatic cysts is associated with a large degree of anxiety and further medical investigation due to concerns about malignancy. This review discusses the different cystic neoplasms of the pancreas and reports diagnostic strategies based on clinical features and imaging data. Surgical and nonsurgical management of the most common cystic neoplasms, based on the recently revised Sendai guidelines, is also discussed, with special reference to intraductal papillary mucinous neoplasm (IPMN; particularly the branch duct variant), which is the lesion most frequently identified incidentally. IPMN pathology, its risk for development into pancreatic ductal adenocarcinoma, the pros and cons of current guidelines for management, and the potential role of endoscopic ultrasound in determining cancer risk are discussed. Finally, surgical treatment, strategies for surveillance of pancreatic cysts, and possible future directions are discussed.
Carcinoma, Pancreatic Ductal/epidemiology/pathology/*surgery ; Cystadenoma/epidemiology/pathology/*surgery ; Early Detection of Cancer/methods ; Endosonography ; Humans ; Pancreatic Cyst/epidemiology/*pathology/surgery ; Pancreatic Neoplasms/epidemiology/*pathology/surgery ; Practice Guidelines as Topic ; Prevalence

Intraductal papillary mucinous neoplasm of the bile duct (IPMN-B) and intraductal papillary mucinous neoplasm of the pancreas (IPMN-P) have striking similarities and are recognized as counterparts. However, simultaneous occurrence of IPMN-B and IPMN-P is extremely rare. A 66 year-old female presented with recurrent epigastric pain and fever. During the past 9 years, she had three clinical episodes related to intrahepatic duct stones and IPMN-P in the pancreas head and was managed by medical treatment. Laboratory test results at admission revealed leukocytosis (12,600/mm3) and elevated CA 19-9 level (1,200 U/mL). Imaging study demonstrated liver abscess in the Couinaud's segment 4, IPMN-B in the left lobe, and IPMN-P in the whole pancreas with suspicious malignant change. Liver abscess was drained preoperatively, followed by left lobectomy with bile duct resection and total pancreatectomy with splenectomy. On histologic examination, non-invasive intraductal papillary mucinous carcinoma arising from various degree of dysplastic mucosa of the liver and pancreas could be observed. However, there was no continuity between the hepatic and pancreatic lesions. This finding in our case supports the theory that double primary lesions are more likely explained by a diffuse IPMN leading to synchronous tumors arising from both biliary and pancreatic ducts rather than by a metastatic process. Herein we present a case of simultaneous IPMN of the bile duct and pancreas which was successfully treated by surgical management.
Adenocarcinoma, Mucinous/*diagnosis/pathology/surgery ; Adenocarcinoma, Papillary/*diagnosis/pathology/surgery ; Aged ; Bile Duct Neoplasms/*diagnosis/pathology/surgery ; Bile Ducts, Intrahepatic/pathology ; CA-19-9 Antigen/analysis ; Carcinoma, Pancreatic Ductal/*diagnosis/pathology/surgery ; Female ; Hepatectomy ; Humans ; Leukocytosis/diagnosis ; Pancreatectomy ; Pancreatic Neoplasms/*diagnosis/pathology/surgery ; Tomography, X-Ray Computed

Carcinoma, Intraductal, Noninfiltrating ; diagnosis ; pathology ; surgery ; Carcinoma, Pancreatic Ductal ; pathology ; Diagnosis, Differential ; Humans ; Male ; Prostate ; pathology ; Prostatic Intraepithelial Neoplasia ; pathology ; Prostatic Neoplasms ; diagnosis ; pathology ; surgery

BACKGROUNDIntraductal papillary mucinous neoplasm (IPMN) is a rare pancreatic cystic neoplasm, accounting for 1% of all exocrine pancreatic neoplasms. This study aimed to summarize the clinicopathological and biological behaviors, as well as the experience in diagnosis and treatment of IPMN.

METHODSClinicopathological data were collected from 36 cases with IPMN who were treated in Department of General Surgery, Peking University Third Hospital from May 2001 to July 2011.

RESULTSThe 36 cases of IPMN patients included 27 males and 9 females (M:F = 3:1). The age of patients ranged from 52 to 78 years, with an average of 67.3 years. Regarding tumor location, 20 tumors were located in pancreatic head, 3 in pancreatic neck, 10 in pancreatic body and tail, and 3 in the whole pancreas. All the 36 cases underwent surgical treatment, with 13 cases of pancreaticoduodenectomy, 3 cases of middle pancreatectomy, 7 cases of tumor resection plus pancreaticojejunostomy, 3 cases of distal pancreatectomy, 7 cases of distal pancreatectomy plus spleen resection, and 3 cases of total pancreaticoduodenectomy. Of the 36 patients, 9 patients underwent the operations under laparoscopy. The 36 cases included main duct type (14 cases, 38.9%), branch duct type (10 cases, 27.7%), and mixed duct type (12 cases, 33.3%). Pathologically, of the 36 cases, there were 7 IPMN adenomas, 11 borderline IPMNs, 6 IPMN with carcinomas in situ, and 12 IPMNs with invasive carcinomas. All the 36 cases were followed up. During an average of 42 months follow-up period (26-129 months), no recurrence occurred.

CONCLUSIONSIPMN, which primarily occurs in male, is a low-grade malignancy which may involve any part of the pancreas, with specific clinicopathological features. IPMN is a different malignancy type from pancreatic ductal carcinoma. Imaging and laboratory examination are helpful for the diagnosis and differential diagnosis. The prediction of invasive IPMN is still difficult. Surgical resection is recommended as the first choice of treatment. Aggressive and proper operation procedure produces better prognosis. Long-term follow-up is necessary for patients after operation. Laparoscopic distal pancreatectomy is a feasible and safe procedure for the indicated patients.

Aged ; Carcinoma, Pancreatic Ductal ; diagnosis ; surgery ; Female ; Humans ; Male ; Middle Aged ; Pancreatectomy ; Pancreatic Neoplasms ; diagnosis ; surgery ; Pancreaticoduodenectomy ; Pancreaticojejunostomy ; Retrospective Studies

OBJECTIVETo analyze the R1 rate of the pancreatic head carcinoma resection specimens which delt with a unified protocol by two different R1 criteria.

METHODSBetween November 2011 and October 2013, a unified pathological protocol was prospectively used to handle 70 consecutive pancreatioduodenectomy specimens for pancreatic ductal adenocarcinoma. Apart from the pancreatic transection margin, the bile duct and stomach/jejunum margins, different colors were used to stain the anterior surface, the superior mesenteric vein (SMV) groove margin, the superior mesenteric artery (SMA) margin, and the posterior surface. Axial slicing technique was used to dissect the pancreatioduodenectomy specimens.

RESULTSAmong the 70 patients, 3, 30 and 37 patients were classified as well, moderately and poorly differentiated respectively;7, 15 and 48 patients were classified as pT1, pT2 and pT3 respectively.Forty patients (57.1%) had metastases in regional lymph nodes (pN1) , and 16 patients (22.9%) had metastases in para-aortic nodes.Resection of the portal vein and/or the superior mesenteric vein was performed in 13 patients (18.6%) .When applying the UICC criteria, 26 cancer resections were classified R1 (37.1%) , 33 margins were turned out to be R1. The SMV groove margin and SMA margin were infiltrated in 13 specimens (13/33, 39.4%) respectively.When applying the Royal College of Pathologist's criteria, 39 cancer resections were classified R1 (55.7%) , 51 margins were turned out to be R1. The SMV groove margin and SMA margin were infiltrated in 18 (18/51, 35.3%) and 19 (19/51, 37.3%) specimen respectively.Until April 2014, the median follow-up was 18(range 6-42) months.

CONCLUSIONSApplying the unified protocol for pancreatic head ductal adenocarcinoma specimens results in an significant R1 rate of the resection margins, and the R1 rate is related to the R1 criterion. The SMV groove margin and SMA margin are the two most frequent sites of R1.

Adenocarcinoma ; pathology ; Carcinoma, Pancreatic Ductal ; pathology ; Diagnostic Techniques and Procedures ; Humans ; Lymph Nodes ; pathology ; Mesenteric Artery, Superior ; surgery ; Pancreas ; pathology ; Pancreatic Neoplasms ; pathology ; Portal Vein ; surgery

OBJECTIVETo investigate the clinical manifestation, individualized surgical treatment, and prognosis of intraductal papillary mucinous neoplasms (IPMN) of pancreas.

METHODSThe clinical data of 56 IPMN cases treated between January 2007 and December 2011 was retrospectively analyzed. Among the 56 patients (38 male and 18 female, mean age (61 ± 7) years), 26 were main-duct type, 18 were branch-duct type, 12 were mixed type. Pancreatectomy was performed on 48 cases, including pancreaticoduodenectomy on 29 patients, distal pancreatectomy on 17 patients, and total pancreatectomy on 2 patients.

RESULTSThe overall postoperative morbidity rate was 27.1% (13/48), there was no perioperative mortality. Pathology showed 31 cases of noninvasive IPMN, 17 cases of invasive IPMN, and 7 cases of lymph node metastasis. The rate of invasive tumors was 46.2% (12/26) in main duct type, 3/12 in mixed type, and 2/18 in branch duct type IPMN, the difference was statistically significant (χ(2) = 6.385, P = 0.041). The five-year survival rate for patients with noninvasive and invasive neoplasms was 100% and 24.6%, respectively. The prognosis of invasive cases with lymph node metastasis was significantly worse than those without lymph node metastasis (P = 0.017). A regular follow-up without surgical treatment was performed on 8 cases with asymptomatic side branch IPMN less than 3 cm in diameter, and no progression was found during the follow-up.

CONCLUSIONSIPMN has a relative good prognosis. Main duct type and mixed type IPMN have a higher malignant potential, and should receive a surgical treatment. Patients of branch duct type IPMN with a <3 cm diameter lesion and no clinical manifestations can be managed with close follow-up only.

Aged ; Carcinoma, Pancreatic Ductal ; pathology ; surgery ; Female ; Humans ; Male ; Middle Aged ; Pancreatectomy ; Pancreatic Neoplasms ; pathology ; surgery ; Prognosis ; Retrospective Studies ; Survival Rate

OBJECTIVETo investigate clinicopathological features of fibrous mass-forming chronic pancreatitis (FMCP), to compare clinicopathological and immunohistochemical characteristics between autoimmune pancreatitis (AIP) and fibrous mass-forming non-autoimmune pancreatitis (nAIP) and to provide evidence for pathological diagnosis, differential diagnosis and clinical treatment strategy.

METHODSClinicopathological features were analyzed in 81 cases of FMCP. Infiltrating IgG4(+) plasmacytes were counted by immunohistochemical staining.

RESULTSAmong 81 cases of FMCP, 20 cases were diagnosed as AIP and 61 cases were interpreted as nAIP. AIP was more common in males over 50 years, whereas nAIP was seen in much younger patients (P = 0.001). The amount of inflammatory cells in the stroma of AIPs was remarkable higher than that in nAIPs (P = 0.002). The incidence of neuritis in AIPs (100%, 20/20) was also higher compared with that of nAIPs (75.4%, 46/61; P = 0.017). Storiformed-fibrosis was more common in AIPs (95.0%, 19/20) than in nAIPs (1.6%, 1/61;P = 0.000). Pancreatic intraepithelial neoplasia (PanIN) was observed in 50.0%(10/20) of AIPs and 32.8%(20/61) of nAIPs, with a greater severity observed in AIPs (P = 0.031). Tubular complex (TC) was more commonly observed in AIPs (65.0%, 13/20) than nAIPs (26.2%, 16/61;P = 0.002). Among 81 cases of FMCP, 61 cases had less than 11 IgG4(+) plasmacytes /HPF, 7 cases had 10-30/HPF and 13 cases had over 30/HPF.

CONCLUSIONSFMCPs include both AIP and nAIP. AIP has distinct pathological features and the presence of IgG4(+) plasmacyte is an important diagnostic parameter. FMCP appears to be an important precancerous lesion of pancreatic ductal adenocarcinoma. Surgery may be considered for patients with FMCP due to its mass-forming nature. In contrast, patients with AIP are treated medically due to its steroid-responsiveness. Therefore, accurate and timely diagnosis of AIP is of clinical relevance to avoid unnecessary surgical complications and to prevent progression of the disease.

Adult ; Aged ; Autoimmune Diseases ; immunology ; pathology ; surgery ; Carcinoma, Pancreatic Ductal ; immunology ; pathology ; surgery ; Diagnosis, Differential ; Female ; Fibrosis ; Humans ; Immunoglobulin G ; metabolism ; Male ; Middle Aged ; Pancreas ; pathology ; Pancreatic Neoplasms ; immunology ; pathology ; surgery ; Pancreatitis, Chronic ; immunology ; pathology ; surgery ; Plasma Cells ; immunology ; Precancerous Conditions ; immunology ; pathology ; surgery ; Young Adult

OBJECTIVETo study the pathologic features, diagnosis, differential diagnosis and molecular characteristics of intraductal tubulopapillary neoplasm of the pancreas (ITPN).

METHODSThe clinical findings, morphologic features, immunophenotype (by EnVision method) and KRAS gene alterations (by reverse transcriptase-polymerase chain reaction) of 6 cases of ITPN encountered during the period from January, 2001 to June, 2010 were analyzed.

RESULTSThere were altogether 2 males and 4 females. The mean age of the patients was 64 years. Gross examination showed that the tumors were located in large pancreatic ducts and appeared as polypoid nodules with ductal obstruction. Solid tumor nodules associated with adjoining dilated ducts were identified in one case. Histologically, the tumors were characterized by tubulopapillary growth pattern without luminal mucin. The tumor cells showed high-grade nuclear atypia with scanty intracytoplasmic mucin. Intraductal necrotic foci were frequently observed. Immunohistochemical study showed that the tumor cells expressed CK7 and CK19. Focal positivity for MUC5AC was demonstrated. Two cases expressed MUC1. The staining for MUC2 was negative. KRAS gene mutations were identified in 2 cases, with a single-amino-acid substitution in codon 12 (35G > A and 35G > T/34G > A).

CONCLUSIONSITPN is a newly described pancreatic intraductal neoplasm and different from intraductal papillary mucinous neoplasm. ITPN is characterized by intraductal tubulopapillary growth pattern, severe cytologic atypia and scanty mucin secretion.

Aged ; Amino Acid Substitution ; Carcinoma, Pancreatic Ductal ; genetics ; metabolism ; pathology ; surgery ; Carcinoma, Papillary ; genetics ; metabolism ; pathology ; surgery ; Female ; Follow-Up Studies ; Humans ; Keratin-19 ; metabolism ; Keratin-7 ; metabolism ; Ki-67 Antigen ; metabolism ; Male ; Middle Aged ; Mucin 5AC ; metabolism ; Mucin-1 ; metabolism ; Pancreatectomy ; Pancreatic Neoplasms ; genetics ; metabolism ; pathology ; surgery ; Treatment Outcome