Årsmøde 2014 Præmaligne forandringer i pancreas: Kirurgisk behandling Professor, dr.med., ph.d. Michael Bau Mortensen G1-sektionen, Kirurgisk afdeling A, Odense Universitetshospital.
Pathology (Sönke Detlefsen) Diagnosis (Eva Fallentin) Treatment (Michael Bau Mortensen) (Follow up)
Treatment Nothing Observe Co-morbidity Overtreatment Undertreatment Active treatment
Surgical treatment MCN Resection (Clores et al. Journal of Multidisciplinary Healthcare 2014) (Farrell & Fernández-del Castillo Gastroenterology 2013) (Lim et al. J Gastroenterol Hepatol 2011) (Del Chiaro et al. Dig Liver Dis 2013) (Zamboni et al. Best Practice & Research Clinical Gastroenterology 2013) (Sahani et al. AJR 2013) (Tanaka et al. Pancreatology 2012) (Werner, Nature Gastroenterology Heparology 2012)
Surgical treatment MD-IPMN & Mixed-type IPMN Resection (Clores et al. Journal of Multidisciplinary Healthcare 2014) (Farrell & Fernández-del Castillo Gastroenterology 2013) (Lim et al. J Gastroenterol Hepatol 2011) (Del Chiaro et al. Dig Liver Dis 2013) (Zamboni et al. Best Prac Res Clin Gastroenterol 2013) (Sahani et al. AJR 2013) (Tanaka et al. Pancreatology 2012) (Werner, Nature Gastroenterology Heparology 2012)
Surgical treatment of BD-IPMN First consensus report (2006) Expert opinion rather than evidence Simple approach Resection of BD-IPMNs: Second symptomatic consensus report (2012) More clinical size > 30 data mm More active or diagnosis a high-risk stigmata (mural nodules, dilated main duct, positive cytology) (Tanaka et al. Pancreatology 2006) Nega ve predic ve value Posi ve predic ve value (20%) (Farrell & Fernández-del Castillo Gastroenterology 2013)
Surgical treatment of BD-IPMN Second consensus report (2012) More clinical data More active diagnosis and treatment High Risk Stigmata Jaundice Enhancing solid component within cyst MPD 10 mm Surgery (Tanaka et al. Pancreatology 2012)
Surgical treatment of BD-IPMN First vs Second Consensus Report 2012 guidelines better sensitivity than 2006 guidelines Improved performance of factors predicting malignancy Balanced accuracy
Surgical treatment of BD-IPMN Prospective (n=350) First vs Second consensus report Independent predictors 2006 of BD-IPMN malignancy 2012 (Multiple logistic regression analysis) Sensitivity 0.64 0.72 Specificity Main pancreatic duct dilatation 0.82 > 5 mm 0.78 (HR 4.54, 2.45 to 8.41; P < 0 001), Mural nodules (HR 6.27, 3.27 to 12.01; P < 0 001) CA 19 9 > 37 units/ml (HR 4.03, 1.83 to 8.90; P = 0 001) (Jang et al. Br J Surg 2014)
Surgical treatment of BD-IPMN Size? Cyst size was not significantly associated with risk of malignancy Malignancy rates in patients with cysts of 2 cm or less in diameter or more than 2 cm were similar Meta-analyses have provided contradictory results (Jang et al. Br J Surg 2014) (Kim et al. Ann Surg 2014) (Anand et al. Clin Gastroenterol Hepatol 2013)
Surgical treatment of BD-IPMN When? Symptoms (jaundice, diabetes, acute pancreatitis) CA 19-9 Cytology Main pancreatic duct dilatation > 5 mm (MPD>10 mm!) Mural nodules Cyst > 3 cm/rapidly increasing size Thickened/enhancing cyst walls Abrupt change in calibre of pancreatic duct with distal atrophy (Tanaka et al. Pancreatology 2006) (Tanaka et al. Pancreatology 2012) (Jang et al. Br J Surg 2014) (Del Chiaro et al. Dig Liver Dis 2013)
Surgical treatment of BD-IPMN When? Combination of several factors? (Jang et al. Br J Surg 2014)
Surgical treatment of IPMN Local resection How? Distal resection Pancreatico-duodenectomy (Whipple s procedure) Total pancreatectomy
Surgical treatment of IPMN MCN Distal resection (+/- splenectomy) Local resection (free margins)
Surgical treatment of IPMN MD-IPMN & Mixed-typeIPMN Distal resection (+/- splenectomy) Pancreatico-duodenectomy (Total pancreatectomy) Frozen section Moderate/severe dysplasia or invasive cancer Re-resection
Surgical treatment of IPMN BD-IPMN Focal lesions Frozen section Distal resection (+/- splenectomy) Local resection Multi-focal lesions (up to 40% with > 2 lesions, lower risk) Local resection (total pancreatectomy)
CASE 1 75-årig kvinde med uspecifikke, øvre abdominalsmerter, nedsat appetit og vægttab på 3 kg over 2 måneder, CT Polycystisk proces som involverer hele pancreas. Solidt parti i caput EUS Multiple cyster/dilaterede sidegange samt solid proces i caput LAP/LUS Ingen disseminering. Multicystisk forandring med hypoekkoisk proces i nedre halvdel af caput. Flere mucin plugs
CASE 1: CT
CASE 1: EUS
CASE 1 75-årig kvinde med uspecifikke, øvre abdominalsmerter, nedsat appetit og vægttab på 3 kg over 2 måneder, Resektion Total pancreatektomi. Frys fra vinklen mellem SMV/SMA med malignitet. Re-resektion Udskrives 10. dag Tilbydes adjuverende kemoterapi (8 serier Gem) MD?
IPMN with associated invasive carcinoma CASE 1
IPMN with associated invasive carcinoma CASE 1
IPMN with associated invasive carcinoma CASE 1
IPMN with associated invasive carcinoma CASE 1
IPMN with associated invasive carcinoma CASE 1
IPMN with associated invasive carcinoma MUC1 CASE 1
IPMN with associated invasive carcinoma MUC2 Pancreatobiliary type CASE 1
IPMN with associated invasive carcinoma CASE 1
CASE 2 72-årig mand med trykkende fornemmelse under ve.kurvatur og palpabel udfyldning centralt CT MR Cystisk forandring i pancreas (primært caput) Multilobulerede cyster i pancreas. Pancreas divisum. IPMN o.p. EUS-1 26 mm cystekompleks, d.p. 7-9 mm, mucin, ingen noduli EUS-2 33-36 mm, septae m.noduli, mucin, begyndende sidegrensdilatation
CASE 2: EUS + EUS-FNA EUS-FNA String Sign (Leung et al. Ann Surg Oncol 2009)
CASE 2 72-årig mand med trykkende fornemmelse under ve.kurvatur og palpabel udfyldning centralt Resektion Total pancreatektomi Udskrevet 11. dag MD?
IPMN (main-duct / branch duct type) CASE 2
IPMN (main-duct / branch duct type) CASE 2
IPMN (main-duct / branch duct type) CASE 2
IPMN (main-duct / branch duct type) MUC1 MUC2 MUC5AC Intestinal type CASE 2
CASE 3 49-årig kvindeudredt på grund af abdominalia Tidligere rask, ingen ko-morbiditet CT viser stor cystisk proces udgået fra cauda pancreatis
CASE 3
CASE 3 49-årig kvinde udredt på grund af abdominalia Tidligere rask, ingen ko-morbiditet Får konstateret DM ved indlæggelsen EUS Resektion Mucinøs proces (FNA: Mucinholdig væske) Distal pancreasresektion Udskrevet 7. dag MD?
Mucinous cystic neoplasm (MCN) - High-grade dysplasia - CASE 3
Mucinous cystic neoplasm (MCN) - Microinvasive carcinoma - CASE 3
CASE 4 (12954, 26.06.14, Serøst cystadenom)
(13312, 23.10.14 IPMN med solid komponent, FNA uden maligne celler) CASE 5
CASE 6 Recidiverende abdominalsmerter efter udlandsrejse, intet vægttab, passer fysisk hårdt arbejde, CT viser mindre cystekomplex sv.t. proc.uncinatus, normal biokemi EUS Cystekompleks Ductus pancreaticus 17.05.11 3 x 18 mm, 3,6 mm (caput) Ingen noduli/septae 08.08.11 (uændret) 4 mm (caput) 07.11.11 (uændret) 10 mm (caput) 6 mm (collum) 4,5 mm (cauda) 25.01.12 Total pancreatectomi (udskrevet 6. dag)