La radiologia medica

, Volume 118, Issue 6, pp 917–929

Multifocal branch-duct intraductal papillary mucinous neoplasms (IPMNs) of the pancreas: magnetic resonance (MR) imaging pattern and evolution over time

  • Federica Castelli
  • Davide Bosetti
  • Riccardo Negrelli
  • Valerio Di Paola
  • Lisa Zantedeschi
  • Anna Ventriglia
  • Riccardo Manfredi
  • Roberto Pozzi Mucelli
Abdominal Radiology / Radiologia Addominale

Abstract

Purpose

The aim of our study was to follow the evolution over time of multifocal intraductal papillary mucinous neoplasms (IPMN) of the pancreatic duct side branches by means of magnetic resonance imaging (MRI).

Materials and methods

A total of 155 patients with multifocal IPMN of the side branches were examined with MRI and MR cholangiopancreatography (MRI/MRCP). Inclusion criteria were patients with ≥2 dilated side branches involving any site of the parenchyma; presence of communication with the main pancreatic duct and previous investigations by MRI/MRCP within at least six months. Median follow-up was 25.8 months (range, 12–217). Patients with a follow-up period shorter than 12 months (n=33) and those with a diagnosis of multifocal IPMN of the side branches without any follow-up (n=14) were excluded from the study. The final study population thus comprised 108 patients. A double, quantitative and qualitative, analysis was carried out. The quantitative image analysis included: number of dilated side branches in the head-uncinate process and body-tail; maximum diameter of lesions in the head-uncinate process; maximum diameter in the body-tail; maximum diameter of the main pancreatic duct in the head and body-tail. The qualitative image analysis included: presence of malformations or anatomical variants of the pancreatic ductal system; site of the lesions (head-uncinate process, body-tail, ubiquitous, bridge morphology); presence of gravity-dependent intraluminal filling defects; presence of enhancing mural nodules.

Results

At diagnosis, the mean number of cystic lesions of the side branches was 7.09. The mean diameter of the cystic lesions was 13.7 mm. The mean diameter of the main pancreatic duct was 3.6 mm. At follow-up, the mean number of cystic lesions was 7.76. The mean diameter of the cystic lesions was 13.9 mm. The mean diameter of the main pancreatic duct was 3.7 mm. Intraluminal filling defects in the side branches were seen in 18/108 patients (16.6%); enhancing mural nodules were seen in 3/108 patients (2.7%).

Conclusions

Multifocal IPMN of the branch ducts shows a very slow growth and evolution over time. In our study, only 3/108 patients showed mural nodules which, however, did not require any surgical procedure, indicating that careful nonoperative management may be safe and effective in asymptomatic patients.

Keywords

Pancreas Intraductal papillary mucinous tumours MR imaging 

Tumori intraduttali papillari mucino-secernenti (IPMN) dei dotti pancreatici secondari: aspetti RM ed evoluzione nel tempo

Riassunto

Obiettivo

L’obiettivo che il nostro studio si propone è quello di seguire l’evoluzione nel tempo delle neoplasie multifocali mucinose intraduttali papillari (IPMN) dei rami collaterali per mezzo della risonanza magnetica (RM).

Materiali e metodi

Sono stati valutati 155 pazienti con IPMN multifocali dei dotti secondari esaminati con RM e con colangiopancreatografia RM (CPRM). Criteri di inclusione: pazienti con ≥2 rami collaterali dilatati che coinvolgono qualunque sito del parenchima pancreatico; presenza di comunicazione con il dotto pancreatico principale, ≥2 esami precedenti RM/CPRM a distanza di almeno sei mesi. La mediana del monitoraggio è stata 25,8 (range 12–217) mesi. Criteri di esclusione: pazienti con un periodo di osservazione inferiore ai 12 mesi (n=33), ed i pazienti con diagnosi di IPMN multifocale dei dotti di II ordine che non hanno un follow-up (n=14). La popolazione considerata è quindi di 108 pazienti. è stata effettuata una duplice analisi, quantitativa e qualitativa. L’analisi quantitativa comprendeva: numero delle ectasie cistiche dei dotti collaterali nella testa-processo uncinato e nel corpo-coda; diametro massimo delle lesioni nella testa-processo-uncinato; diametro massimo nel corpocoda, diametro massimo del dotto pancreatico principale nella testa e nel corpo-coda. L’analisi qualitativa comprendeva: presenza/assenza di malformazioni/varianti anatomiche del sistema duttale pancreatico, localizzazione delle lesioni nel parenchima pancreatico, presenza di difetti endoluminali declivi, presenza di noduli parietali con impregnazione di mezzo di contrasto.

Risultati

Alla diagnosi il numero medio di ectasie cistiche dei rami collaterali è stato 7,09. Il diametro medio delle ectasie cistiche era di 13,7 mm. Il diametro medio del dotto pancreatico principale era di 3,6 mm. Al follow-up il numero medio di ectasie cistiche era di 7,76. Il diametro medio delle lesioni cistiche era di 13,9. Il diametro medio del dotto pancreatico principale era di 3,7 mm. In 18/108 pazienti (16,6%) sono stati osservati difetti di riempimento intraluminali nei dotti pancreatici secondari, mentre sono stati riscontrati noduli murali in 3/108 pazienti (2,7%).

Conclusioni

Gli IPMN multifocali dei dotti pancreatici secondari mostrano una crescita molto lenta. Nel nostro studio solo 3/108 pazienti hanno mostrato noduli murali, che comunque non sono stati sottoposti ad intervento chirurgico.

Parole chiave

Pancreas Tumori intraduttali papillari mucino-secernenti Risonanza magnetica 

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References/Bibliografia

  1. 1.
    Procacci C, Megibow AJ, Carbognin G et al (1999) Intraductal papillary mucinous tumor of the pancreas: a pictorial essay. Radiographics 19:1447–1463PubMedGoogle Scholar
  2. 2.
    Lim FH, Lee G, Lyun Oh Y (2001) Radiologic spectrum of intraductal papillary mucinous tumor of the pancreas. Radiographics 21:323–340PubMedGoogle Scholar
  3. 3.
    Tanaka M, Chiari S, Adsay V et al (2006) International consensus guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of the pancreas. Pancreatology 6:17–32PubMedCrossRefGoogle Scholar
  4. 4.
    Maguchi H, Tanno S, Mizuno N et al (2011) Natural history of branch duct intraductal papillary mucinous neoplasms of the pancreas: a multicenter study in Japan. Pancreas 40:364–370PubMedCrossRefGoogle Scholar
  5. 5.
    Yonezawa S, Nakamura A, Horinouchi M et al (2002) The expression of several types of mucin is related to the biological behavior of pancreatic neoplasms. J Hepatobiliary Pancreat Surg 9:328–341PubMedCrossRefGoogle Scholar
  6. 6.
    Lee KS, Sekhar A, Rofsky N et al (2010) Prevalence of incidental pancreatic cysts in the adult population on MR Imaging. Am J Gastroenterol 105:2079–2084PubMedCrossRefGoogle Scholar
  7. 7.
    Hruban RH, Takaori K, Klimstra DS et al (2004) An illustrated consensus on the classification of pancreatic intraepithelial neoplasia and intraductal papillary mucinous neoplasms. Am J Surg Pathol 28:977–987PubMedCrossRefGoogle Scholar
  8. 8.
    Manfredi R, Mehrabi S, Motton M et al (2008) MR imaging and MR cholangiopancreatography of multifocal intraductal papillary mucinous neoplasms of the side branches: MR pattern and its evolution. Radiol Med 113:414–428PubMedCrossRefGoogle Scholar
  9. 9.
    Hutchins GF, Draganov PV (2009) Cystic neoplasms of the pancreas: a diagnostic challenge. World J Gastroenterol 15:48–54PubMedCrossRefGoogle Scholar
  10. 10.
    Irie H, Honda H, Aibe H et al (2000) MR cholangiopancreatographic differentiation of benign and malignant intraductal mucin-producing tumors of the pancreas. AJR Am J Roentgenol 174:1403–1408PubMedCrossRefGoogle Scholar
  11. 11.
    Salvia R, Fernandez-del Castillo C, Bassi C et al (2004) Main-duct intraductal papillary mucinous neoplasms of the pancreas: clinical predictors of malignancy and long-term survival following resection. Ann Surg 239:678–685PubMedCrossRefGoogle Scholar
  12. 12.
    Sahani DV, Kadavigere R, Blake M et al (2006) Pancreatic cysts 3 cm or smaller: how aggressive should treatment be? Radiology 238:912–919PubMedCrossRefGoogle Scholar
  13. 13.
    Manfredi R, Graziani R, Motton M et al (2009) Main pancreatic duct intraductal papillary mucinous neoplasms: accuracy of MR imaging in differentiation between benign and malignant tumors compared with histopathologic analysis. Radiology 253:106–115PubMedCrossRefGoogle Scholar
  14. 14.
    Salvia R, Crippa S, Falconi M et al (2007) Branch-duct intraductal papillary mucinous neoplasms of the pancreas: to operate or not to operate? Gut 56:1086–1090PubMedCrossRefGoogle Scholar
  15. 15.
    Chiang KC, Hsu JT, Chen HY et al (2009) Multifocal intraductal papillary mucinous neoplasm of the pancreas- -a case report. World J Gastroenterol 15:628–632PubMedCrossRefGoogle Scholar
  16. 16.
    Sugiyama M, Izumisato Y, Abe N, Masaki T (2003) Predictive factors for malignancy in intraductal papillarymucinous tumours of the pancreas. Br J Surg 90:1244–1249PubMedCrossRefGoogle Scholar
  17. 17.
    Sai JK, Suyama M, Kubokawa Y et al (2003) Management of branch ducttype intraductal papillary mucinous tumor of the pancreas based on magnetic resonance imaging. Abdom Imaging 28:694–699PubMedCrossRefGoogle Scholar
  18. 18.
    Warshaw AL, Compton CC, Lewandrowski K et al (1990) Cystic tumors of the pancreas. New clinical, radiologic, and pathologic observations in 67 patients. Ann Surg 212:432–445PubMedCrossRefGoogle Scholar
  19. 19.
    Sarr MG, Murr M, Smyrk TC et al (2003) Primary cystic neoplasms of the pancreas. Neoplastic disorders of emerging importance-current state-of-the-art and unanswered questions. J Gastrointest Surg 7:417–428PubMedCrossRefGoogle Scholar
  20. 20.
    Zhang HM, Yao F, Liu GF et al (2011) The differences in imaging features of malignant and benign branch duct type of intraductal papillary mucinous tumor. Eur J Radiol 80:744–748PubMedCrossRefGoogle Scholar
  21. 21.
    Turner BG and WR Brugge (2010) Pancreatic cystic lesions: when to watch, when to operate, and when to ignore. Curr Gastroenterol Rep 12:98–105PubMedCrossRefGoogle Scholar
  22. 22.
    Salvia R, Partelli S, Crippa S et al (2009) Intraductal papillary mucinous neoplasms of the pancreas with multifocal involvement of branch ducts. Am J Surg 198:709–714PubMedCrossRefGoogle Scholar
  23. 23.
    Sohn TA, Yeo CJ, Cameron JL et al (2004) Intraductal papillary mucinous neoplasms of the pancreas: an updated experience. Ann Surg 239:788–799PubMedCrossRefGoogle Scholar
  24. 24.
    Calculli L, Pezzilli R, Brindisi C et al (2010) Pancreatic and extrapancreatic lesions in patients with intraductal papillary mucinous neoplasms of the pancreas: a single-centre experience. Radiol Med 115:442–452PubMedCrossRefGoogle Scholar
  25. 25.
    Shimizu Y, Yasui K, Morimoto T et al (1999) Case of intraductal papillary mucinous tumor (noninvasive adenocarcinoma) of the pancreas resected 27 years after onset. Int J Pancreatol 26:93–98PubMedCrossRefGoogle Scholar
  26. 26.
    Azar C, Van de Stadt J, Rickaert F et al (1996) Intraductal papillary mucinous tumours of the pancreas. Clinical and therapeutic issues in 32 patients. Gut 39:457–464PubMedCrossRefGoogle Scholar
  27. 27.
    Pilleul F, Rochette A, Partensky C et al (2005) Preoperative evaluation of intraductal papillary mucinous tumors performed by pancreatic magnetic resonance imaging and correlated with surgical and histopathologic findings. J Magn Reson Imaging 21:237–244PubMedCrossRefGoogle Scholar
  28. 28.
    Prasad SR, Sahani D, Nasser S et al (2003) Intraductal papillary mucinous tumors of the pancreas. Abdom Imaging 28:357–365PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2013

Authors and Affiliations

  • Federica Castelli
    • 1
  • Davide Bosetti
    • 1
  • Riccardo Negrelli
    • 1
  • Valerio Di Paola
    • 1
  • Lisa Zantedeschi
    • 1
  • Anna Ventriglia
    • 1
  • Riccardo Manfredi
    • 1
  • Roberto Pozzi Mucelli
    • 1
  1. 1.Istituto di RadiologiaAzienda Ospedaliero Universitaria Integrata - Policlinico “G.B. Rossi”VeronaItaly

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