Diagnosing microscopic pancreatic neuroendocrine tumor using 68-Ga-DOTATATE PET/CT: case series

Neuroendocrine tumors (NETs) are an uncommon diagnosis which often present asymptomatically or with vague symptoms. They can originate from many different organs such as the GI tract, lungs, pancreas and others. 68Gallium DOTATATE positron emission topography/computed topography has been shown to be an effective imaging modality for diagnosing NET and evaluating management options for patients. Here, we present two cases of positive findings in the distal pancreas on the DOTATATE PET/CT scans without any morphological lesion found to be NET in a healthy 48-year-old male and 68-year-old male

Mucinous cystic neoplasms of the liver: presence of biliary communication

A 35-year-old woman was referred for a symptomatic liver mass. Diagnostic workup detected a septated cyst located centrally in the liver measuring 10 × 7 cm. The cyst had gradually increased in size from previous studies with new intrahepatic biliary dilation. Due to concern for malignancy and symptomatic presentation of the patient, a partial central hepatectomy was performed. Pathology revealed a smooth-walled, multiloculated cyst lined with mucinous epithelium and ovarian-type stroma. The diagnosis of low-grade mucinous cystic neoplasm of the liver (MCN-L) was made. Characteristics of MCN-L have not been elucidated due to its rarity

Post-Pancreatoduodenectomy Outcomes and Epidural Analgesia: A 5-Year Single Institution Experience

Introduction Optimal pain control post-pancreatoduodenectomy is a challenge. Epidural analgesia (EDA) is increasingly utilized despite inherent risks and unclear effects on outcomes. Methods All pancreatoduodenectomies (PD) performed from 1/2013-12/2017 were included. Clinical parameters were obtained from retrospective review of a prospective clinical database, the ACS NSQIP prospective institutional database and medical record review. Chi-Square/Fisher’s Exact and Independent-Samples t-Tests were used for univariable analyses; multivariable regression (MVR) was performed. Results 671 consecutive PD from a single institution were included (429 EDA, 242 non-EDA). On univariable analysis, EDA patients experienced significantly less wound disruption (0.2% vs. 2.1%), unplanned intubation (3.0% vs. 7.9%), pulmonary embolism (0.5% vs. 2.5%), mechanical-ventilation >48hrs (2.1% vs. 7.9%), septic shock (2.6% vs. 5.8%), and lower pain scores. On MVR accounting for baseline group differences (gender, hypertension, pre-operative transfusion, labs, approach, pancreatic duct size), EDA was associated with less superficial wound infections (OR 0.34; CI 0.14-0.83; P=0.017), unplanned intubations (OR 0.36; CI 0.14-0.88; P=0.024), mechanical ventilation >48 hrs (OR 0.22; CI 0.08-0.62; P=0.004), and septic shock (OR 0.39; CI 0.15-1.00; P=0.050). EDA improved pain scores post-PD days 1-3 (P<0.001). No differences were seen in cardiac or renal complications; pancreatic fistula (B+C) or delayed gastric emptying; 30/90-day mortality; length of stay, readmission, discharge destination, or unplanned reoperation. Conclusion Based on the largest single institution series published to date, our data support the use of EDA for optimization of pain control. More importantly, our data document that EDA significantly improved infectious and pulmonary complications

Cancer History: A Predictor of IPMN Subtype and Dysplastic Status?

Introduction The aim of this study was to determine the association of PMH and FH of pancreatic (PDAC) and non-pancreatic cancers with IPMN malignant risk. Methods A retrospective review of a prospective database of IPMN patients undergoing resection was performed to assess FH and PMH. Results FH of PDAC was present in 13% of 362 included patients. Of these, 8% had at least one first degree relative (FDR) with PDAC. The rate of PDAC positive FH in non-invasive versus invasive IPMN patients was 14% and 8%, respectively (p = 0.3). In main duct IPMN patients, FH (44%) and PMH of non-pancreatic cancer (16%) was higher than that seen in branch duct IPMN (FH 29%; PMH 6%; p = 0.004 and 0.008). Conclusions FH of PDAC is not associated with IPMN malignant progression. FH and PMH of non-pancreatic cancer is associated with main duct IPMN, the subtype with the highest rate of invasive transformation

Evolving treatment of necrotizing pancreatitis

Background Over the past decade, the treatment of necrotizing pancreatitis (NP) has incorporated greater use of minimally invasive techniques, including percutaneous drainage and endoscopic debridement. No study has yet compared outcomes of patients treated with all available techniques. We sought to evaluate the evolution of NP treatment at our high volume pancreas center. We hypothesized that minimally invasive techniques (medical only, percutaneous, and endoscopic) were used more frequently in later years. Methods Treatment strategy of NP patients at a single academic medical center between 2005 and 2014 was reviewed. Definitive management of pancreatic necrosis was categorized as: 1) medical treatment only; 2) surgical only; 3) percutaneous (interventional radiology – IR) only; 4) endoscopic only; and 5) combination (Surgery ± IR ± Endoscopy). Results 526 NP patients included biliary (45%), alcoholic (17%), and idiopathic (20%) etiology. Select patients were managed exclusively by medical, IR, or endoscopic treatment; use of these therapies remained relatively consistent over time. A combination of therapies was used in about 30% of patients. Over time, the percentage of NP patients managed without operation increased from 28% to 41%. 247 (47%) of patients had operation as the only NP treatment; an additional 143 (27%) required surgery as part of a multidisciplinary management. Conclusion Select NP patients may be managed exclusively by medical, IR, or endoscopic treatment. Combination treatment is necessary in many NP patients, and surgical treatment continues to play an important role in the definitive therapy of necrotizing pancreatitis patients

DNA profile components predict malignant outcomes in select cases of intraductal papillary mucinous neoplasm with negative cytology

Predicting malignancy in intraductal papillary mucinous neoplasm remains challenging. Integrated molecular pathology combines pancreatic fluid DNA and clinical factors into a malignant potential score. We sought to determine the utility of DNA components alone in predicting high-grade dysplasia/invasive disease. Methods We reviewed prospectively the records from 1,106 patients with intraductal papillary mucinous neoplasm. We excluded non-intraductal papillary mucinous neoplasm cases and cases with definitive malignant cytology. A total 225 patients had 283 DNA profiles (98 followed by surgery, 185 followed by ≥23-month surveillance). High-grade dysplasia/invasive outcomes were high-grade dysplasia, intraductal papillary mucinous neoplasm-invasive, and adenocarcinoma on surgical pathology or mesenteric or vascular invasion, metastases, or biopsy with high-grade dysplasia or adenocarcinoma during surveillance. Results High-quantity DNA predicted (P = .004) high-grade dysplasia/invasive disease outcomes with sensitivity of 78.3%, but 52.7% specificity, indicating benign cases may exhibit high-quantity DNA. High clonality loss of heterozygosity of tumor suppressor genes was 98.0% specific, strongly predicted high-grade dysplasia/invasive disease but lacked sensitivity (20.0%). High-quantity DNA + high clonality loss of heterozygosity had 99.0% specificity for high-grade dysplasia/invasive disease. KRAS mutation alone did not predict high-grade dysplasia/invasive disease, but, when combined with high-quantity DNA (specificity 84.7%) and high clonality loss of heterozygosity (specificity 99.0%) strongly predicted high-grade dysplasia/invasive outcomes. Conclusion Certain DNA components are highly specific for high-grade dysplasia/invasive disease and may indicate aggressive lesions, requiring resection when cytology fails

High Rates of Readmission in Necrotizing Pancreatitis: Natural History or Opportunity for Improvement?

Background Necrotizing pancreatitis (NP) is a complex and heterogeneous disease with a protracted disease course. Hospital readmission is extremely common; however, few data exist regarding the cause of readmission in NP. Methods A retrospective review of NP patients treated between 2005 and 2017 identified patients readmitted both locally and to our hospital. All patients with unplanned hospital readmissions were evaluated to determine the cause for readmission. Clinical and demographic factors of all patients were recorded. As appropriate, two independent group t tests and Pearson’s correlation or Fisher’s exact tests were performed to analyze the relationship between index admission clinical factors and readmission. p values of < 0.05 were accepted as statistically significant. Results Six hundred one NP patients were reviewed. Median age was 52 years (13–96). Median index admission length of stay was 19 days (2–176). The most common etiology was biliary (49.9%) followed by alcohol (20.0%). Unplanned readmission occurred in 432 patients (72%) accounting for a total of 971 unique readmissions (mean readmissions/patient, 2.3). The most common readmission indications were symptomatic necrosis requiring supportive care and/or intervention (31.2%), infected necrosis requiring antibiotics and/or intervention (26.6%), failure to thrive (9.7%), and non-necrosis infection (6.6%). Patients requiring readmission had increased incidence of index admission renal failure (21.3% vs. 14.2%, p = 0.05) and cardiovascular failure (12.5% vs. 4.7%, p = 0.01). Discussion Readmission in NP is extremely common. Significant portions of readmissions are a result of the disease natural history; however, a percentage of readmissions appear to be preventable. Patients with organ failure are at increased risk for unplanned readmission and will benefit from close follow-up

The Dilemma of the Dilated Main Pancreatic Duct in the Distal Pancreatic Remnant After Proximal Pancreatectomy for IPMN

Objective(s) A dilated main pancreatic duct in the distal remnant after proximal pancreatectomy for intraductal papillary mucinous neoplasms (IPMN) poses a diagnostic dilemma. We sought to determine parameters predictive of remnant main-duct IPMN and malignancy during surveillance. Methods Three hundred seventeen patients underwent proximal pancreatectomy for IPMN (Indiana University, 1991–2016). Main-duct dilation included those ≥ 5 mm or “dilated” on radiographic reports. Statistics compared groups using Student’s T/Mann-Whitney U tests for continuous variables or chi-square/Fisher’s exact test for categorical variables with P < 0.05 considered significant. Results High-grade/invasive IPMN or adenocarcinoma at proximal pancreatectomy predicted malignant outcomes (100.0% malignant outcomes; P < 0.001) in remnant surveillance. Low/moderate-grade lesions revealed benign outcomes at last surveillance regardless of duct diameter. Twenty of 21 patients undergoing distal remnant reoperation had a dilated main duct. Seven had main-duct IPMN on remnant pathology; these patients had greater mean maximum main-duct diameter prior to reoperation (9.5 vs 6.2 mm, P = 0.072), but this did not reach statistical significance. Several features showed high sensitivity/specificity for remnant main-duct IPMN. Conclusions Remnant main-duct dilation after proximal pancreatectomy for IPMN remains a diagnostic dilemma. Several parameters show a promise in accurately diagnosing main-duct IPMN in the remnant