Imaging Finding Analysis and Prognosis Comparison of Pancreatic Head Cancer Invading the Peripheral Nerve Plexus Among Different Groups

Background: To compare imaging features and analyze prognostic differences among different groups with pancreatic head cancer invading the peripheral nerve plexus. Methods: We reviewed preoperative multislice spiral CT (MSCT) images, complete surgical records, and postoperative pathological results of 93 patients with pancreatic head cancer and peripheral nerve invasion. Two radiologists who were unaware of surgical and pathological results evaluated the MSCT images to determine peripheral nerve invasion of pancreatic head cancer. A pathologist who was unaware of the imaging findings grouped the patients based on surgical records and pathological findings. Pancreatic head cancer invasion of the anterior neural pathway was assigned to group A and invasion of pancreatic plexus 1, pancreatic plexus 2, and root of the mesenteric pathway to group B. Both groups were evaluated for peripheral nerve invasion, tumor size, dilatation of the common bile duct/main pancreatic duct, duodenal invasion, and prognosis of pancreatic head cancer.Results: A mass- and strand-like pattern or coarse reticular pattern was frequently observed when two groups of pancreatic head cancer invaded the peripheral nerve plexus. Intergroup differences in tumor size and common bile duct/main pancreatic duct dilatation were insignificant. The duodenal invasion rate was higher in group A than in group B; however, the intergroup difference was insignificant. The prognosis was poorer for group A than for group B.Conclusions: Although the intergroup differences in radiographic findings were not significant, the prognosis was poorer for group A than for group B.

Wirsungectomy for pancreatic hypertension in chronic pancreatitis

Background. Pain in chronic pancreatitis (CP) can occur as a consequence of mechanical factors — pancreatic ductal hypertension, interstitial pressure, inflammatory and neuropathic pathological changes in the pancreas. The purpose was to evaluate a novel modification of the classic Partington-Rochelle procedure via comparing functional results of conventional surgery group and wirsungectomy group. Materials and methods. A retrospective analysis of the case histories of patients with CP and an enlarged (≥ 4 mm) main pancreatic duct was carried out for the period from 2003 to 2009, which underwent surgical treatment of CP. The SF-36 and EORTC QLQ-C30 questionnaires, and visual analogue scale of pain were used for the assessment. The first group included five patients with wirsungectomy with lateral pancreaticojejunostomy (PEA + WE); the second group consisted of 20 patients after the lateral pancreaticojejunostomy (PEA) only. Cross-tabulation analyses were performed to compare PEA and PEA + WE groups as well as those groups in different time points using a two-sided Student’s t-test. The significance level was set to p < 0.05. Results. The groups were compared in terms of VAS and the EORTC QLQ-C30 questionnaire before and 2 years after surgery using Student’s t-test for unrelated values: statistically significant differences between the groups according to VAS as before (p = 0.757) and after surgery (p = 0.696) were not obtained. There were no significant differen­ces (p > 0.05) between the PEA and PEA + WE groups before and after surgery according to the EORTC QLQ-C30 questionnaires, except for some items (p < 0.05) Within the groups according to VAS and EORTC QLQ-C30 (pain severity), in the PEA group (p = 0.000001, p = 0.000109) and the PEA + WE group (p = 0.018, p = 0.017) after surgery, there was a statistically significant decrease in pain. Conclusions. Longitudinal pancreaticojejunostomy with wirsungectomy is justified in patients with long-term CP, severe fibrosis of the pancreas with multiple calcifications of the periphery pancreatic ducts to decompress pancreatic ducts, and parenchyma. In the long-term period after 2 years, the proposed method of longitudinal pancreaticojejunostomy with wirsungectomy in patients with CP with dilation of main pancreatic duct according to the VAS scale and EORTC QLQ questionnaires C30 and SF-36 is accompanied by a significant reduction in pain.

The role of extracorporeal shock wave lithotripsy in the treatment of chronic pancreatitis

Pain is the most frequent symptom in chronic pancreatitis (CP) and has an important impact on quality of life. One of its major pathophysiological mechanisms is ductal hypertension, caused by main pancreatic duct stones and/or strictures. In this article, we focus on extracorporeal shock wave lithotripsy (ESWL) as a treatment for main pancreatic duct stones, which have been reported in >50% of CP patients. ESWL uses acoustic pulses to generate compressive stress on the stones, resulting in their gradual fragmentation. In patients with radiopaque obstructive main pancreatic duct (MPD) stones larger than 5 mm, located in the pancreas head or body, ESWL improves ductal clearance, thereby relieving pain and improving quality of life. In case of insufficient ductal clearance or the presence of an MPD stricture, ESWL can be followed by endoscopic retrograde cholangiopancreatography (ERCP) to increase success rate. Alternatively, direct pancreaticoscopy with intracorporeal lithotripsy or surgery can be performed

Humoral Predictors of Malignancy in IPMN: A Review of the Literature

Pancreatic cystic lesions are increasingly detected in cross-sectional imaging. Intraductal papillary mucinous neoplasm (IPMN) is a mucin-producing subtype of the pancreatic cyst lesions arising from the pancreatic duct system. IPMN is a potential precursor of pancreatic cancer. The transformation of IPMN in pancreatic cancer is progressive and requires the occurrence of low-grade dysplasia, high-grade dysplasia, and ultimately invasive cancer. Jaundice, enhancing mural nodule >5 mm, main pancreatic duct diameter >10 mm, and positive cytology for high-grade dysplasia are considered high-risk stigmata of malignancy. While increased levels of carbohydrate antigen 19-9 (CA 19-9) (>37 U/mL), main pancreatic duct diameter 5–9.9 mm, cyst diameter >40 mm, enhancing mural nodules <5 mm, IPMN-induced acute pancreatitis, new onset of diabetes, cyst grow-rate >5 mm/year are considered worrisome features of malignancy. However, cross-sectional imaging is often inadequate in the prediction of high-grade dysplasia and invasive cancer. Several studies evaluated the role of humoral and intra-cystic biomarkers in the prediction of malignancy in IPMN. Carcinoembryonic antigen (CEA), CA 19-9, intra-cystic CEA, intra-cystic glucose, and cystic fluid cytology are widely used in clinical practice to distinguish between mucinous and non-mucinous cysts and to predict the presence of invasive cancer. Other biomarkers such as cystic fluid DNA sequencing, microRNA (mi-RNA), circulating microvesicles, and liquid biopsy are the new options for the mini-invasive diagnosis of degenerated IPMN. The aim of this study is to review the literature to assess the role of humoral and intracystic biomarkers in the prediction of advanced IPMN with high-grade dysplasia or invasive carcinoma.

Establishing Correlations Between Normal Pancreatic and Submandibular Gland Ducts

BACKGROUND. The objectives of this study were to evaluate the relationship between ductal morphometry and ramification patterns in the submandibular gland and pancreas in order to validate their common fractal dimension. METHODS. X-ray ductography with software-aided morphometry were obtained by injecting barium sulphate in the ducts of post-mortem submandibular gland and pancreas specimens harvested from 42 adult individuals. RESULTS. Three cases were excluded from the study because of underlying pathology. There was a significant correlation between the length of the main pancreatic duct (MPD) and the intraglandular portion of the right submandibular duct (SMD) (r = 0.3616; p=0.028), and left SMD (r = 0.595; p<0.01), respectively, but their maximal diameters did not correlate (r = 0.139 - 0.311; p>0.05). Both dimensions of the SMD showed a significant right-left correlation (p<0.05). The number of MPD side branches (mean=37) correlated with the number of side branches of left SMD, but not with the right one (mean = 9). Tortuosity was observed in 54% of the MPD, 32% of the right SMD, and 24% of the left SMD, with mutual association only between the two salivary glands. CONCLUSIONS. Although the length of intraglandular SMD and MPD correlate, other morphometric ductal features do not, thus suggesting a more complex relationship between the two digestive glands.