LETTERS TO THE EDITOR

 

Intraductal papillary mucinous neoplasm - The experience of natural history

Neoplasia papilar intraductal mucinosa de páncreas. Experiencia de la historia natural

 

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Key words: Introductal papillary mucinous neoplasm. Acute pancreatitis. Endoscopic ultrasound.

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Dear Editor,

 

The intraductal papillary mucinous neoplasm (NMPI) is a pre-malignant lesion, with a well known adenoma-carcinoma sequence. However, the appropriate surgical treatment and the optimal timing of action remain undefined, due to the still limited knowledge about the natural history of this tumor and the absence of long follow-up after surgery. Their initial benign nature, highlights the need for an early diagnosis, essential to avoid development of advanced incurable malignancy. In 20% of cases there is a history of acute pancreatitis (AP) without identified etiology (1-3).

Here, we present a case where we could observe sequentially all the natural history of the tumor since its initial manifestation until criteria for surgical resectability presented.

This is a 70 years old female with a previous hospitalization in 2004 for AP of unexplained etiology. The abdominal ultrasound (US) showed a slightly enlarged pancreas. The patient was followed-up in gastro outpatient clinic. Repeated US, 6 months later, with identification of a dilated and irregular pancreatic duct, confirmed by colangio-MRI.

Endoscopic ultrasound (EUS) 2 years later showed dilated and irregular Wirsung duct with apparent vegetations in the wall (Figs. 1-2). Endoscopic retrograde cholangiopancreatography was performed with brushing of the pancreatic duct unveiling cells arranged in papillary clusters (Fig. 3). EUS, past 3,5 years, displayed dilated Wirsung with 2 small vegetations. (Figs. 4-5) US, 4 years after AP, showed ectasia of Wirsung with vegetation in the cephalic segment (Fig. 6).

 

Given the probable diagnosis of NMPI with criteria for resection, the patient was subjected to total pancreatectomy with confirmation of the diagnosis. Without complications at 6 months follow up.

It is not always possible to immediately clarify the etiology of an episode of AP. Nonetheless, there is a potential indication for a careful follow-up vigilant of pancreatic changes, in these patients, and where EUS might become of great utility.

 

A. Caldeira, B. Pereira, E. Pereira, R. Sousa, J. Tristan, R. Gonçalves and A. Banhudo
Gastroenterology Department. Hospital Amato Lusitano. Castelo Branco. Portugal

 

References

1. Pausawasdi N, Scheiman J, Anderson M. Awareness of International Consensus Guidelines for the Management of Intraductal Papillary Mucinous Neoplasms (IPMN) and Mucinous Cystic Neoplasms (MCN) and Impact of Guidelines On Current Practice Gastrointestinal Endoscopy 2008: 67: AB211.         [ Links ]

2. Crippa S, Salvia R, Partelli S, Germenia S, Bassi S. Intraductal papillary mucinous neoplasms of the pancreas. In: Surgery of pancreatic tumors, Shrikhande SV, Friess H, Bunhler MW (eds). 1st edn. New Delhi: BI Publicatios Pvt Ltd. 2008: 289-98.         [ Links ]

3. Tanaka M, Chari S, Adsay V, et al. International Consensus Guidelines for Management of Intraductal Papillary Mucinous Neoplasms and Mucinous Cystic Neoplasms of the Pancreas. Pancreatology 2005; 6: 17-32.         [ Links ]