Traverso L W, Peralta E A, Ryan J A, Kozarek R A
Section of General, Thoracic, and Vascular Surgery, Virginia Mason Medical Center, Seattle, Washington 98111, USA.
Am J Surg. 1998 May;175(5):426-32. doi: 10.1016/s0002-9610(98)00039-7.
Since 1980 a group of pancreatic tumors have been termed intraductal papillary mucinous tumors (IPMT). Because these tumors occupy an intraductal position they are demonstrated by pancreatography to reside in the main pancreatic duct (MPD) or side branch ducts (SBD). Lesions of IPMT result in abdominal pain or pancreatitis symptoms because mucin production or papillary growth results in ductal obstruction. Only 104 cases had been reported in the literature by 1996 but more are being presented in abstract form. We reviewed our own 33 cases to assist defining operative decision-making criteria.
All cases of IPMT between 1989 and 1997 were reviewed for clinical presentation, anatomy by endoscopic retrograde cholangiopancreatography and computed tomography, histologic findings, and long-term outcomes.
Our cases were older (65 years) and presented with disease centered mainly in the head of the gland. Clinical presentation was epigastric pain (82%), pancreatitis (56%), weight loss (36%), diabetes (27%), and jaundice (9%). Operations were pancreatectomy in 31 (Whipple n = 15, total n = 5, distal n = 10, local n = 1), bypass only (n = 1), and no operation (n = 1). Malignancy was found in 14 of 33 (42%). Factors significantly associated (P <0.05 Fisher exact test) with malignancy were history of alcohol abuse or death from disease. Jaundice or presence in both MPD and SBD approached a significant association with malignancy but not abdominal pain, weight loss, diabetes, preoperative serum elevations of amylase, SGOT, CA-19-9, or CEA; diffuse MPD dilation, gland region, gross mucus in ducts or filling defects, cytology, calcifications, or a pancreatic mass. In 31 resected patients after a follow-up of 37 months (1 to 103) death had occurred in 6 of 13 malignant cases and 0 of 18 with benign disease. Three-year actuarial survival was 82% (all) and 56% (malignant). Symptom recurrence after resection was found in 6 of 31 at a mean of 13 months postoperatively and was associated with death from disease (P <0.05) or presence of pain preoperatively.
Malignancy is common with IPMT and is more likely to be present with the clinical history of alcohol abuse or jaundice and if the tumor involves both the MPD and the SBD. The prognosis after resection is better than pancreatic cancer but the 19% recurrence of symptoms was equally seen with benign or malignant cases owing to residual disease in pancreatic remnants. The amount of resection should be extensive in patients likely to have malignancy (alcohol, jaundice, MPD+SBD). In those likely to redevelop symptoms, ie, those with preoperative pain, a careful assessment should be made via imaging studies for extent of disease.
自1980年以来，一组胰腺肿瘤被称为导管内乳头状黏液性肿瘤（IPMT）。由于这些肿瘤位于导管内，胰管造影显示它们位于主胰管（MPD）或分支胰管（SBD）中。IPMT病变会导致腹痛或胰腺炎症状，因为黏液分泌或乳头状生长会导致导管阻塞。到1996年，文献中仅报道了104例，但更多病例以摘要形式呈现。我们回顾了我们自己的33例病例，以协助确定手术决策标准。
对1989年至1997年间所有IPMT病例的临床表现、通过内镜逆行胰胆管造影和计算机断层扫描的解剖结构、组织学发现以及长期结果进行了回顾。
我们的病例年龄较大（65岁），疾病主要集中在胰腺头部。临床表现为上腹部疼痛（82%）、胰腺炎（56%）、体重减轻（36%）、糖尿病（27%）和黄疸（9%）。手术方式为胰切除术31例（惠普尔手术15例、全胰切除术5例、远端胰切除术10例、局部切除术1例）、仅行旁路手术（1例）和未手术（1例）。33例中有14例（42%）发现恶性肿瘤。与恶性肿瘤显著相关（P<0.05，费舍尔精确检验）的因素是酗酒史或死于疾病。黄疸或同时存在于MPD和SBD与恶性肿瘤有接近显著的关联，但与腹痛、体重减轻、糖尿病、术前血清淀粉酶、谷草转氨酶、CA-19-9或癌胚抗原升高、MPD弥漫性扩张、腺体区域、导管内大量黏液或充盈缺损、细胞学检查结果、钙化或胰腺肿块无关。在31例接受切除术后随访37个月（1至103个月）的患者中，13例恶性病例中有6例死亡，18例良性疾病患者无死亡。三年精算生存率为82%（全部）和56%（恶性）。31例患者中有6例在术后平均13个月出现切除术后症状复发，且与死于疾病（P<0.05）或术前存在疼痛有关。
IPMT中恶性肿瘤很常见，在有酗酒史或黄疸的临床病史以及肿瘤累及MPD和SBD时更可能存在。切除术后的预后优于胰腺癌，但由于胰腺残端残留疾病，19%的症状复发在良性或恶性病例中均可见。对于可能患有恶性肿瘤（酗酒、黄疸、MPD+SBD）的患者，切除范围应广泛。对于那些可能再次出现症状的患者，即术前有疼痛的患者，应通过影像学检查仔细评估疾病范围。
