SANTORINI'S DUCT IPMN: SHOULD IT BE ADDED AS A NEW HIGH-RISK CRITERION?
Marcel C C. Machado*1, Marcel Autran Machado2
1Universidade de Sao Paulo, Sao Paulo, São Paulo, Brazil; 2Hospital Sirio Libanes, São Paulo, São Paulo, Brazil
Backgrounds: Intraductal papillary mucinous neoplasm of the pancreas (IPMN) originates from the ductal epithelium of the pancreas and can progress to an invasive cancer. Since not every IPMN tend to be aggressive, development of guidelines to with recommendations to observe or to surgically treat those patients is needed. IPMN has been classified into two groups: main-duct (Wirsung duct) and branch-duct types. The main-duct IPMNs are considered as more aggressive while branch-type are benign or low-grade lesions, however, no mentions are made related to Santorini's duct (SD) IPMN that has been so far considered as a branch-type lesion in the literature. The main objective of this study is to present a case of Santorini's duct IPMN with high-grade dysplasia and invasive carcinoma, review of the literature and to propose the inclusion of this type of IPMN as a high risk criterion in the IPMN guidelines.
Methods: We reviewed all papers reporting IPMN in the SD. We found a total of 21 cases, including ours. Sixteen patients (76.2%) presented with malignant disease at diagnosis. In our case on histological evaluation a well-defined intraductal mucinous neoplasm originating in the Santorini's duct with minor invasive component and exuberant exudative/suppurative inflammatory process in organization, surrounded by fibrosis was found (the set of neoplasia and inflammatory and fibrous changes measures 4.3 cm). Microscopic neoplastic extension: invasive adenocarcinoma is restricted to the pancreas, the intraductal component extends to the minor duodenal papilla and the fibrous inflammatory process adheres the pancreas to the duodenum. Neoplastic involvement was not detected in the main pancreatic duct, in the greater duodenal papilla and in the choledochal duct.
Conclusion: Due to its malignant behavior, similar to the main pancreatic duct, Santorini's IPMN should be included as a high-risk criterion in the guidelines for the management of intra ductal papillary mucinous neoplasm of the pancreas .
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