High-grade pancreatic intraepithelial lesions: prevalence and implications in pancreatic neoplasia.

BACKGROUND: High-grade pancreatic intraepithelial neoplasia (PanIN-3), a precursor of pancreatic ductal adenocarcinoma (PDAC), is not universally detected in resected pancreatic neoplasms. We sought to determine the prevalence and prognostic relevance of PanIN-3 lesions in primary surgical resections of PDACs and intraductal papillary mucinous neoplasms (IPMNs). METHODS: A retrospective review of a tertiary care center pathology database (1/2000-6/2014) was performed. Demographics, imaging, pathology, disease-recurrence, and survival data were reviewed. RESULTS: A total of 458 patients who underwent primary pancreatic resection were included. "PanIN-3" lesions were found in 74 (16.2%) patients who either had PDAC (n=67) or main duct (MD)-IPMN (n=7). Among IPMN-MDs, PanIN-3 lesions were exclusively found in those with pathological evidence of chronic pancreatitis. For PDACs, the median overall survival (OS) for pancreata with PanIN-3 lesions was significantly better than those without (OS 1.12 years, inter-quartile range [IQR] 0.72, 2.05 years vs OS 0.86 years, IQR 0.64, 1.60 years respectively; P=0.04). Multivariate Cox regression analysis demonstrated that the presence of PanIN-3 lesions was associated with a reduced risk of death (HR=0.43; 95% CI: 0.23-0.82; P=0.01). CONCLUSIONS: Following primary resection of pancreatic adenocarcinoma, the lower survival observed in patients without PanIN-3 lesions might suggest a state of complete or accelerated transformation. Further investigations are necessary to validate these findings that might impact disease prognosis and management.

Primary Care of the Patient with Inflammatory Bowel Disease.

Inflammatory bowel disease involves 2 major disorders, ulcerative colitis and Crohn disease, both of which are due to inflammatory dysregulation in the gastrointestinal tract. Although these disorders have many overlapping features in pathophysiology and management, our current understanding of inflammatory bowel disease has illuminated several distinguishing features of the 2 diseases. This article highlights similarities and differences most applicable to a primary care physician's practice. Also detailed are disease-related and treatment-related complications, and routine health maintenance practices for the patient with inflammatory bowel disease.

Asymptomatic Duodenal Perforation from an Inferior Vena Cava Filter.

Recent exponential increase in inferior vena cava (IVC) filter placements has led to a higher rate of filter complications. A 46-year-old man with a past history of IVC filter placement for bilateral deep vein thrombosis presented with lower abdominal pain. Imaging studies demonstrated IVC filter strut penetrations into multiple structures. Upper endoscopy confirmed an uncomplicated single IVC filter strut penetration into the duodenal wall. The abdominal pain was determined to be unrelated to IVC filter strut penetration, and the patient was managed conservatively. Although IVC filter strut penetrations can cause significant complications, current guidelines remain unclear for management of asymptomatic enteric IVC filter strut penetrations.