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Progression of intraductal papillary neoplasm of the bile duct (IPNB): A proposed model through the observation of patients with non-resected tumors
Vor Luvira
Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Proposed model of IPNB progression&#46; The blue numbers indicate median survival of the patients treated by curative-intent resection of the IPNB&#44; based on the author experience &#91;<a class="elsevierStyleCrossRef" href="#bib0045">9</a>&#93;&#46; The red numbers indicate malignancy rate&#44; and chance of lymph node involvement of curative-intent resection of the IPNB&#44; based on the author experience&#44; according to pathological examination &#91;<a class="elsevierStyleCrossRef" href="#bib0045">9</a>&#93;&#46; &#8224;The indicated number may be imprecise due to small sample size&#44; unpublished data&#46; IPNB&#58; intraductal papillary neoplasm of the bile duct&#44; LN&#43;&#58; chance of lymph node involvement&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Intraductal papillary neoplasm of the bile duct &#40;IPNB&#41; is a specific entity&#44; characterized by intraluminal growth of bile duct epithelia with a fine fibro-vascular core from microscopy &#91;<a class="elsevierStyleCrossRef" href="#bib0005">1</a>&#93;&#46; IPNB has many unique characteristics in risk factor &#91;<a class="elsevierStyleCrossRef" href="#bib0010">2</a>&#93;&#44; pathogenesis &#91;<a class="elsevierStyleCrossRef" href="#bib0015">3</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0020">4</a>&#93; and disease nature &#91;<a class="elsevierStyleCrossRef" href="#bib0025">5</a>&#93;&#46; The nature of IPNB includes slow growth&#44; multiplicity &#91;<a class="elsevierStyleCrossRef" href="#bib0030">6</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0035">7</a>&#93;&#44; various cell types&#44; various degrees of invasion &#91;<a class="elsevierStyleCrossRef" href="#bib0025">5</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0030">6</a>&#93; and various amounts of mucin production&#44; resulting in the many characteristics of IPNB &#91;<a class="elsevierStyleCrossRef" href="#bib0040">8</a>&#93;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We have classified IPNB&#44; in order to predict the patient prognosis and guide the treatment&#44; according to its morphology&#44; into five common subtypes &#91;<a class="elsevierStyleCrossRef" href="#bib0045">9</a>&#93;&#44; including &#40;i&#41; intrahepatic intraductal lesion &#40;i&#46;e&#46;&#44; presence of an intraductal tumor with unilateral intrahepatic duct dilatation&#41;&#44; &#40;ii&#41; extrahepatic intraductal lesion &#40;i&#46;e&#46;&#44; presence of an intraductal tumor with bilateral intrahepatic duct dilatation&#41;&#44; &#40;iii&#41; cystic variant &#40;i&#46;e&#46;&#44; cystic tumor with a papillary tumor inside and the presence of bile duct communication&#41;&#44; which has a radiological picture similar to a hepatic mucinous neoplasm &#91;<a class="elsevierStyleCrossRef" href="#bib0050">10</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0055">11</a>&#93;&#44; &#40;iv&#41; micro-papillary lesion &#40;i&#46;e&#46;&#44; disproportional bile duct dilatation in the absence of any discernible tumor&#41;&#44; and &#40;v&#41; macro-invasive IPNB &#40;i&#46;e&#46;&#44; presence of a mass-forming tumor incorporate with intraductal tumor&#41; &#91;<a class="elsevierStyleCrossRef" href="#bib0045">9</a>&#93;&#46; However&#44; we still believe that the progression of IPNB is more a continuous spectrum that is unable to be clearly divided type by type&#46; Since North-Eastern Thailand is an endemic area for bile duct tumors &#91;<a class="elsevierStyleCrossRef" href="#bib0060">12</a>&#93;&#44; we had opportunities to find IPNB patients who did not undergo surgical resection for various reasons&#44; allowing us to observe the in-vivo progression of IPNB&#46; We found the progression of IPNB from one class to another&#46; We&#44; therefore&#44; are proposing this progression model of IPNB &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">We believe that all IPNBs start from a micro-papillary type&#44; with various degrees of mucin production&#46; When IPNB produces a large amount of gross mucin without any bile duct obstruction by the tumor&#44; it would present a mucobilia picture&#59; diffuse biliary dilatation without a discernible mass &#40;a&#41;&#46; If the predominant progression is by intraductal tumor growth and there is a relatively low amount of gross mucin production&#44; it would be typical IPNB&#59; intraductal mass in dilated bile duct &#40;b&#41;&#46; When the degree of biliary obstruction has increased to nearly complete obstruction at any level of the intrahepatic bile duct &#40;relative with the viscosity of the mucin&#41;&#44; the cystic IPNB appears &#91;<a class="elsevierStyleCrossRef" href="#bib0065">13</a>&#93; &#40;c&#41;&#46; Since the hepatic hilum is the region which consists of a complicated network of peri-biliary gland &#91;<a class="elsevierStyleCrossRef" href="#bib0070">14</a>&#93;&#44; that enhances the progression of the tumor&#59; IPNB with luminal extension approaching this point is usually related with a worse prognosis &#91;<a class="elsevierStyleCrossRef" href="#bib0045">9</a>&#44;<a class="elsevierStyleCrossRef" href="#bib0075">15</a>&#93; &#40;d&#41;&#46; Some mutation makes IPNB more invasive&#44; resulting in vertical extension through the bile duct to adjacent liver parenchyma &#40;e&#41;&#44; increasing the chance of lymph node involvement and distant metastasis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">To the best of our knowledge&#44; this is the first proposed model of the progression of IPNB&#46; Our model would explain the presence of a combined morphology&#44; the differences in nature of each morphology of the IPNB&#44; in terms of the chance of lymph node involvement&#44; distant metastasis and prognosis of the patients&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors received no financial support for the manuscript&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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