Progression vs cyst stability of branch-duct intraductal papillary mucinous neoplasms after observation and surgery

Published on Jul 1, 2021in JAMA Surgery13.625
· DOI :10.1001/JAMASURG.2021.1802
Importance The progression of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas to malignant disease is still poorly understood. Observational and surgical series have failed to provide comprehensive information. Objective To identify dynamic variables associated with the development of malignant neoplasms by combining pathological features with data from preoperative repeated observations. Design, Setting, and Participants The Crossover Observational Multicentric Study included a retrospective cohort of patients with branch-duct IPMNs (BD IPMNs) enrolled in a surveillance program from January 1, 2000, to December 31, 2019. Patients were enrolled from 5 referral centers: the Pancreas Institute, Verona, Italy; Seoul National University Hospital, Seoul, South Korea; Singapore General Hospital, Singapore; Johns Hopkins School of Medicine, Baltimore, Maryland; and University of Texas MD Anderson Cancer Center, Houston. Patients underwent a minimum of 12 months of preoperative surveillance (median, 37 [interquartile range (IQR), 20-68] months). Main Outcomes and Measures Dynamic variables associated with malignant disease were explored to estimate the presence of high-grade dysplasia (HGD) and invasive cancer at final pathological examination. Results A total of 292 patients were included in the analysis (137 women [46.9%] and 155 men [53.1%]; median age, 64 [IQR, 56-71] years). During surveillance, 27 patients (9.2%) developed a worrisome feature after 5 years, and 46 of 276 (16.7%) developed high-risk stigmata (HRS). At final pathological evaluation, 107 patients (36.6%) had HGD or invasive cancer, and 16 (5.5%) had IPMNs with concomitant pancreatic ductal adenocarcinoma. Rates of HGD and invasive cancer at pathological evaluation significantly differed between those without worrisome features and those developing HRS from a previous worrisome feature (9 [27.3%] vs 13 [61.9%]; P < .001). Developing an additional worrisome feature during surveillance (odds ratio [OR], 3.24 [95% CI, 1.38-7.60]; P = .007) or an HRS from a baseline worrisome feature (OR, 2.87 [95% CI, 1.01-8.17]; P = .048) was associated with HGD at final pathological evaluation. Among HRS, development of jaundice on a low-risk cyst was independently associated with invasive cancer (OR, 16.04 [95% CI, 2.94-87.40]; P = .001). Conclusions and Relevance These findings suggest that in BD IPMNs under surveillance, harboring a stable worrisome feature carries the lowest risk of malignant disease. Development of additional worrisome features or HRS is associated with the presence of HGD, whereas the occurrence of jaundice is associated with invasive cancer.
#1R. Matthew Walsh (Cleveland Clinic)H-Index: 32
#2Breanna Perlmutter (Cleveland Clinic)H-Index: 1
Last. Brian K. P. Goh (SGH: Singapore General Hospital)H-Index: 51
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1 CitationsSource
#1Marco Del ChiaroH-Index: 31
#2Ross Beckman (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 2
Last. Christopher L. WolfgangH-Index: 102
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MiniThis retrospective analysis of 901 patients who underwent pancreatic resection for IPMN shows significant risk of malignancy associated with main duct dilatation greater than 5 mm. While previous studies and guidelines have focused on a 10 mm cutoff for criteria for resection, we provide evidenc
32 CitationsSource
#1Wataru IzumoH-Index: 6
#2Ryota HiguchiH-Index: 25
Last. Masakazu YamamotoH-Index: 63
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Abstract Background High-risk stigmata (HRS) and ‘worrisome features’ (WFs) are defined as predictive factors for malignancies of intraductal papillary mucinous neoplasms (IPMNs). We performed this study to determine the importance and odds ratio (OR) of each HRS and WFs as predictors for high-grade dysplasia (HGD). Methods We analyzed 295 patients who underwent pancreatectomy for branch duct and mixed-type IPMN, and evaluated the association between HRS and WFs (as defined by the ‘2017 Fukuoka ...
5 CitationsSource
#1Michael Goggins (Johns Hopkins University)H-Index: 118
#2Kasper A. Overbeek (Erasmus University Medical Center)H-Index: 3
Last. Marco J. Bruno (Erasmus University Medical Center)H-Index: 23
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Background and aim The International Cancer of the Pancreas Screening Consortium met in 2018 to update its consensus recommendations for the management of individuals with increased risk of pancreatic cancer based on family history or germline mutation status (high-risk individuals). Methods A modified Delphi approach was employed to reach consensus among a multidisciplinary group of experts who voted on consensus statements. Consensus was considered reached if ≥75% agreed or disagreed. Results ...
110 CitationsSource
#1Hiroki Oyama (UTokyo: University of Tokyo)H-Index: 4
#2Minoru Tada (UTokyo: University of Tokyo)H-Index: 60
Last. Kazuhiko Koike (UTokyo: University of Tokyo)H-Index: 91
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Abstract Background & Aims Long-term outcomes of patients with branch-duct intraductal papillary mucinous neoplasms (IPMNs), particularly those after 5 years if surveillance, have not been fully evaluated in large studies. We analyzed incidences of IPMN-derived carcinoma and concomitant ductal adenocarcinoma (PDAC) over 20 years in a large population of patients. Methods We identified 1404 consecutive patients (52% female; mean age, 67.5 years) with a diagnosis of branch-duct IPMN, from 1994 thr...
60 CitationsSource
#1Giovanni Marchegiani (University of Verona)H-Index: 29
#2Stefano Andrianello (University of Verona)H-Index: 16
Last. Roberto Salvia (University of Verona)H-Index: 52
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OBJECTIVES:The management of small and incidental branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) still is of concern. The aim is assessing the safety of a surveillance protocol through the evaluation of their progression to malignancy.METHODS:All presumed BD-IPMNs observed from 2000
24 CitationsSource
#1Ingrid C. Konings (EUR: Erasmus University Rotterdam)H-Index: 6
#2M. I. Canto (Johns Hopkins University)H-Index: 8
Last. Marco J. Bruno (EUR: Erasmus University Rotterdam)H-Index: 67
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textabstractBackground: Surveillance of individuals at high risk of pancreatic ductal adenocarcinoma (PDAC) and its precursors might lead to better outcomes. The aim of this study was to determine the prevalence and outcomes of PDAC and high-risk neoplastic precursor lesions among such patients participating in surveillance programmes. Methods: A multicentre study was conducted through the International CAncer of the Pancreas Screening (CAPS) Consortium Registry to identify high-risk individuals...
9 CitationsSource
Abstract Background Significant overtreatment of intraductal papillary mucinous neoplasms can be attributed to low specificity of the current International Consensus Guidelines as well as nonconformity with the guidelines. We compare the ability of the 2012 and revised 2017 intraductal papillary mucinous neoplasms International Consensus Guidelines to predict high-grade dysplasia/invasive cancer and to determine the preoperative variables that predict resection of benign or low-grade dysplasia i...
17 CitationsSource
#1Giovanni Marchegiani (University of Verona)H-Index: 29
#2Stefano Andrianello (University of Verona)H-Index: 16
Last. Roberto Salvia (University of Verona)H-Index: 52
view all 9 authors...
BACKGROUND: The association between risk of pancreatic cancer and a dilated main pancreatic duct (MPD) in intraductal papillary mucinous neoplasm (IPMN) is debated. The aim of this study was to assess the role of MPD size in predicting pancreatic cancer in resected IPMNs and those kept under surveillance. METHODS: All patients with IPMN referred to the Pancreas Institute, University of Verona Hospital Trust, from 2006 to 2016 were included. The primary endpoint was the occurrence of malignancy d...
15 CitationsSource
#1Keiichi Akahoshi (Tokyo Medical and Dental University)H-Index: 6
#2Hiroaki Ono (Tokyo Medical and Dental University)H-Index: 9
Last. Minoru Tanabe (Tokyo Medical and Dental University)H-Index: 30
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Abstract Background Branch duct intraductal papillary mucinous neoplasm (BD-IPMN) has the potential for malignant transformation. Current risk factors used to predict malignant transformation, such as mural nodules and cyst size > 30 mm, are insufficient. Therefore, we aimed to investigate the predictive significance of cyst growth speed. Materials and methods Between 2006 and 2017, 102 patients underwent pancreatectomy for IPMN. Of these, 50 patients with pathologically diagnosed BD-IPMN were s...
5 CitationsSource
Cited By1
#1Patricia C. Conroy (UCSF: University of California, San Francisco)
#2Eric K. Nakakura (UCSF: University of California, San Francisco)H-Index: 23