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Kazmi SZ, Jung HS, Han Y, Yun WG, Cho YJ, Lee M, Kwon W, Castillo CFD, Del Chiaro M, Marchegiani G, Goh BKP, Hijioka S, Majumder S, Nakai Y, Shin A, Jang JY. Systematic review on surveillance for non-resected branch-duct intraductal papillary mucinous neoplasms of the pancreas. Pancreatology 2024; 24:463-488. [PMID: 38480047 DOI: 10.1016/j.pan.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 01/08/2024] [Accepted: 02/24/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND The management of branch-duct type intraductal papillary mucinous neoplasms (BD-IPMN) varies in existing guidelines. This study investigated the optimal surveillance protocol and safe discontinuation of surveillance considering natural history in non-resected IPMN, by systematically reviewing the published literature. METHODS This review was guided by PRISMA. Research questions were framed in PICO format "CQ1-1: Is size criteria helpful to determine surveillance period? CQ1-2: How often should surveillance be carried out? CQ1-3: When should surveillance be discontinued? CQ1-4: Is nomogram predicting malignancy useful during surveillance?". PubMed was searched from January-April 2022. RESULTS The search generated 2373 citations. After screening, 83 articles were included. Among them, 33 studies were identified for CQ1-1, 19 for CQ1-2, 26 for CQ1-3 and 12 for CQ1-4. Cysts <1.5 or 2 cm without worrisome features (WF) were described as more indolent, and most studies advised an initial period of surveillance. The median growth rate of cysts <2 cm ranged from 0.23 to 0.6 mm/year. Patients with cysts <2 cm showing no morphological changes and no WF after 5-years of surveillance have minimal malignancy risk of 0-2%. Two nomograms created with over 1000 patients had AUCs of around 0.8 and appear to be feasible in a real-world practice. CONCLUSIONS For patients with suspected BD-IPMN <2 cm and no other WF, less frequent surveillance is recommended. Surveillance may be discontinued for cysts that remain stable during 5-year surveillance, with consideration of patient condition and life expectancy. With this updated surveillance strategy, patients with non-worrisome BD-IPMN should expect more streamlined management and decreased healthcare utilization.
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Affiliation(s)
- Sayada Zartasha Kazmi
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hye-Sol Jung
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Won-Gun Yun
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Young Jae Cho
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Mirang Lee
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Giovanni Marchegiani
- Department of Surgery, Oncology and Gastroenterology (DiSCOG), Padova University Hospital, Padova, Italy
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital & National Cancer Centre Singapore, Singapore
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Chuo-ku, Japan
| | - Shounak Majumder
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Aesun Shin
- Department of Preventive Medicine and Cancer Research Institute, Seoul National University, Seoul, South Korea.
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea.
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Chhoda A, Singh S, Sheth AH, Grimshaw AA, Gunderson CG, Sharma P, Kunstman JW, Sharma A, Ahuja N, Gonda TA, Farrell JJ. Benefit of Extended Surveillance of Low-Risk Pancreatic Cysts After 5-Year Stability: A Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2022; 21:1430-1446. [PMID: 35568304 DOI: 10.1016/j.cgh.2022.04.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS Low-risk branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) lacking worrisome features (WF) and high-risk stigmata (HRS) warrant surveillance. However, their optimal duration, especially among cysts with initial 5 years of size stability, warrants further investigation. We systematically reviewed the surveillance of low-risk BD-IPMNs and investigated the incidence of WF/HRS and advanced neoplasia, high-grade dysplasia, and pancreatic cancer during the initial (<5 years) and extended surveillance period (>5-years). METHODS A systematic search (CRD42020117120) identified studies investigating long-term IPMN surveillance outcomes of low-risk IPMN among the Cochrane Library, Embase, Google Scholar, Ovid Medline, PubMed, Scopus, and Web of Science, from inception until July 9, 2021. The outcomes included the incidence of WF/HRS and advanced neoplasia, disease-specific mortality, and surveillance-related harm (expressed as percentage per patient-years). The meta-analysis relied on time-to-event plots and used a random-effects model. RESULTS Forty-one eligible studies underwent systematic review, and 18 studies were meta-analyzed. The pooled incidence of WF/HRS among low-risk BD-IPMNs during initial and extended surveillance was 2.2% (95% CI, 1.0%-3.7%) and 2.9% (95% CI, 1.0%-5.7%) patient-years, respectively, whereas the incidence of advanced neoplasia was 0.6% (95% CI, 0.2%-1.00%) and 1.0% (95% CI, 0.6%-1.5%) patient-years, respectively. The pooled incidence of disease-specific mortality during initial and extended surveillance was 0.3% (95% CI, 0.1%-0.6%) and 0.6% (95% CI, 0.0%-1.6%) patient-years, respectively. Among BD-IPMNs with initial size stability, extended surveillance had a WF/HRS and advanced neoplasia incidence of 1.9% (95% CI, 1.2%-2.8%) and 0.2% (95% CI, 0.1%-0.5%) patient-years, respectively. CONCLUSIONS A lower incidence of advanced neoplasia during extended surveillance among low-risk, stable-sized BD-IPMNs was a key finding of this study. However, the survival benefit of surveillance among this population warrants further exploration through high-quality studies before recommending surveillance cessation with certainty.
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Affiliation(s)
- Ankit Chhoda
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut
| | - Sidhant Singh
- Yale Waterbury Internal Medicine Program,Yale School of Medicine, New Haven, Connecticut
| | | | - Alyssa A Grimshaw
- Cushing/Whitney Medical Library, Yale University, New Haven, Connecticut
| | - Craig G Gunderson
- Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Prabin Sharma
- Department of Advanced Gastroenterology, NYU Winthrop Hospital, Mineola, New York
| | - John W Kunstman
- Section of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Anup Sharma
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Nita Ahuja
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Tamas A Gonda
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Langone Health, New York, New York
| | - James J Farrell
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut.
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Kim TH, Woo YS, Chon HK, Hwang JH, Yoo KS, Lee WJ, Lee KH, Lee JK, Dong SH, Park CH, Park ET, Moon JH, Kim HG, Cho KB, Kim HJ, Lee SO, Cheon YK, Lee JM, Park JW, Kim MH. Predictors of Malignancy in "Pure" Branch-Duct Intraductal Papillary Mucinous Neoplasm of the Pancreas without Enhancing Mural Nodules on CT Imaging: A Nationwide Multicenter Study. Gut Liver 2019; 12:583-590. [PMID: 29730906 PMCID: PMC6143451 DOI: 10.5009/gnl17582] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 01/21/2018] [Accepted: 01/30/2018] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Presence of enhanced mural nodules, which can be visualized using computed tomography (CT), is one of high-risk stigmata in branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs). Conversely, the absence of enhanced mural nodules on preoperative imaging does not exclude malignant risk. The present study aimed to investigate other morphological features as predictors of malignancy in "pure" BD-IPMNs without enhanced mural nodules on CT. Methods This retrospective study included 180 patients with surgically confirmed "pure" BD-IPMNs of the pancreas and no enhanced mural nodules on preoperative CT. The study was conducted at 15 tertiary referral centers throughout South Korea. Univariate and multivariate analyses were used to identify significant predictors of malignancy. Results BD-IPMNs with low-grade (n=84) or moderate-grade (n=76) dysplasia were classified as benign; those with high-grade dysplasia (n=8) or invasive carcinoma (n=12) were classified as malignant. The multivariate analysis revealed that cyst size ≥30 mm (odds ratio, 8.6; p=0.001) and main pancreatic duct diameter ≥5 mm (odds ratio, 4.1; p=0.01) were independent risk factors for malignancy in "pure" BD-IPMNs without enhanced mural nodules on CT. Endoscopic ultrasound detected enhanced mural nodules (6/82) that had been missed on CT, and two IPMNs with enhanced mural nodules were malignant. Conclusions In patients with "pure" BD-IPMNs who have no enhanced mural nodules on CT, cyst size ≥30 mm and main pancreatic duct diameter ≥5 mm may be associated with malignancy.
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Affiliation(s)
- Tae-Hyeon Kim
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Young-Sik Woo
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyung-Ku Chon
- Department of Internal Medicine, Wonkwang University College of Medicine, Iksan, Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University College of Medicine, Seongnam, Korea
| | - Kyo-Sang Yoo
- Department of Internal Medicine, Hanyang University College of Medicine, Guri, Korea
| | - Woo-Jin Lee
- Pancreatobiliary Cancer Clinic, Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Kwang-Hyuck Lee
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Kyun Lee
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok-Ho Dong
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Chang-Hwan Park
- Department of Internal Medicine, Chonnam University College of Medicine, Gwangju, Korea
| | - Eun-Taek Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Jong-Ho Moon
- Department of Internal Medicine, Soonchunhyang University School of Medicine, Bucheon, Korea
| | - Ho-Gak Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Kwang-Bum Cho
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Hong-Ja Kim
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Seung-Ok Lee
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Young-Koog Cheon
- Digestive Disease Center, Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jeong-Mi Lee
- Department of Public Health, Wonkwang University Graduate School, Iksan, Korea
| | - Jin-Woo Park
- Department of Internal Medicine, Hepatobiliary and Pancreas Center, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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