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Quero G, Pecorelli N, Paiella S, Fiorillo C, Petrone MC, Capretti G, Laterza V, De Sio D, Menghi R, Kauffmann E, Nobile S, Butturini G, Ferrari G, Rosa F, Coratti A, Casadei R, Mazzaferro V, Boggi U, Zerbi A, Salvia R, Falconi M, Alfieri S. Pancreaticoduodenectomy in octogenarians: The importance of "biological age" on clinical outcomes. Surg Oncol 2021; 40:101688. [PMID: 34844071 DOI: 10.1016/j.suronc.2021.101688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/01/2021] [Accepted: 11/22/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION With the prolongation of life expectancy, an increasing number of elderly patients are evaluated for pancreatic surgery. However, the influence of increasing age on outcomes after pancreaticoduodenectomy (PD) is still unclear, especially in octogenarians. Aim of this study is to evaluate the perioperative characteristics and outcomes of octogenarians undergoing PD. METHODS Data for 812 patients undergoing PD between 2019 and 2020 in 10 referral centers in Italy were reviewed. Patients aged 80 years or older were matched based on nearest neighbor propensity scores in a 1:1 ratio to patients younger than 80 years. Propensity scores were calculated using 7 perioperative variables including gender, ASA score, neoadjuvant treatment (NAT), biliary stent positioning, type of surgical approach (open, laparoscopic, robot-assisted), associated vascular resections, type of lesion. Perioperative characteristics and short-term postoperative outcomes were compared before and after matching. RESULTS Overall, 81 (10%) patients had 80 years or more. Before matching, octogenarians had a higher rate of ASA score≥ 3 (n = 35, 43.2% vs. n = 207, 28.3%; p = 0.005) and less frequently underwent NAT (n = 11, 13.6% vs. n = 213, 29.1%; p = 0.003). Matching was successfully performed for 70 octogenarians. After matching, no differences in preoperative and intraoperative characteristics were found. Postoperatively, ICU admission was more frequent in octogenarians (50% vs 30%; p = 0.01). Although in-hospital mortality was higher in octogenarians before matching (7.4% vs 2.9% in the younger cohort; p = 0.03), no difference was noted between the matched cohorts (p = 0.36). Postoperative morbidity was comparable between groups in the whole and selected populations. At the multivariate analysis, chronological age was not recognized as a prognostic factor for cumulative major complications, while ASA ≥3 was the only confirmed influencing feature (OR 2.98; 95%CI: 1.6-6.8; p = 0.009). CONCLUSIO In high-volume centers, PD in octogenarians shows similar outcomes than younger patients. Age itself should not be considered an exclusion criterion for PD, but a focused preoperative assessment is essential for adequate patient selection.
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Affiliation(s)
- Giuseppe Quero
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy; Pancreato-Biliary Endoscopy and EUS Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Claudio Fiorillo
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy.
| | - Maria Chiara Petrone
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy; Pancreato-Biliary Endoscopy and EUS Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Capretti
- Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, MI, Italy
| | - Vito Laterza
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Davide De Sio
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Roberta Menghi
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Emanuele Kauffmann
- Chirurgia Generale Universitaria dell'Ospedale di Cisanello, Via Paradisa, 2, 56124, Pisa, Italy
| | - Sara Nobile
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giovanni Butturini
- Casa di Cura Pederzoli, Via Monte Baldo 24, 37019, Peschiera del Garda, Verona, Italy
| | - Giovanni Ferrari
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Fausto Rosa
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Andrea Coratti
- Division of Surgical Oncology and Robotics, Department of Oncology, Careggi University Hospital, Florence, Italy
| | - Riccardo Casadei
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Vincenzo Mazzaferro
- HPB Surgery and Liver Transplantation, Department of Oncology, University of Milan, Milan, Italy; Istituto Nazionale Tumori, Fondazione IRCCS, Milan, Italy
| | - Ugo Boggi
- Chirurgia Generale Universitaria dell'Ospedale di Cisanello, Via Paradisa, 2, 56124, Pisa, Italy
| | - Alessandro Zerbi
- Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, MI, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy; Pancreato-Biliary Endoscopy and EUS Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sergio Alfieri
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy
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Sakai A, Masuda A, Eguchi T, Anami T, Nishi K, Furumatsu K, Okabe Y, Kakuyama S, Sato Y, Nishioka C, Sanuki T, Yagi Y, Kobayashi T, Shiomi H, Kodama Y. Clinical outcome of conservatively managed pancreatic intraductal papillary mucinous neoplasms with mural nodules and main duct dilation. J Gastroenterol 2021; 56:285-292. [PMID: 33112991 DOI: 10.1007/s00535-020-01739-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/15/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Surgical resection of intraductal papillary mucinous neoplasm (IPMN) is strongly recommended for patients exhibiting high-risk stigmata (HRS). However, determining surgical indications for elderly patients with comorbidities is challenging, as clinical outcomes are not well characterized. This multicenter observational study elucidated the clinical outcomes of patients with IPMN exhibiting HRS who did not undergo surgery. METHODS This study enrolled 101 IPMN patients exhibiting HRS with follow-up observations at 11 hospitals in Japan (2011-2016). The median observation period was 37 months (maximum: 86 months). Primary outcomes were estimated 5-year overall survival (OS) and disease-specific survival (DSS). Survival was also stratified based on HRS features. RESULTS Of 101 patients, 32 (31.7%) had the main pancreatic duct (MPD) measuring ≥ 10 mm and 80 (79.2%) had mural nodules measuring ≥ 5 mm. The estimated 5-year OS and DSS were 74% and 91%, respectively. In the stratified analysis, the co-presence of MPD ≥ 10 mm and mural nodules ≥ 5 mm or mural nodule ≥ 10 mm were related to worse 5-year DSS (MPD ≥ 10 mm and mural nodules ≥ 5 mm vs other characteristics: 60% vs 95%, log-rank test: p = 0.049; mural nodules ≥ 10 mm vs < 10 mm: 77% vs 95%, log-rank test: p = 0.003). CONCLUSIONS The estimated 5-year DSS of conservatively managed IPMN patients with mural nodules and main duct dilation was 91%. Only IPMN patients with plural HRS or large nodule formation might have an increased mortality risk. This is an important insight that can help facilitate appropriate clinical decision-making, especially in the elderly or high-surgical risk IPMN patients.
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Affiliation(s)
- Arata Sakai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0071, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0071, Japan.
| | - Takaaki Eguchi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Takahiro Anami
- Department of Gastroenterology, Yodogawa Christian Hospital, Osaka, Japan
| | - Katsuhisa Nishi
- Department of Gastroenterology, Hyogo Prefectural Awaji Medical Center, Sumoto, Japan
| | - Keisuke Furumatsu
- Department of Gastroenterology, Akashi Medical Center, Akashi, Japan
| | - Yoshihiro Okabe
- Department of Gastroenterology, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Saori Kakuyama
- Department of Gastroenterology, Takatsuki General Hospital, Takatsuki, Japan
| | - Yu Sato
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba, Japan
| | | | - Tsuyoshi Sanuki
- Department of Gastroenterology, Kita-harima Medical Center, Ono, Japan
| | - Yosuke Yagi
- Department of Internal Medicine, Shiso Municipal Hospital, Shiso, Japan
| | - Takashi Kobayashi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0071, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0071, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0071, Japan
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Giuffrida P, Biagiola D, Ardiles V, Uad P, Palavecino M, de Santibañes M, Clariá RS, Pekolj J, de Santibañes E, Mazza O. Long-term follow-up of Branch-Duct Intraductal Papillary Mucinous Neoplasms with negative Sendai Criteria: the therapeutic challenge of patients who convert to positive Sendai Criteria. HPB (Oxford) 2021; 23:290-300. [PMID: 32709558 DOI: 10.1016/j.hpb.2020.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 04/15/2020] [Accepted: 06/19/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The management of Branch-Duct Intraductal Papillary Mucinous Neoplasm (BD-IPMN) is still controversial. Our objective was to assess the long-term follow-up (FU) of patients with "low-risk" BD-IPMN according to the Sendai-International Consensus Guidelines (ICG-I). METHODS We retrospectively analyzed a cohort of patients with BD-IPMN and Negative Sendai-Criteria (NSC) from January 2004 to October 2019. A univariate analysis was performed to determine factors associated with conversion to Positive Sendai-Criteria (PSC) and malignancy. Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of the IGC-I were assessed for the development of malignancy. RESULTS A total of 219 patients were selected and underwent a median 58-month FU. Thirty-seven (17%) patients developed PSC during FU including 12 (5.5%) with malignant lesions. Conversely, 182 patients (83%) did not develop malignancy. The NPV and PPV of ICG-I for malignancy were 100% and 32.4%, respectively. Among patients who developed PSC, those with cancer were >65years (OR = 3.57;p = 0.015) and had significantly higher serum CA-19-9 levels (OR = 5.27;p = 0.007). CONCLUSION The ICG-I is a safe strategy for FU of patients with BD-IPMN. The absence of PSC exclude malignancy. Among patients who develops PSC, the risk of cancer remains low and surgery should be decided according to their surgical risk and life expectancy.
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Affiliation(s)
- Pablo Giuffrida
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - David Biagiola
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Victoria Ardiles
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Pedro Uad
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Martin Palavecino
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Martín de Santibañes
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Rodrigo S Clariá
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Juan Pekolj
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Eduardo de Santibañes
- HPB Surgery Section and Liver Transplant Unit, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina
| | - Oscar Mazza
- HPB Surgery Section, Department of General Surgery, Hospital Italiano de Buenos Aires, Tte. Gral. Juan Domingo Perón 4190, C1199ABD, Buenos Aires, Argentina.
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Vaalavuo Y, Siiki A, Antila A, Rinta-Kiikka I, Sand J, Laukkarinen J. The European evidence-based guidelines on pancreatic cystic neoplasms (PCN) in clinical practice: The development of relative and absolute indications for surgery during prospective IPMN surveillance. Pancreatology 2020; 20:1393-1398. [PMID: 32938553 DOI: 10.1016/j.pan.2020.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The European evidence-based guidelines on PCN recommend surveillance for IPMN patients who are fit for surgery but who have no indication for immediate surgery. Our aim was to demonstrate the feasibility of the new guidelines in clinical practice. METHODS This is a prospective cohort study of patients included in the IPMN register in Tampere University Hospital, Finland. IPMN was diagnosed from January 1, 2013 to December 31, 2018. Patients were analyzed for surveillance and indications for surgery according to the European guidelines on PCN. RESULTS Out of 128 patients in register 23 was decided to operate upfront and 105 patients were included in the surveillance programme. Invasive carcinoma was found in 4/23 of operated patients. Median follow-up time was 26 months (6-69). Median size of the cyst at the beginning and end of the surveillance was 16 mm (4-58 mm). During surveillance 0/105 (0.0%) patients had or developed an absolute indication for surgery. Relative indication for surgery was present in 8/105 (7.6%) patients in the beginning surveillance and 9/105 (8.6%) patients developed at least one relative indication for surgery during surveillance. From the surveillance cohort 2/105 patients were operated. Surveillance was abandoned in 15/105 (14.1%) patients all due to poor general condition or other medical conditions. CONCLUSIONS In clinical practice, surveillance of IPMN according to the European guidelines on PCN is feasible. Among our patients 16% were detected to have relative indications for surgery during the median 26 (range 3-135) months of surveillance. Nearly 15% became surgically unfit during surveillance period.
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Affiliation(s)
- Yrjö Vaalavuo
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Antti Siiki
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Anne Antila
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Irina Rinta-Kiikka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Dept. of Radiology, Tampere University Hospital, Tampere, Finland
| | - Juhani Sand
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
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Abstract
Evidence-based guidelines on the management of pancreatic cystic neoplasms (PCN) are lacking. This guideline is a joint initiative of the European Study Group on Cystic Tumours of the Pancreas, United European Gastroenterology, European Pancreatic Club, European-African Hepato-Pancreato-Biliary Association, European Digestive Surgery, and the European Society of Gastrointestinal Endoscopy. It replaces the 2013 European consensus statement guidelines on PCN. European and non-European experts performed systematic reviews and used GRADE methodology to answer relevant clinical questions on nine topics (biomarkers, radiology, endoscopy, intraductal papillary mucinous neoplasm (IPMN), mucinous cystic neoplasm (MCN), serous cystic neoplasm, rare cysts, (neo)adjuvant treatment, and pathology). Recommendations include conservative management, relative and absolute indications for surgery. A conservative approach is recommended for asymptomatic MCN and IPMN measuring <40 mm without an enhancing nodule. Relative indications for surgery in IPMN include a main pancreatic duct (MPD) diameter between 5 and 9.9 mm or a cyst diameter ≥40 mm. Absolute indications for surgery in IPMN, due to the high-risk of malignant transformation, include jaundice, an enhancing mural nodule >5 mm, and MPD diameter >10 mm. Lifelong follow-up of IPMN is recommended in patients who are fit for surgery. The European evidence-based guidelines on PCN aim to improve the diagnosis and management of PCN.
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Vanella G, Crippa S, Archibugi L, Arcidiacono PG, Delle Fave G, Falconi M, Capurso G. Meta-analysis of mortality in patients with high-risk intraductal papillary mucinous neoplasms under observation. Br J Surg 2018; 105:328-338. [PMID: 29405253 DOI: 10.1002/bjs.10768] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 06/25/2017] [Accepted: 10/26/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although consensus guidelines suggest that patients with high-risk intraductal papillary mucinous neoplasms (IPMNs) should have surgery, a non-operative strategy is often selected in patients who are poor surgical candidates. The aim was to determine the risk of disease-related death from IPMN in patients with worrisome features or high-risk stigmata who were kept under observation. METHODS A PubMed literature search was undertaken of articles published from August 1992 to June 2016 (updated October 2017). The methodology was developed from PRISMA and MOOSE checklists. Incidence proportions and rates of overall and IPMN-related deaths were calculated, with subgroup analyses for main-duct/mixed-type and branch-duct IPMNs. Quality of the studies, publication bias and heterogeneity were explored. RESULTS Six studies reported data on overall mortality and eight described disease-specific mortality for 556 patients during follow-up ranging from 24·9 to 60·0 months. Pooled rates of overall and IPMN-related mortality were 30·9 (95 per cent c.i. 19·6 to 45·1) and 11·6 (6·0 to 21·2) per cent respectively. The pooled incidence rate for overall mortality was substantially higher than that for IPMN-related mortality: 78 (95 per cent c.i. 44 to 111) and 23 (9 to 37) per 1000 patient-years respectively. The pooled incidence rate for disease-specific mortality was considerably lower for branch-duct than for main-duct or mixed-type IPMNs: 5 (0 to 10) and 32 (12 to 52) per 1000 patient-years respectively. CONCLUSION In patients unfit for surgery, IPMN-related mortality among patients with worrisome features and high-risk stigmata is low, and the risk of death from other causes much higher.
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Affiliation(s)
- G Vanella
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - S Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy
| | - L Archibugi
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - P G Arcidiacono
- Pancreato-Biliary Endoscopy Division and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Milan, Italy
| | - G Delle Fave
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - M Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy
| | - G Capurso
- Digestive and Liver Disease Unit, Sant'Andrea Hospital, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
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7
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Pak LM, D'Angelica MI, DeMatteo RP, Kingham TP, Balachandran VP, Jarnagin WR, Allen PJ. Natural History of Patients Followed Radiographically with Mucinous Cysts of the Pancreas. J Gastrointest Surg 2017; 21:1599-1605. [PMID: 28516310 PMCID: PMC5693653 DOI: 10.1007/s11605-016-3338-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 11/23/2016] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the outcome of patients presumed to have mucinous cysts of the pancreas who were initially selected for radiographic surveillance. METHODS Patients with a pancreatic cyst and a measured cyst fluid carcinoembryonic antigen (CEA) ≥192 ng/mL were included. Patients were stratified by those who underwent initial resection and those who were recommended for radiographic surveillance. The natural history of these two groups was examined. RESULTS From 1999 to 2014, 227 patients were identified who had a cyst fluid CEA ≥192 ng/mL (median 961, range 192-300,000 ng/mL). Immediate resection was performed on 63 patients (28%). Initial radiographic surveillance was recommended for 164 patients; 87% did not have main pancreatic duct dilation, and 87% met consensus criteria for radiographic surveillance. After a median follow-up of 56 months, 48 of the 164 patients (29%) had undergone resection. Ultimately, there were three cases (2%) of high-grade dysplasia and two cases of invasive carcinoma (1%) within these 164 patients selected for observation. Three of the five cases of either high-grade dysplasia or invasive carcinoma were among the 22 patients followed outside of consensus guidelines. CONCLUSIONS Appropriately selected patients with mucinous pancreatic cysts can be safely followed with serial surveillance with a low risk of malignant progression.
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Affiliation(s)
- Linda M Pak
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-896, New York, NY, 10065, USA
| | - Michael I D'Angelica
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-896, New York, NY, 10065, USA
| | - Ronald P DeMatteo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-896, New York, NY, 10065, USA
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-896, New York, NY, 10065, USA
| | - Vinod P Balachandran
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-896, New York, NY, 10065, USA
| | - William R Jarnagin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-896, New York, NY, 10065, USA
| | - Peter J Allen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave, C-896, New York, NY, 10065, USA.
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Mukewar S, de Pretis N, Aryal-Khanal A, Ahmed N, Sah R, Enders F, Larson JJ, Levy MJ, Takahashi N, Topazian M, Pearson R, Vege SS, Chari ST. Fukuoka criteria accurately predict risk for adverse outcomes during follow-up of pancreatic cysts presumed to be intraductal papillary mucinous neoplasms. Gut 2017; 66:1811-1817. [PMID: 27390303 PMCID: PMC7597030 DOI: 10.1136/gutjnl-2016-311615] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Fukuoka consensus guidelines classify pancreatic cystic lesions (PCLs) presumed to be intraductal papillary mucinous neoplasms (IPMNs) into Fukuoka positive (FP) (subgroups of high-risk (HR) and worrisome features (WFs)) and Fukuoka negative (FN) (non-HR feature/WF cysts). We retrospectively estimated 5-year risk of pancreatic cancer (PC) in FN, WF and HR cysts of patients with PCL-IPMN. DESIGN From Mayo Clinic databases, we randomly selected 2000 patients reported to have a PCL; we excluded inflammatory or suspected non-IPMN cysts and those without imaging follow-up. We re-reviewed cross-sectional imaging and abstracted clinical and follow-up data on PCL-IPMNs. The study contained 802 patients with FN cysts and 358 with FP cysts. RESULTS Patients with PCL-IPMN had median (IQR) follow-up of 4.2 (1.8-7.1) years. Among FN cysts, 5-year PC risk was low (2-3%) regardless of cyst size (p=0.67). After excluding events in the first 6 months, 5-year PC risk remained low (0-2%) regardless of cyst size (p=0.61). Among FP cysts, HR cysts (n=66) had greater 5-year PC risk than WF cysts (n=292) (49.7% vs 4.1%; p<0.001). In HR cysts, 3-year PC risk was greatest for obstructive jaundice versus enhancing solid component or main pancreatic duct >10 mm (79.8% vs 37.3% vs 39.4%, respectively; p=0.01). CONCLUSIONS Fukuoka guidelines accurately stratify PCL-IPMNs for PC risk, with FN cysts having lowest and HR cysts having greatest risk. After 6-month follow-up, WF and FN cysts had a low 5-year PC risk. Surveillance strategies should be tailored appropriately.
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Affiliation(s)
- Saurabh Mukewar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicolo de Pretis
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Anupama Aryal-Khanal
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nazir Ahmed
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Raghuwansh Sah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Felicity Enders
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph J Larson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Naoki Takahashi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Randall Pearson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santhi S Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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9
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Crippa S, Bassi C, Salvia R, Malleo G, Marchegiani G, Rebours V, Levy P, Partelli S, Suleiman SL, Banks PA, Ahmed N, Chari ST, Fernández-Del Castillo C, Falconi M. Low progression of intraductal papillary mucinous neoplasms with worrisome features and high-risk stigmata undergoing non-operative management: a mid-term follow-up analysis. Gut 2017; 66:495-506. [PMID: 26743012 DOI: 10.1136/gutjnl-2015-310162] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 11/15/2015] [Accepted: 11/16/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate mid-term outcomes and predictors of survival in non-operated patients with pancreatic intraductal papillary mucinous neoplasms (IPMNs) with worrisome features or high-risk stigmata as defined by International Consensus Guidelines for IPMN. Reasons for non-surgical options were physicians' recommendation, patient personal choice or comorbidities precluding surgery. METHODS In this retrospective, multicentre analysis, IPMNs were classified as branch duct (BD) and main duct (MD), the latter including mixed IPMNs. Univariate and multivariate analysis for overall survival (OS) and disease-specific survival (DSS) were obtained. RESULTS Of 281 patients identified, 159 (57%) had BD-IPMNs and 122 (43%) had MD-IPMNs; 50 (18%) had high-risk stigmata and 231 (82%) had worrisome features. Median follow-up was 51 months. The 5-year OS and DSS for the entire cohort were 81% and 89.9%. An invasive pancreatic malignancy developed in 34 patients (12%); 31 had invasive IPMNs (11%) and 3 had IPMN-distinct pancreatic ductal adenocarcinoma (1%). Independent predictors of poor DSS in the entire cohort were age >70 years, atypical/malignant cyst fluid cytology, jaundice and MD >15 mm. Compared with MD-IPMNs, BD-IPMNs had significantly better 5-year OS (86% vs 74.1%, p=0.002) and DSS (97% vs 81.2%, p<0.0001). Patients with worrisome features had better 5-year DSS compared with those with high-risk stigmata (96.2% vs 60.2%, p<0.0001). CONCLUSIONS In elderly patients with IPMNs that have worrisome features, the 5-year DSS is 96%, suggesting that conservative management is appropriate. By contrast, presence of high-risk stigmata is associated with a 40% risk of IPMN-related death, reinforcing that surgical resection should be offered to fit patients.
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Affiliation(s)
- Stefano Crippa
- Division of Pancreatic Surgery, Università Politecnica delle Marche, Ancona, Italy.,Division of Pancreatic Surgery, Università Vita-Salute, San Raffaele Scientific Institute, Milan, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.,Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vinciane Rebours
- Service de Gastroenterologie-Pancreatologie, Hopital Beaujon, APHP, Université Paris Diderot, DHU UNITY, Clichy, France
| | - Philippe Levy
- Service de Gastroenterologie-Pancreatologie, Hopital Beaujon, APHP, Université Paris Diderot, DHU UNITY, Clichy, France
| | - Stefano Partelli
- Division of Pancreatic Surgery, Università Politecnica delle Marche, Ancona, Italy.,Division of Pancreatic Surgery, Università Vita-Salute, San Raffaele Scientific Institute, Milan, Italy
| | - Shadeah L Suleiman
- Center for Pancreatic Disease, Brigham and Woman's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter A Banks
- Center for Pancreatic Disease, Brigham and Woman's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nazir Ahmed
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Massimo Falconi
- Division of Pancreatic Surgery, Università Politecnica delle Marche, Ancona, Italy.,Division of Pancreatic Surgery, Università Vita-Salute, San Raffaele Scientific Institute, Milan, Italy
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10
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Del Chiaro M, Ateeb Z, Hansson MR, Rangelova E, Segersvärd R, Kartalis N, Ansorge C, Löhr MJ, Arnelo U, Verbeke C. Survival Analysis and Risk for Progression of Intraductal Papillary Mucinous Neoplasia of the Pancreas (IPMN) Under Surveillance: A Single-Institution Experience. Ann Surg Oncol 2016; 24:1120-1126. [PMID: 27822633 PMCID: PMC5339331 DOI: 10.1245/s10434-016-5661-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Indexed: 12/15/2022]
Abstract
Purpose While surveillance of the majority of patients with IPMN is considered best practice, consensus regarding the duration of follow-up is lacking. This study assessed the survival rate and risk for progression of IPMN under surveillance. Methods All patients diagnosed with and surveyed for IPMN between January 2008 and December 2013 were identified and assigned to two groups: patients without indication for surgery (Group 1), and patients whose IPMN required surgery but were inoperable for general reasons (Group 2). Disease progression and survival data were compared between both groups. Results In total 503 patients were identified, of whom 444 (88.3%) were followed up. Group 1 included 395 patients, and Group 2 had 49. In Group 1, IPMN-specific 1-, 5-, and 10-year survival rates were 100, 100, and 94.2%, respectively. Four patients died of associated or concomitant pancreatic cancer, and 230 patients (58.2%) experienced disease progression. The 1-, 4-, 10-year cumulative risk for progression and for surgery was 11.2, 70.6, 97.5, and 2.9, 26.2, 72.1%, respectively. In Group 2, the 1-, 5-, 10-year IPMN-specific survival rate was 90.7, 74.8, and 74.8%, respectively. Conclusions This study confirmed the safety of surveillance for patients with IPMN who do not require surgery. However, the risk for disease progression and for surgery increases significantly over time. The study results support International and European guidelines not to discontinue IPMN surveillance and validate the European recommendation to intensify follow-up after 5 years. The fairly good prognosis of patients whose IPMN requires surgery but cannot undergo resection suggests a relatively indolent disease biology.
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Affiliation(s)
- Marco Del Chiaro
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases Karolinska University Hospital, Stockholm, Sweden.
| | - Zeeshan Ateeb
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Reuterwall Hansson
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases Karolinska University Hospital, Stockholm, Sweden
| | - Elena Rangelova
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases Karolinska University Hospital, Stockholm, Sweden
| | - Ralf Segersvärd
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases Karolinska University Hospital, Stockholm, Sweden
| | - Nikolaos Kartalis
- Division of Radiology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Christoph Ansorge
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases Karolinska University Hospital, Stockholm, Sweden
| | - Matthias J Löhr
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases Karolinska University Hospital, Stockholm, Sweden
| | - Urban Arnelo
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet at Center for Digestive Diseases Karolinska University Hospital, Stockholm, Sweden
| | - Caroline Verbeke
- Department of Pathology, Karolinska University Hospital, Stockholm, Sweden
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11
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Effects of Comorbidities on Outcomes of Patients With Intraductal Papillary Mucinous Neoplasms. Clin Gastroenterol Hepatol 2015; 13:1816-23. [PMID: 25956837 DOI: 10.1016/j.cgh.2015.04.177] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 04/20/2015] [Accepted: 04/22/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas occur mostly in older individuals. Individual life expectancy and risk of death from other factors must be carefully considered in analyzing the risks that IPMNs pose. We investigated whether there is a subset of patients with IPMNs and a high risk of dying from other causes who would not benefit from pancreatic surgery. METHODS We collected data from 725 patients at Massachusetts General Hospital who underwent resection or have been under observation for IPMNs from 1992 through 2012. Comorbidities were classified according to the age-adjusted Charlson comorbidity index (CACI). Causes of death were recorded, and survival data were analyzed by the Kaplan-Meier method. RESULTS The patients' median CACI score was 3; 10% of patients had CACI of 7 or more. Of the entire cohort, 55% underwent resection, and the remaining 45% have been under observation. After a median follow-up period of 5 years, 177 patients died (24%, 55% of deaths within 5 years of diagnosis); 78% of deaths were not related to IPMNs. The median survival time for all patients with CACI score of 7 or more was 43 months. Multivariate regression analysis revealed that the chance of non-IPMN-related death within 3 years of diagnosis is 11-fold higher for patients with CACI score of 7 or more than for patients with lower scores. CONCLUSIONS The CACI can be used to identify patients with a high risk of death from factors other than IPMNs within a few years after diagnosis. These patients are therefore not likely to benefit from further IPMN observation or pancreatic resection.
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12
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Machado NO, Al Qadhi H, Al Wahibi K. Intraductal Papillary Mucinous Neoplasm of Pancreas. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2015; 7:160-75. [PMID: 26110127 PMCID: PMC4462811 DOI: 10.4103/1947-2714.157477] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are neoplasms that are characterized by ductal dilation, intraductal papillary growth, and thick mucus secretion. This relatively recently defined pathology is evolving in terms of its etiopathogenesis, clinical features, diagnosis, management, and treatment guidelines. A PubMed database search was performed. All the relevant abstracts in English language were reviewed and the articles in which cases of IPMN could be identified were further scrutinized. Information of IPMN was derived, and duplication of information in several articles and those with areas of persisting uncertainties were excluded. The recent consensus guidelines were examined. The reported incidence of malignancy varies from 57% to 92% in the main duct-IPMN (MD-IPMN) and from 6% to 46% in the branch duct-IPMN (BD-IPMN). The features of high-risk malignant lesions that raise concern include obstructive jaundice in a patient with a cystic lesion in the pancreatic head, the findings on radiological imaging of a mass lesion of >30 mm, enhanced solid component, and the main pancreatic duct (MPD) of size ≥10 mm; while duct size 5-9 mm and cyst size <3 mm are considered as “worrisome features.” Magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS) are primary investigations in diagnosing and following up on these patients. The role of pancreatoscopy and the analysis of aspirated cystic fluid for cytology and DNA analysis is still to be established. In general, resection is recommended for most MD-IPMN, mixed variant, and symptomatic BD-IPMN. The 5-year survival of patients after surgical resection for noninvasive IPMN is reported to be at 77-100%, while for those with invasive carcinoma, it is significantly lower at 27-60%. The follow-up of these patients could vary from 6 months to 1 year and would depend on the risk stratification for invasive malignancy and the pathology of the resected specimen. The understanding of IPMN has evolved over the years. The recent guidelines have played a role in this regard.
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Affiliation(s)
| | - Hani Al Qadhi
- Department of Surgery, Sultan Qaboos University Hospital, Muscat, Oman
| | - Khalifa Al Wahibi
- Department of Surgery, Sultan Qaboos University Hospital, Muscat, Oman
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13
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Scheiman JM, Hwang JH, Moayyedi P. American gastroenterological association technical review on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015; 148:824-48.e22. [PMID: 25805376 DOI: 10.1053/j.gastro.2015.01.014] [Citation(s) in RCA: 263] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- James M Scheiman
- Department of Internal Medicine and Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Joo Ha Hwang
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington
| | - Paul Moayyedi
- Division of Gastroenterology, Hamilton Health Sciences, Farncombe Family Digestive Health Research Institute, McMaster University Hamilton, Ontario, Canada
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14
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Jana T, Shroff J, Bhutani MS. Pancreatic cystic neoplasms: Review of current knowledge, diagnostic challenges, and management options. J Carcinog 2015; 14:3. [PMID: 25821410 PMCID: PMC4374202 DOI: 10.4103/1477-3163.153285] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 02/01/2015] [Indexed: 12/12/2022] Open
Abstract
Pancreatic cystic lesions are being detected with increasing frequency, largely due to advances in cross-sectional imaging. The most common neoplasms include serous cystadenomas, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, solid pseudopapillary neoplasms, and cystic pancreatic endocrine neoplasms. Computed tomography (CT), magnetic resonance imaging (MRI), and endoscopic ultrasound (EUS) are currently used as imaging modalities. EUS-guided fine needle aspiration has proved to be a useful diagnostic tool, and enables an assessment of tumor markers, cytology, chemistries, and DNA analysis. Here, we review the current literature on pancreatic cystic neoplasms, including classification, diagnosis, treatment, and recommendations for surveillance. Data for this manuscript was acquired via searching the literature from inception to December 2014 on PubMed and Ovid MEDLINE.
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Affiliation(s)
- Tanima Jana
- Department of Internal Medicine, University of Texas Medical School at Houston, Houston, TX, USA
| | - Jennifer Shroff
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Texas Medical School at Houston, Houston, TX, USA
| | - Manoop S Bhutani
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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15
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Abstract
OBJECTIVES The majority of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are branch duct (BD) IPMNs, and these neoplasms are being diagnosed with increasing frequency; no data are also available on the well-being (quality of life [QoL]) of these patients. We aimed to evaluate the 2-year follow-up results in consecutive patients with BD-IPMNs to assess symptoms at presentation and their morphological progression; the physical and psychological statuses of these patients were also evaluated. METHODS One hundred one patients with BD-IPMN of the pancreas were enrolled in the study (37.6% men and 62.4% women; mean [SD] age, 66.3 [10.4] years). Magnetic resonance imaging was used to evaluate the modification of the cystic lesions at baseline as well as in the follow-up. The SF-12 Health Survey, the State-Trait Anxiety Inventory Y-1 and Y-2, the 12-Item General Health Questionnaire, as well as the Beck Depression Inventory-II were used to evaluate the QoL once a year. RESULTS The mean (SD) basal size of the major lesion was 15.5 (8.9) mm, and in the follow-up period, the size remained stable. The QoL did not change during the follow-up period. CONCLUSIONS Branch duct IPMNs are very slow-growing neoplasms, and they do not affect the QoL of affected patients.
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16
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Klöppel G, Basturk O, Schlitter AM, Konukiewitz B, Esposito I. Intraductal neoplasms of the pancreas. Semin Diagn Pathol 2014; 31:452-466. [DOI: 10.1053/j.semdp.2014.08.005] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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17
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Liu Q, Jiang JX. Endoscopic techniques for diagnosis and therapy of pancreatic intraductal papillary mucinous neoplasm. Shijie Huaren Xiaohua Zazhi 2014; 22:3416-3423. [DOI: 10.11569/wcjd.v22.i23.3416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a cystic neoplasm with potential malignancy. In the past, screening of IPMN depended on traditional imaging examinations, such as transabdominal ultrasonography and computed tomography (CT). With the development of endoscopic techniques, endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography (ERCP) and other endoscopic techniques are becoming significant diagnostic methods for IPMN. Meanwhile, endoscopic interventional therapy with the advantage of minimal invasiveness has been used to treat some patients who cannot tolerate or refuse surgery. This paper elucidates the advances in diagnosis and therapy of pancreatic IPMNs using endoscopic techniques.
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18
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Roch AM, DeWitt JM, Al-Haddad MA, Schmidt CM, Ceppa EP, House MG, Zyromski NJ, Nakeeb A, Schmidt CM. Nonoperative management of main pancreatic duct-involved intraductal papillary mucinous neoplasm might be indicated in select patients. J Am Coll Surg 2014; 219:122-9. [PMID: 24862887 DOI: 10.1016/j.jamcollsurg.2014.03.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 03/05/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND Although the natural history of intraductal papillary mucinous neoplasm (IPMN) remains unclear, large surgical series have reported malignancy in 40% to 90% of main pancreatic duct (MPD)-involved IPMN. Accordingly, the 2012 International Consensus Guidelines recommend surgical resection in patients with suspected MPD involvement. We hypothesized that nonoperative management of select patients with suspected MPD-involved IPMN might be indicated. STUDY DESIGN From 1992 to 2012, 362 patients underwent surgical resection for pathologically confirmed IPMN at a single academic center. A retrospective review of prospectively collected data was performed. Main pancreatic duct involvement was suspected with an MPD diameter ≥5 mm on preoperative imaging. A multivariate analysis was conducted to assess predictors of malignancy. RESULTS Of 362 patients, 334 had complete data for analysis. Main pancreatic duct involvement was suspected preoperatively in 171 patients. Final pathology revealed 20% high-grade dysplastic and 27% invasive IPMN (47% malignant). Preoperative cytopathology and serum carbohydrate antigen 19-9 independently predicted malignancy (p = 0.003 and p = 0.002, respectively) and invasiveness (p < 0.0001 and p = 0.001, respectively). Patients with both negative preoperative cytopathology and normal serum carbohydrate antigen 19-9 (ie, double negatives) had a lower rate of malignancy and invasiveness (28% and 8% vs 58% and 38%; p < 0.0001). The MPD diameter did not predict malignancy or invasiveness (p = 0.36 and p = 0.46, respectively). CONCLUSIONS Patients with suspected MPD-involved IPMN have a highly variable rate of malignancy. Despite recent International Consensus Guidelines recommendations, these data suggest that MPD diameter is not an optimal gauge of malignant risk. Nonoperative management of suspected MPD-involved IPMN in select patients, particularly double negatives, might be indicated. Depending on age and comorbidity, operative risk might outweigh the risk of malignant progression in these patients.
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Affiliation(s)
- Alexandra M Roch
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - John M DeWitt
- Department of Medicine, Division of Gastroenterology, Indiana University Hospital, Indianapolis, IN
| | - Mohammad A Al-Haddad
- Department of Medicine, Division of Gastroenterology, Indiana University Hospital, Indianapolis, IN
| | - Christian M Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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