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Vujasinovic M, Elbe P, Ekheden I, Wang QL, Thuresson M, Roelstraete B, Ghazi S, Löhr JM, Ludvigsson JF. Gastrointestinal cancer precursor risk and mortality in pancreatic intraductal papillary mucinous neoplasms: a nationwide cohort study. Scand J Gastroenterol 2024; 59:600-607. [PMID: 38351653 DOI: 10.1080/00365521.2024.2310162] [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: 09/27/2023] [Accepted: 01/21/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND AND AIMS Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a precursor of pancreatic cancer. While earlier research has shown a high prevalence of synchronous/metachronous extrapancreatic tumors in IPMN patients, these studies have often been small with retrospective data collection. The aim of the study was to examine absolute and relative risks of non-pancreatic gastrointestinal (GI) cancer precursors and mortality in histologically confirmed IPMN. METHODS Through the nationwide ESPRESSO histopathology cohort, we retrieved data on IPMN between 1965 and 2016. Each index case was matched to ≤5 general population controls. Through Cox regression, we estimated hazard ratios (HRs) for future GI cancer precursors and death. RESULTS A total of 117 patients with IPMN and 539 age- and sex-matched controls were included. Over a median of 2.1 years of follow up, we confirmed two (1.7%) incident GI cancer precursors in IPMN vs. four (0.7%) in controls, corresponding to an HR of 1.89 (95%CI = 0.34-10.55). By contrast, IPMN patients were at increased risk of death (HR 3.61 (95%CI = 1.79-7.27)). The most common cause of death in IPMN was pancreatic cancer (n = 14; 45.2% of all deaths). CONCLUSIONS We found no association between IPMN and other GI cancer precursors. This argues against comprehensive routine surveillance for other GI cancer precursors in IPMN patients. Mortality was increased in IPMN with pancreatic cancer being the most common cause of death, indicating the need for lifelong follow up in all resected and non-resected patients with IPMN. However, results should be confirmed in larger cohorts.
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Affiliation(s)
- Miroslav Vujasinovic
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Peter Elbe
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Isabella Ekheden
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Qiao-Li Wang
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | | | - Bjorn Roelstraete
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Sam Ghazi
- Department of Pathology, Karolinska University Hospital, Stockholm, Sweden
| | - J-Matthias Löhr
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Jonas F Ludvigsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Celiac Disease Center, Department of Medicine, Columbia University Medical Center, NY, NY, USA
- Department of Pediatrics, Örebro University Hospital, Örebro University, Örebro, Sweden
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2
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Kaneko J, Yamada T, Sasada Y, Watahiki M, Kosugi T, Kusama D, Tamakoshi H, Niwa T, Takinami M, Tsuji A, Nishino M, Takahashi Y, Kawata K, Sugimoto K. Incidental detection of upper gastrointestinal epithelial neoplasia by screening endoscopy prior to endoscopic ultrasonography in patients with pancreaticobiliary disease. BMC Gastroenterol 2024; 24:13. [PMID: 38166726 PMCID: PMC10763099 DOI: 10.1186/s12876-023-03107-5] [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: 09/05/2023] [Accepted: 12/26/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Screening esophagogastroduodenoscopy plays an important role in the early detection of upper gastrointestinal cancer. To provide more opportunities for patients with pancreaticobiliary disease to undergo this screening, we have performed esophagogastroduodenoscopy prior to endoscopic ultrasonography. However, the usefulness of this protocol is not elucidated. This study aimed to investigate the utility of screening esophagogastroduodenoscopy in this protocol in the detection of upper gastrointestinal epithelial neoplasms. METHODS The outcomes of screening esophagogastroduodenoscopy performed prior to endoscopic ultrasonography in patients with pancreaticobiliary disease at our hospital between April 2020 and September 2022 were investigated. A logistic regression model was used to identify factors affecting the detection of epithelial neoplasms. Additionally, we compared the detection rate of gastric epithelial neoplasms between screening esophagogastroduodenoscopy performed prior to endoscopic ultrasonography and that performed at our medical checkup center. RESULTS A total of 615 screening esophagogastroduodenoscopies prior to endoscopic ultrasonography were performed, and 12 (2.0%) epithelial neoplasms were detected, including esophageal lesions (n = 2) and gastric lesions (n = 10). Of these lesions, 75% (9/12) underwent curative endoscopic resection. A multivariate analysis showed that open-type gastric mucosal atrophy (odds ratio, 7.7; 95% confidence interval, 1.5-38.4; p = 0.01) and the use of magnification endoscopy (odds ratio, 7.3; 95% confidence interval, 1.9-27.9; p < 0.01) independently affected the detection of epithelial neoplasms. The detection rate of gastric epithelial neoplasms was significantly higher using this protocol than that in our medical checkup center (1.6% versus 0.2%, p < 0.01). CONCLUSIONS A protocol of screening esophagogastroduodenoscopy prior to endoscopic ultrasonography may be recommended because epithelial neoplasms could be detected at a non-negligible rate.
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Affiliation(s)
- Junichi Kaneko
- Department of Gastroenterology, Iwata City Hospital, 512-3 Ookubo, Shizuoka, Shizuoka, 438-8550, Japan
| | - Takanori Yamada
- Department of Gastroenterology, Iwata City Hospital, 512-3 Ookubo, Shizuoka, Shizuoka, 438-8550, Japan.
| | - Yuzo Sasada
- Medical Checkup Center, Iwata City Hospital, Shizuoka, Japan
- Department of Hepatology, Iwata City Hospital, Shizuoka, Japan
| | - Moeka Watahiki
- Department of Gastroenterology, Iwata City Hospital, 512-3 Ookubo, Shizuoka, Shizuoka, 438-8550, Japan
| | - Toshikatsu Kosugi
- Department of Gastroenterology, Iwata City Hospital, 512-3 Ookubo, Shizuoka, Shizuoka, 438-8550, Japan
| | - Daisuke Kusama
- Department of Gastroenterology, Iwata City Hospital, 512-3 Ookubo, Shizuoka, Shizuoka, 438-8550, Japan
| | - Hiroki Tamakoshi
- Department of Gastroenterology, Iwata City Hospital, 512-3 Ookubo, Shizuoka, Shizuoka, 438-8550, Japan
| | - Tomoyuki Niwa
- Department of Gastroenterology, Iwata City Hospital, 512-3 Ookubo, Shizuoka, Shizuoka, 438-8550, Japan
| | - Masaki Takinami
- Department of Gastroenterology, Iwata City Hospital, 512-3 Ookubo, Shizuoka, Shizuoka, 438-8550, Japan
| | - Atsushi Tsuji
- Department of Gastroenterology, Iwata City Hospital, 512-3 Ookubo, Shizuoka, Shizuoka, 438-8550, Japan
| | - Masafumi Nishino
- Department of Gastroenterology, Iwata City Hospital, 512-3 Ookubo, Shizuoka, Shizuoka, 438-8550, Japan
| | | | - Kazuhito Kawata
- Department of Internal Medicine II, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Ken Sugimoto
- First Department of Medicine, Hamamatsu University School of Medicine, Shizuoka, Japan
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Zelnik Yovel D, Santo E, Khader M, Tzadok R, Bar N, Aizic A, Shibolet O, Ben-Ami Shor D. Esophagogastroduodenal Findings in Patients with Intraductal Papillary Mucinous Neoplasms. Diagnostics (Basel) 2023; 13:2127. [PMID: 37371022 DOI: 10.3390/diagnostics13122127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023] Open
Abstract
The association between intraductal papillary mucinous neoplasms (IPMNs) and extra-pancreatic malignancies is controversial. This cross-sectional study compared esophagogastroduodenal findings in 340 IPMN patients to those of age- and gender-matched controls without known IPMNs who underwent esophagogastroduodenoscopies (EGDs) for similar clinical reasons. The presence of gastric and esophageal cancer, Barrett's esophagus, neuroendocrine tumors (NETs), gastrointestinal stromal tumors (GISTs), gastric adenomas, and ampullary tumors was assessed. The results showed that 4/340 (1.2%) of the IPMN patients had gastric cancer and 1/340 (0.3%) had esophageal cancer. The matched control group had a similar incidence of gastric cancer (5/340) (1.5%), with no esophageal cancer cases (p > 0.999). The overall incidence of other esophagogastroduodenal conditions did not significantly differ between the IPMN patients and the controls. However, the incidence of gastric cancer in the IPMN patients was higher than expected based on national cancer registry data (standardized incidence ratio of 31.39; p < 0.001; CI 8.38-78.76). In conclusion, IPMN patients have a significantly higher incidence of gastric cancer compared to the general population. However, the incidence of esophagogastroduodenal findings, including gastric and esophageal cancer, is similar between IPMN patients and those who undergo an EGD for similar clinical indications. Further research is needed to determine optimal surveillance strategies for IPMN patients regarding their risk of developing gastric cancer.
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Affiliation(s)
- Dana Zelnik Yovel
- The Kamila Gonczarowski Institute of Gastroenterology and Liver Diseases, Shamir (Assaf Harofeh) Medical Center, Zerifin 703000, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Erwin Santo
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Majd Khader
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
| | - Roie Tzadok
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Nir Bar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Asaf Aizic
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
- Department of Pathology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Oren Shibolet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Dana Ben-Ami Shor
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel
- Department of Gastroenterology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
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Mirchev MB, Boeva I, Peshevska-Sekulovska M, Stoitsov V, Peruhova M. Synchronous manifestation of colorectal cancer and intraductal papillary mucinous neoplasms. World J Clin Cases 2023; 11:3408-3417. [PMID: 37383909 PMCID: PMC10294181 DOI: 10.12998/wjcc.v11.i15.3408] [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] [Received: 01/10/2023] [Revised: 02/26/2023] [Accepted: 04/17/2023] [Indexed: 05/25/2023] Open
Abstract
High rates of extrapancreatic malignancies, in particular colorectal cancer (CRC), have been detected in patients with intraductal papillary mucinous neoplasm (IPMN). So far, there is no distinct explanation in the literature for the development of secondary or synchronous malignancies in patients with IPMN. In the past few years, some data related to common genetic alterations in IPMN and other affiliated cancers have been published. This review elucidated the association between IPMN and CRC, shedding light on the most relevant genetic alterations that may explain the possible relationship between these entities. In keeping with our findings, we suggested that once the diagnosis of IPMN is made, special consideration of CRC should be undertaken. Presently, there are no specific guidelines regarding colorectal screening programs for patients with IPMN. We recommend that patients with IPMNs are at high-risk for CRC, and a more rigorous colorectal surveillance program should be implemented.
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Affiliation(s)
| | - Irina Boeva
- Department of Gastroenterology, Heart and Brain Hospital, Burgas 8000, Bulgaria
| | | | - Veselin Stoitsov
- Department of Gastroenterology, Heart and Brain Hospital, Burgas 8000, Bulgaria
| | - Milena Peruhova
- Department of Gastroenterology, Heart and Brain Hospital, Burgas 8000, Bulgaria
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Kiritani S, Iwano T, Yoshimura K, Saito R, Nakayama T, Yamamoto D, Hakoda H, Watanabe G, Akamatsu N, Arita J, Kaneko J, Takeda S, Ichikawa D, Hasegawa K. New Diagnostic Modality Combining Mass Spectrometry and Machine Learning for the Discrimination of Malignant Intraductal Papillary Mucinous Neoplasms. Ann Surg Oncol 2023; 30:3150-3157. [PMID: 36611070 PMCID: PMC10085898 DOI: 10.1245/s10434-022-13012-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/09/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND An intraductal papillary mucinous neoplasm (IPMN) is a pancreatic tumor with malignant potential. Although we anticipate a sensitive method to diagnose the malignant conversion of IPMN, an effective strategy has not yet been established. The combination of probe electrospray ionization-mass spectrometry (PESI-MS) and machine learning provides a promising solution for this purpose. METHODS We prospectively analyzed 42 serum samples obtained from IPMN patients who underwent pancreatic resection between 2020 and 2021. Based on the postoperative pathological diagnosis, patients were classified into two groups: IPMN-low grade dysplasia (n = 17) and advanced-IPMN (n = 25). Serum samples were analyzed by PESI-MS, and the obtained mass spectral data were converted into continuous variables. These variables were used to discriminate advanced-IPMN from IPMN-low grade dysplasia by partial least square regression or support vector machine analysis. The areas under receiver operating characteristics curves were obtained to visualize the difference between the two groups. RESULTS Partial least square regression successfully discriminated the two disease classes. From another standpoint, we selected 130 parameters from the entire dataset by PESI-MS, which were fed into the support vector machine. The diagnostic accuracy was 88.1%, and the area under the receiver operating characteristics curve was 0.924 by this method. Approximately 10 min were required to perform each method. CONCLUSION PESI-MS combined with machine learning is an easy-to-use tool with the advantage of rapid on-site analysis. Here, we show the great potential of our system to diagnose the malignant conversion of IPMN, which would be a promising diagnostic tool in clinical settings.
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Affiliation(s)
- Sho Kiritani
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomohiko Iwano
- Department of Anatomy and Cell Biology, Faculty of Medicine, The University of Yamanashi, Yamanashi, Japan
| | - Kentaro Yoshimura
- Division of Molecular Biology, Center for Medical Education and Sciences, Interdisciplinary Graduate School of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Ryo Saito
- Department of Digestive Surgery and Breast and Endocrine Surgery, The University of Yamanashi, Yamanashi, Japan
| | - Takashi Nakayama
- Department of Digestive Surgery and Breast and Endocrine Surgery, The University of Yamanashi, Yamanashi, Japan
| | - Daisuke Yamamoto
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Hakoda
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Genki Watanabe
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Arita
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Kaneko
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sén Takeda
- Department of Anatomy and Cell Biology, Faculty of Medicine, The University of Yamanashi, Yamanashi, Japan.,Department of Anatomy, Teikyo University School of Medicine, Tokyo, Japan
| | - Daisuke Ichikawa
- Department of Digestive Surgery and Breast and Endocrine Surgery, The University of Yamanashi, Yamanashi, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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A meta-analysis: incidental intraductal papillary mucinous neoplasm and extra-pancreatic malignancy. Langenbecks Arch Surg 2021; 407:451-458. [PMID: 34664122 DOI: 10.1007/s00423-021-02355-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 10/06/2021] [Indexed: 12/09/2022]
Abstract
INTRODUCTION Meta-analysis aimed to quantify the relationship between intraductal papillary mucinous neoplasm (IPMN) and increased incidence of extra-pancreatic malignancy (EPM) previously reported in qualitative observational cohort studies. METHODS Study protocol was registered with PROSPERO (CRD42020169614) and conducted to the Meta-analysis Of Observational Studies in Epidemiology and systematic review reported with Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Assessing the Methodological Quality of Systematic Reviews guidelines. RESULTS Sixteen studies (total of 8240 patients) were included in the pooled, and 7399 patients in the subgroup meta-analyses. The odds ratio (OR) for any EPM in the presence of IPMN was 57.9 (95% confidence interval 40.5-82.7), fixed effects, I2 = 59% (p < 0.0014). Subgroup analysis for any gastrointestinal EPM (i.e. oesophagus, stomach, colon and rectum) in the presence of an IPMN estimated an overall OR of 12.9 (95% confidence interval 8.8-19.0), fixed effects, I2 = 64% (p < 0.0004). CONCLUSION Patients with an IPMN are categorically at increased risk for a higher incidence of EPM and particularly the odds of a gastrointestinal malignancy are also increased in comparison with the general population. We advocate that patients presenting with an IPMN should be considered for gastrointestinal screening including colonoscopy, upper gastrointestinal endoscopy or computed tomography.
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Association between pancreatic intraductal papillary mucinous neoplasms and extrapancreatic malignancies: A systematic review with meta-analysis. Eur J Surg Oncol 2021; 48:632-639. [PMID: 34620511 DOI: 10.1016/j.ejso.2021.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/05/2021] [Accepted: 09/23/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND It is unclear whether patients with intraductal papillary mucinous neoplasia harbor a higher risk of developing extrapancreatic malignancies. AIMS We performed a pooled estimate of the incidence of extrapancreatic malignancies in patients with intraductal papillary mucinous neoplasia, with a particular focus on the comparison to the general population. METHODS Computerized bibliographic search of main databases was performed through February 2021. The primary endpoint was the pooled incidence of extrapancreatic malignancies in patients with intraductal papillary mucinous neoplasms. Additional outcome was the comparison between intraductal papillary mucinous neoplasia patients and the general population, expressed in terms of standardized incidence ratio along with 95% confidence intervals. RESULTS Eighteen studies with 8709 patients were included. The pooled rate of metachronous extrapancreatic malignancies was 10 (6-13)/1000 persons-year. No difference was observed according to intraductal papillary mucinous neoplasia histology and sex, whereas a significantly superior incidence of extrapancreatic malignancies was observed in patients with main-duct (36.7%, 25.4%-48%) as compared to branch-duct intraductal papillary mucinous neoplasia (26.2%, 17.6%-34.8%; p = 0.03). Pooled standardized incidence ratio comparing expected rates in the general population was 1.01 (0.79-1.29); no difference was observed concerning rates of metachronous gastric cancer (standardized incidence ratio 1.60, 0.72-3.54) and colorectal cancer (1.29, 0.92-1.18), whereas biliary cancer was observed more frequently in intraductal papillary mucinous neoplasia patients (2.29, 1.07-4.93). CONCLUSION Patients with intraductal papillary mucinous neoplasia harbor an overall rate of extrapancreatic malignancies as high as 27.3%. The rate of metachronous extrapancreatic malignancies is not superior to the general population.
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Tatarsky BA, Kazennova NV, Napalkov DA. The Risk of Myocardial Infarction in Patients with Atrial Fibrillation Taking a Direct Thrombin Inhibitor: Myths and Reality. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-04-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The purpose of this review is to analyze the results of randomized clinical trials, meta-analyses of cohort and observational studies in real clinical practice on the influence of dabigatran etexilate on the risk of myocardial infarction in patients with atrial fibrillation. A pivotal RE-LY study on dabigatran use in patients with atrial fibrillation did not show statistically significant differences in the frequency of myocardial infarction between any of the doses of dabigatran and warfarin, and the risk of coronary events did not depend on the presence of coronary heart disease or myocardial infarction in the patient's history. Subsequently, a number of meta-analyses have reported an increased risk of myocardial infarction when dabigatran was administered to patients with atrial fibrillation. In general, these studies were characterized by conflicting data, which did not allow to draw any definite conclusions regarding the use of dabigatran in relation to the risk of myocardial infarction. Two FDA cohort observational studies were published in 2014 and 2017, and the former was significantly criticized by experts, and the results of the second study did not provide a definitive answer to the question about the importance of the effect of dabigatran on the development of myocardial infarction in patients with atrial fibrillation. Even more "confusing" the problem arose after the publication of meta-analyses of randomized trials, which showed that the risk of myocardial infarction was increased in patients treated with direct oral anticoagulants compared to patients treated with warfarin. This review provides high quality evidence for the efficacy of dabigatran in preventing myocardial infarction and other vascular complications in patients with atrial fibrillation.
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Affiliation(s)
| | | | - D. A. Napalkov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
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9
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Mehta S, Tan GI, Nahm CB, Chua TC, Pearson A, Gill AJ, Samra JS, Mittal A. Pancreatic resection in patients with synchronous extra-pancreatic malignancy: outcomes and complications. ANZ J Surg 2020; 90:290-294. [PMID: 31943690 DOI: 10.1111/ans.15651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 12/05/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients may present with a resectable pancreatic tumour in the context of a concurrent primary extra-pancreatic malignancy. These patients pose a dilemma regarding their suitability for surgery. We evaluated our experience with such patients who underwent pancreatic resection with curative intent and detailed their outcomes and rationale for surgical decision-making. METHODS A retrospective review of patients with pancreatic concurrent extra-pancreatic primary malignancy who underwent pancreatic resection at our institution over a 12-year period (2005-2016) was performed. Clinical, histopathological and perioperative outcomes were reviewed. RESULTS Ten patients with a median age of 74 years (40-85 years) were identified. Secondary primary tumours included thyroid (n = 2), gastrointestinal (n = 4), small bowel neuroendocrine (n = 1), renal (n = 1) and haematological malignancies (n = 2). Pancreatic tumours included pancreatic ductal adenocarcinomas (n = 6), solid pseudopapillary neoplasms (n = 2) and ampullary carcinomas (n = 2). After a median follow up of 41.3 months (31.3-164 months), 8 of 10 patients were still alive. Two patients died due to metastatic disease from the secondary malignancy (small bowel neuroendocrine tumour and sigmoid colon adenocarcinoma). The post-operative complication rate was 30% with no perioperative 90-day mortality. CONCLUSION Selected patients with a pancreatic and concurrent primary extra-pancreatic malignancy may undergo curative pancreatic resection with favourable outcomes.
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Affiliation(s)
- Shreya Mehta
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Grace I Tan
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Christopher B Nahm
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Terence C Chua
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Department of Surgery, Logan Hospital, Metro South Health, Logan City, Queensland, Australia
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Andrew Pearson
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Anthony J Gill
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jaswinder S Samra
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Macquarie University Hospital, Macquarie University, Sydney, New South Wales, Australia
| | - Anubhav Mittal
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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10
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Overbeek KA, Alblas M, Gausman V, Kandel P, Schweber AB, Brooks C, Van Riet PA, Wallace MB, Gonda TA, Cahen DL, Bruno MJ. Development of a stratification tool to identify pancreatic intraductal papillary mucinous neoplasms at lowest risk of progression. Aliment Pharmacol Ther 2019; 50:789-799. [PMID: 31429105 PMCID: PMC6772152 DOI: 10.1111/apt.15440] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/11/2019] [Accepted: 07/06/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Because most pancreatic intraductal papillary mucinous neoplasms (IPMNs) will never become malignant, currently advocated long-term surveillance is low-yield for most individuals. AIM To develop a score chart identifying IPMNs at lowest risk of developing worrisome features or high-risk stigmata. METHODS We combined prospectively maintained pancreatic cyst surveillance databases of three academic institutions. Patients were included if they had a presumed side-branch IPMN, without worrisome features or high-risk stigmata at baseline (as defined by the 2012 international Fukuoka guidelines), and were followed ≥ 12 months. The endpoint was development of one or more worrisome features or high-risk stigmata during follow-up. We created a multivariable prediction model using Cox-proportional logistic regression analysis and performed an internal-external validation. RESULTS 875 patients were included. After a mean follow-up of 50 months (range 12-157), 116 (13%) patients developed worrisome features or high-risk stigmata. The final model included cyst size (HR 1.12, 95% CI 1.09-1.15), cyst multifocality (HR 1.49, 95% CI 1.01-2.18), ever having smoked (HR 1.40, 95% CI 0.95-2.04), history of acute pancreatitis (HR 2.07, 95% CI 1.21-3.55), and history of extrapancreatic malignancy (HR 1.34, 95% CI 0.91-1.97). After validation, the model had good discriminative ability (C-statistic 0.72 in the Mayo cohort, 0.71 in the Columbia cohort, 0.64 in the Erasmus cohort). CONCLUSION In presumed side branch IPMNs without worrisome features or high-risk stigmata at baseline, the Dutch-American Risk stratification Tool (DART-1) successfully identifies pancreatic lesions at low risk of developing worrisome features or high-risk stigmata.
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Affiliation(s)
- Kasper A. Overbeek
- Department of Gastroenterology & HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Maaike Alblas
- Department of Public HealthErasmus University Medical CenterRotterdamThe Netherlands
| | - Valerie Gausman
- Department of MedicineNYU – Langone Medical CenterNew YorkUSA
| | - Pujan Kandel
- Department of Gastroenterology and HepatologyMayo ClinicJacksonvilleUSA
| | - Adam B. Schweber
- Division of Digestive and Liver Diseases, Department of MedicineColumbia University Medical CenterNew YorkUSA
| | - Christian Brooks
- Division of Digestive and Liver Diseases, Department of MedicineColumbia University Medical CenterNew YorkUSA
| | - Priscilla A. Van Riet
- Department of Gastroenterology & HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | | | - Tamas A. Gonda
- Division of Digestive and Liver Diseases, Department of MedicineColumbia University Medical CenterNew YorkUSA
| | - Djuna L. Cahen
- Department of Gastroenterology & HepatologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Marco J. Bruno
- Department of Gastroenterology & HepatologyErasmus University Medical CenterRotterdamThe Netherlands
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11
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Abstract
Introduction: Both breast and pancreatic cancers have high mortality rates. Breast cancer is the second leading cause of cancer death in females, while pancreatic ductal adenocarcinoma (PDAC) is the fourth most common cause of cancer death. Almost 4-16 % of individuals with pancreatic cancer have a family history of the disease. Intra-ductal papillary mucinous neoplasms (IPMNs) are cystic lesions that received more attention lately due to their associations with PDAC and other solid organ tumors, such as breast cancer. Aim: The purpose of this article is to discuss the association of the familiar pancreatic cancer (FPC), sporadic pancreatic cancer, and IPMNs with the breast cancer. Results: Mutations in BRCA2, BRCA1, p16 and PALB2 play a major role in the genetic etiologies of familial pancreatic cancer. In familial and sporadic pancreatic cancers, mutations in BRCA2 are associated with a high incidence of PDAC, while mutations in BRCA1have shown inconsistent results. Data is insufficient to prove an association between IPMNs and breast cancer. Conclusion: The familial clustering of PDAC is not well understood. Further studies are required for greater comprehension of the genetic basis of PDAC and the association between IPMNs and breast cancer.
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Affiliation(s)
- Mary Barbara
- Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Adrianne Tsen
- Department of Medicine, UT Health San Antonio, San Antonio, TX, USA
| | - Laura Tenner
- Department of Hematology and Oncology, UT Health San Antonio, San Antonio, Tx, USA
| | - Laura Rosenkranz
- Department of Gastroenterology, UT Health San Antonio San Antonio, TX, USA
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12
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Cortegoso Valdivia P, Chialà C, Venezia L, Gaiani F, Leandro G, Di Mario F, De' Angelis GL. Diagnosis and management of intraductal papillary mucinous neoplasms of the pancreas. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:147-152. [PMID: 30561408 PMCID: PMC6502192 DOI: 10.23750/abm.v89i9-s.7958] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Indexed: 12/16/2022]
Abstract
Background and aim of the work: Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are cystic lesions with malignant potential. Given their increasing incidence in the latest years, a precise characterization and management of these lesions have become more and more crucial: even though the majority of IPMN has a benign and indolent course, it is fundamental to early recognize and stratify patients in order to accurately plan a tailored follow-up and to individuate those that would benefit of surgical treatment. The aim of this paper is to highlight the most recent evidence on IPMN available in the current literature. Methods: We performed a review of the recent literature and of the recent guidelines about pancreatic cystic lesions, especially IPMN. Results: The incidence of IPMN is now on the rise: an increasing number of patients, possibly because of the increasing diagnostic yield of imaging techniques, is being diagnosed with pancreatic cystic lesions, a great part of which are IPMN. The possibility of malignant transformation requires a careful approach to these patients, in the need of tailoring the follow-up and the therapy. Conclusion: A detailed diagnosis, the determination of risk factors for malignant transformation and a multisciplinary approach are of foremost importance for an effective management of IPMN. (www.actabiomedica.it)
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13
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Prevalence of Extrapancreatic Malignancies Among Patients With Intraductal Papillary Mucinous Neoplasms of the Pancreas. Pancreas 2018; 47:721-724. [PMID: 29771766 DOI: 10.1097/mpa.0000000000001072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES We conducted a study in order to assess the prevalence of extrapancreatic malignancies (EPMs) in a cohort of patients with intraductal papillary mucinous neoplasms (IPMNs) from northeastern Italy. METHODS A study was conducted in hospital Santa Maria della Misericordia, Udine, Italy. Hospital records were screened in order to identify newly diagnosed IPMN cases in the period from January 1, 2009, to December 31, 2015. We searched for EPMs diagnosed previous to, synchronous to, or after the IPMN. The ratio of the observed (O) number of patients with EPMs to the expected (E) was calculated. RESULTS We identified 72 EPMs in 63 (31.8%) of 198 patients included. Among them, 51 (70.8%) were diagnosed previous to, 17 (23.6%) synchronous to, and 4 (5.6%) after the IPMN. Most frequently diagnosed were colorectal (12 patients [6.1%]), breast (8 patients [6.8%, in females]), renal cell (8 patients [4.0%]), and prostate cancer (7 patients [8.6%, in males]). The O/E ratios for EPMs were significantly increased for cancer in general (3.66; 95% confidence interval [CI], 2.39-5.37), renal cell (9.62; 95% CI, 1.98-28.10), prostate (4.91; 95% CI, 1.59-11.45), and breast cancer (3.16; 95% CI, 1.03-7.37). CONCLUSIONS We report an increased risk of EPMs in patients with IPMN, especially for renal cell, prostate, colorectal, and breast cancer.
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14
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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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15
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Carr RA, Kiel BA, Roch AM, Ceppa EP, House MG, Zyromski NJ, Nakeeb A, Schmidt CM. Cancer history: A predictor of IPMN subtype and dysplastic status? Am J Surg 2018; 215:522-525. [DOI: 10.1016/j.amjsurg.2017.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 11/09/2017] [Accepted: 11/09/2017] [Indexed: 01/03/2023]
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16
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Overbeek KA, Cahen DL, Canto MI, Bruno MJ. Surveillance for neoplasia in the pancreas. Best Pract Res Clin Gastroenterol 2016; 30:971-986. [PMID: 27938791 PMCID: PMC5552042 DOI: 10.1016/j.bpg.2016.10.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 10/25/2016] [Accepted: 10/31/2016] [Indexed: 01/31/2023]
Abstract
Despite its low incidence in the general population, pancreatic cancer is one of the leading causes of cancer-related mortality. Survival greatly depends on operability, but most patients present with unresectable disease. Therefore, there is great interest in the early detection of pancreatic cancer and its precursor lesions by surveillance. Worldwide, several programs have been initiated for individuals at high risk for pancreatic cancer. Their first results suggest that surveillance in high-risk individuals is feasible, but their effectiveness in decreasing mortality remains to be proven. This review will discuss which individuals are eligible for surveillance, which lesions are aimed to be detected, and which surveillance modalities are being used in current clinical practice. Furthermore, it addresses the management of abnormalities found during surveillance and topics for future research.
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Affiliation(s)
- Kasper A. Overbeek
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, ‘s Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands,Corresponding author. Fax: +31 10 703 03 31
| | - Djuna L. Cahen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, ‘s Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
| | - Marcia Irene Canto
- Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, 1800 Orleans St., Blalock 407, Baltimore, MD, 21287, USA
| | - Marco J. Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, ‘s Gravendijkwal 230, 3015 CE, Rotterdam, The Netherlands
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17
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Abstract
OBJECTIVES Structured follow-up after surgery for pancreatic ductal adenocarcinoma (PDAC) remains controversial and is currently not recommended due to a supposed lack of therapeutic consequences. Furthermore, it is not clear whether noncancer patients after pancreas resection need to be seen in the clinic on a regular basis. The present study analyzed how follow-up after pancreatic surgery affected postoperative treatment and long-term outcomes. METHODS Data of all postoperative visits in a specialized outpatient clinic for pancreatic diseases were analyzed for a 1-year period with regard to symptoms, diagnostic procedures, and therapeutic consequences. RESULTS Six hundred eighteen patients underwent 940 postoperative follow-ups. Nearly half of them needed a change of medication due to altered pancreatic function. In 74 (40%) of 184 resected PDAC patients, recurrence (local or systemic) was detected during follow-up, although only 19 of these had shown associated symptoms (26%). In all patients with recurrence, a cancer-directed treatment was induced. Eleven (69%) of 16 patients with isolated local recurrence were referred for reresection. CONCLUSIONS Follow-up examinations are a substantial part of the clinical management after pancreas resections. Follow-up is particularly important for PDAC because recurrence is often asymptomatic, but its detection allows for therapeutic interventions and potentially improved prognosis. This should be implemented in future guidelines.
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18
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Abstract
The incidence of pancreatic cystic neoplasms is rising, in part from detection through the increasing use of high-resolution cross-sectional imaging techniques. Initial diagnosis is generally based on imaging characteristics identified on computed tomography and/or MRI. Endoscopic ultrasound provides further imaging characterization and also enables fluid aspiration and analysis to additionally aid differentiation. The general approach to these lesions includes surgical intervention and/or surveillance imaging. Taking into account diverse presentations, varying malignant potential, and the uncertain natural history of some of these lesions, an evidence-based approach is limited. This article discusses recent updates in the diagnosis and management of cystic neoplasms of the pancreas.
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Affiliation(s)
| | - Koenraad J Mortele
- Division of Abdominal Imaging, Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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19
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Roch AM, Rosati CM, Cioffi JL, Ceppa EP, DeWitt JM, Al-Haddad MA, House MG, Zyromski NJ, Nakeeb A, Schmidt CM. Intraductal papillary mucinous neoplasm of the pancreas, one manifestation of a more systemic disease? Am J Surg 2015; 211:512-8. [PMID: 26830712 DOI: 10.1016/j.amjsurg.2015.12.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 12/21/2015] [Accepted: 12/21/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Several studies have demonstrated a high prevalence of extrapancreatic malignancies, and an association with autoimmune pancreatitis in patients with intraductal papillary mucinous neoplasm (IPMN). We hypothesized that IPMNs were associated with an increase rate of systemic diseases. METHODS From 1996 to 2013, a retrospective analysis of a prospectively collected database was performed and supplemented with electronic medical charts review. RESULTS Two hundred twenty extrapancreatic malignancies were found in 185 patients (22%) compared with expected 5% in the general population. Colorectal, lung, and renal cell carcinoma had significant observed/expected ratios (P < .0001). One hundred ten synchronous autoimmune diseases were found in 96 patients (11%). Systemic lupus erythematosus, rheumatoid arthritis, and inflammatory bowel disease showed statistically significant observed/expected ratios (P < .0001, .01, and <.0001, respectively). There was no impact of immunosuppressive treatment on the IPMN subtype and malignancy rate. CONCLUSIONS IPMN are associated with surprisingly high rates of autoimmune diseases suggesting that IPMN might be 1 manifestation of a more systemic disease.
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Affiliation(s)
- Alexandra M Roch
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA
| | - Carlo Maria Rosati
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA
| | - Jessica L Cioffi
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA
| | - John M DeWitt
- Division of Gastroenterology, Department of Medicine, Indiana University Hospital, Indianapolis, IN, USA
| | - Mohammad A Al-Haddad
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, 980 West Walnut Street C522, Indianapolis, IN, 46202, USA.
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