Clinical Utility of the Fukuoka 2017 Consensus and 2015 American Gastroenterological Association Guidelines in the Management of Intraductal Papillary Mucinous Neoplasms (IPMNs)

Abstract

Introduction: To evaluate the clinical utility of 2017 Fukuoka (FG) and 2015 AGA (AGA-G) guidelines in patients with IPMNs. Methods: Patients who presented with pancreatic cystic lesions (PCLs) during 1/1/2007 - 12/31/2016 were identified. We used FG and AGA-G to define worrisome and/or high-risk cyst features. Descriptive statistics were used to summarize patient and procedure characteristics. Receiver Operating Characteristic (ROC) curve was used to create a sensitivity (SN)/specificity (SP) analysis. Results: Of 200 with PCL (table 1) 133 had IPMNs. EUS-FNA was performed in 98/133 (74.2%). 62 of 93 (63.9%) in whom string sign was performed had a stretch of the mucin, median 3 (2-7) mm. In only 17/53(32.1%) where CEA level was obtained had a value greater than 192 ng/dL. In follow-up of a median 1,533 d (IQR 879 -886), no difference was seen in cyst growth or developing high risk or worrisome features between groups with CEA >192 vs. 5mm, development of a solid component, or new PD dilation was noted in 60 (45.1%) patients. The median time to cyst change was 639 (193-992.5) days. For prediction of changes in cyst characteristic, FGW had a sensitivity (SN) of 45.8%, specificity (SP) of 55.4%, PPV 45%, NPV 56% with an AUC 0.51; FG-HR had a SN of 14.3%, SP of 53.2%, PPV 1.7%, NPV 91.8% with an AUC 0.34. AGA-HR1 had a SN of 35.3%, SP of 51.5%, PPV 20%, NPV 69.9% with an AUC 0.43. AGA-HR2 had a SN of 0%, SP of 54.2%, PPV 0%, NPV 97.3% with an AUC 0.27. During follow up, 14 patients died, but only one patient died of pancreatic cancer. Pancreatic resection was performed in 21 (15.8%). 4/21, had benign lesions at surgical path with preop diagnoses of premalignant lesions. 6 (28.6%) patients had post-surgical complications (Table 3). Conclusion: Both Fukuoka and AGA guidelines are difficult to validate because the incident of malignant transformation is rare in clinical setting. There was no correlation between CEA level and development of worrisome features. FG with 1 worrisome feature had a best performance in predicting changes in cyst. Considering only 1/133 having malignant transformation in follow-up, BD-IPMN appears to have non-aggressive clinical course even with high risk or worrisome features. Therefore, surgical candidates should be carefully selected.76_A Figure 1. No Caption available.76_B Figure 2. No Caption available.76_C Figure 3. No Caption available.