Branch-duct Intraductal Papillary Mucinous Neoplasms Research Articles

Pancreatic sphincterotomy improves pain symptoms due to branch-duct intrapapillary mucinous neoplasia without worrisome features: a multicenter study.

Abstract Introduction Branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) require follow-up to detect worrisome features (WF). Data are missing about endoscopic pancreatic sphincterotomy (PS) for symptomatic IPMN. Patients and methods This was a retrospective multicenter study in four expert centers. Patients treated with endoscopic PS for symptomatic (painful) BD-IPMN without WF were included. Age, sex, follow-up time, characteristics of IPMNs and endoscopic retrograde cholangiopancreatographies (ERCPs), and indications for surgery were recorded. Results In total, 21 patients were included (median age 68 years, range 45 – 87 years). The median number of cysts was 2 (range 1 – 10), located in the head (59 %), body/tail (17 %), or multifocal (24 %). ERCP including PS was completed in all of the cases, with biliary sphincterotomy in 33 %. Clinical efficacy after one session was 81 % (17/21). Among the failures, one had a second successful PS and three were operated. The final efficacy was 86 % (18/21). Seven patients were operated after a mean of 19 months: four for WF, three for pain. The histopathology showed four low grade dysplasia, one high grade dysplasia, and two no dysplasia. No adenocarcinoma occurred during a follow-up of 99 months (range 14 – 276 months). Conclusions Endoscopic PS for symptomatic IPMN without WF is effective in more than 80 % of cases, without increasing the risk for adenocarcinoma.

"Trivial" Cysts Redefine the Risk of Cancer in Presumed Branch-Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Potential Target for Follow-Up Discontinuation?

The management of small and incidental branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) still is of concern. The aim is assessing the safety of a surveillance protocol through the evaluation of their progression to malignancy. All presumed BD-IPMNs observed from 2000 to 2016 were included. Only patients presenting without worrisome features (WFs) and high-risk stigmata (HRS) at diagnosis were included. Development of WF, HRS, pancreatic cancer (PC), and survival were analyzed. BD-IPMNs were defined as trivial in the continuing absence of WF/HRS after 5 years of surveillance. The age-specific standardized incidence ratio of PC in the general population was used for comparison. A total of 1,036 BD-IPMNs without WF/HRS at diagnosis were included, 4.2% developed WF or HRS, and 1.1% developed PC after a median of 62 months. The median cyst growth rate was 0 mm/yr. A growth rate ≥2.5 mm/yr and the development of WF resulted independent predictors of PC. The standardized incidence ratio of PC for trivial BD-IPMN (n = 378) was 22.45 (95% confidence interval 8.19-48.86), but considering only patients aged >65 years (n = 198), it decreased to 3.84 (95% confidence interval 0.77-11.20). Surveillance of the vast majority of presumed BD-IPMNs is safe, as the risk of PC is comparable to postoperative mortality of pancreatic surgery. A growth rate ≥2.5 mm/yr is the main predictor of PC, reinforcing the role of repeated observations. A trivial BD-IPMN in patients aged >65 years might not increase the risk of developing PC compared with general population, identifying potential targets for follow-up discontinuation.

Increased hardness of the underlying pancreas correlates with the presence of intraductal papillary-mucinous neoplasm in a limited number of cases.

Pancreatic fibrosis or fibrosing reactions have been reported in intraductal papillary-mucinous neoplasm (IPMN) patients. We assessed whether a higher elastic modulus (EM) measured using shear wave elastography (SW-EG) correlated with the existence of branch-duct (BD) IPMN. In total, 183 normal pancreas (NP) and 123 BD-IPMN cases were enrolled. First, we assessed the difference in pancreatic EM (PEM) at different sites (head or tail side of the cyst). Second, a comparison was done between the median PEM of the NP and the BD-IPMN cases. Receiver-operating characteristic analysis was performed to determine the BD-IPMN diagnostic capabilities. Finally, in patients whose cyst was not visualized, the test-positive rate was determined. No significant difference was seen between the cyst head side PEM (4.61kPa) and the tail side PEM (5.35kPa) (P = 0.471). Among these cases matched by age, 73 were selected each from NP and BD-IPMN cases (median age 65years). The median PEM of the BD-IPMN cases (5.18kPa) was significantly higher than that of the NP cases (3.17kPa) (P < 0.001). When the cut-off value was set at 4.75kPa, the sensitivity, specificity, PPV, NPV, and accuracy were 75.3%, 64.4%, 72.3%, 67.9%, and 69.9%, respectively. The cut-off value of 4.75kPa helped for the indirect selection of BD-IPMN patients (10/17, 58.8%) whose cyst was not detected on B-mode ultrasonography. SW-EG measurement of the underlying pancreatic parenchyma may correlate with the presence of BD-IPMN.

Tu1442 – Association of Diabetes Mellitus for Long Term Followed Branch Duct Ipmn Along International Guidelein Ipmn 2017

Tu1442 – Association of Diabetes Mellitus for Long Term Followed Branch Duct Ipmn Along International Guidelein Ipmn 2017

Management and outcomes of intraductal papillary mucinous neoplasms.

BackgroundThis study evaluated the outcome and survival of patients with radiologically suspected intraductal papillary mucinous neoplasms (IPMNs).MethodsIPMN management was reviewed according to Fukuoka risk factors and IPMN localization, differentiating main‐duct (MD), mixed‐type (MT) and branch‐duct (BD) IPMNs. Perioperative results were compared with those of patients undergoing resection of pancreatic ductal adenocarcinoma (PDAC) over the same interval (2010–2014). Overall (OS) and disease‐specific (DSS) survival rates were calculated and subgroups compared.ResultsOf 142 patients with IPMNs, 26 had MD‐IPMN, eight had MT‐IPMN and 108 had BD‐IPMN. Some 74 per cent of patients with MD‐ and MT‐IPMN were managed by primary resection, whereas this was used in only 27·8 per cent of those with BD‐IPMN. The risk of secondary resection and malignant transformation for BD‐IPMNs smaller than 20 mm was 8 and 2 per cent respectively during follow‐up. Pancreatic head resection of IPMNs was associated with an increased risk of postoperative pancreatic fistula grade B/C compared with resection of PDAC (12 of 33 (36 per cent) versus 41 of 221 (18·6 per cent) respectively; P = 0·010), and greater morbidity and mortality (Clavien–Dindo grade III: 15 of 33 (45 per cent) versus 56 of 221 (25·3 per cent) respectively; grade IV: 1 (3 per cent) versus 7 (3·2 per cent); grade V: 2 (6 per cent) versus 2 (0·9 per cent); P = 0·008). Five‐year OS and DSS rates in patients with MD‐IPMN were worse than those for MT‐ and BD‐IPMN (OS: 44, 86 and 97·4 per cent respectively, P < 0·001; DSS: 60, 100 and 98·6 per cent; P < 0·001). Patients with invasive IPMN had worse OS and DSS rates than those with non‐invasive dysplasia (OS: IPMN‐carcinoma (10 patients) 33 per cent, high‐grade dysplasia 100 per cent, intermediate‐grade dysplasia 63 per cent, low grade‐dysplasia 100 per cent, P < 0·001; DSS: IPMN‐carcinoma 43 per cent, all grades of dysplasia 100 per cent, P < 0·001). Patients with high‐risk stigmata had poorer survival than those without risk factors (OS: high‐risk stigmata (35 patients) 55 per cent, worrisome features (31) 95 per cent, no risk factors (76) 100 per cent, P < 0·001; DSS: 71, 100 and 100 per cent respectively, P < 0·001).ConclusionThe risk of malignant transformation was very low for BD‐IPMNs, but the development of high‐risk stigmata was associated with disease‐specific mortality. Patients with IPMN had greater morbidity after resection than those having resection of PDAC.

Pancreatic cancer screening in patients with presumed branch-duct intraductal papillary mucinous neoplasms.

Because delayed diagnosis is one of the causes of poor prognosis in pancreatic ductal adenocarcinoma (PDAC), early detection is a key for overall improvement of prognosis. Towards this end, periodic screening is recommended for individuals considered high-risk for PDAC. Advances in diagnostic imaging modalities have increased the frequency of incidental findings of pancreatic cysts, including the intraductal papillary mucinous neoplasm (IPMN) - a major risk factor of PDAC, having 1% annual prevalence of concomitance with IPMN. Proper retainment of patients with IPMN and regular follow-up by routine imaging examination will likely improve early detection and better prognosis of PDAC. Unfortunately, current guidelines only address management of PDAC derived from IPMN and overlook PDAC concomitant with IPMN. Screening of patients with IPMN, by endoscopic ultrasonography (currently the most reliable modality for detecting small PDAC), may facilitate early detection of both IPMN-derived and -concomitant PDAC. Prospective studies to evaluate the usefulness of endoscopic ultrasonography in screening of IPMN-concomitant PDAC will also help in determining the optimal surveillance strategy for more widespread applications.

Cyst Fluid Biosignature to Predict Intraductal Papillary Mucinous Neoplasms of the Pancreas with High Malignant Potential

Current standard-of-care technologies, such as imaging and cyst fluid analysis, are unable to consistently distinguish intraductal papillary mucinous neoplasms (IPMNs) of the pancreas at high risk of pancreatic cancer from low-risk IPMNs. The objective was to create a single-platform assay to identify IPMNs that are at high risk for malignant progression. Building on the Verona International Consensus Conference branch duct IPMN biomarker review, additional protein, cytokine, mucin, DNA, and microRNA cyst fluid targets were identified for creation of a quantitative polymerase chain reaction-based assay. This included messenger RNA markers: ERBB2, GNAS, interleukin 1β, KRAS, MUCs1, 2, 4, 5AC, 7, prostaglandin E2R, PTGER2, prostaglandin E synthase 2, prostaglandin E synthase 1, TP63; microRNA targets: miRs 101, 106b, 10a, 142, 155, 17, 18a, 21, 217, 24, 30a, 342, 532, 92a, and 99b; and GNAS and KRAS mutational analysis. A multi-institutional international collaborative contributed IPMN cyst fluid samples to validate this platform. Cyst fluid gene expression levels were normalized, z-transformed, and used in classification and regression analysis by a support vector machine training algorithm. From cyst fluids of 59 IPMN patients, principal component analysis confirmed no institutional bias/clustering. Lasso (least absolute shrinkage and selection operator)-penalized logistic regression with binary classification and 5-fold cross-validation used area under the curve as the evaluation criterion to create the optimal signature to discriminate IPMNs as low risk (low/moderate dysplasia) or high risk (high-grade dysplasia/invasive cancer). The most predictive signature was achieved with interleukin 1β, MUC4, and prostaglandin E synthase 2 to accurately discriminate high-risk cysts from low-risk cysts with an area under the curve of up to 0.86 (p= 0.002). We have identified a single-platform polymerase chain reaction-based assay of cyst fluid to accurately predict IPMNs with high malignant potential for additional studies.

The value of cytology in the management of patients with pancreatic cysts.

The value of cytology in the management of patients with pancreatic cysts.

Cystic lesions of the pancreas : Differential diagnostics and treatment

Cystic space-occupying lesions of the pancreas represent incidental findings in most cases. As there is apotential risk of malignant transformation further evaluation of the lesions as well as afollow-up of these patients is usually recommended. Before this work-up is initiated the clinical situation of the patient as awhole and comorbidities, age and personal preferences have to be taken into account. So far there are no biomarkers that reliably predict the risk of malignant transformation. Imaging by magnetic resonance tomography (MRI) in combination with magnetic resonance cholangiopancreatography (MRCP) is more accurate than computed tomography to identify worrisome features. During follow-up, endoscopic ultrasound (EUS) can be used as complementary method to MRI/MRCP. Using contrast enhancement or endoscopic fine needle aspiration (EUS-FNA) may influence the therapeutic strategy in some patients. Whereas for some cystic pancreatic lesions consensus has been reached, varying recommendations exist for intraductal papillary mucinous neoplasms (IPMN). There is consensus that in main-duct as well as in mixed-type IPMN surgery is recommended. The management of branch-duct type IPMN, however, remains controversial. Amultidisciplinary expert panel including gastroenterologists, visceral surgeons, radiologists and pathologists is essential to discuss all cases of patients with cystic pancreatic lesions and to guarantee an optimal, patient-centered treatment recommendation.

Clinical validation of the 2017 international consensus guidelines on intraductal papillary mucinous neoplasm of the pancreas

Introduction: The 2017 international consensus guidelines (ICG) for intraductal papillary mucinous neoplasm (IPMN) of the pancreas were recently released. Important changes included the addition of the relevant risk indicators elevated serum carbohydrate antigen 19-9 (CA 19-9) and rapid cyst growth (>5 mm over 2 years). We aimed to clinically validate the 2017 ICG and compare the diagnostic performance between the 2017 and 2012 ICG. Method: This was a retrospective cohort study. During January 2000–January 2017, patients who underwent complete surgical resection and had pathologic confirmation of branch-duct or mixed-type IPMN were included. Demographic, laboratory, and radiologic data were compiled in a prospectively collected database. To evaluate diagnostic performance, the areas under the receiver operating curves (AUCs) were evaluated. Result: A total of 448 patients were included. The presence of mural nodule (hazard ratio [HR] 9.12, 95% confidence interval [CI] 4.60–18.09, p=0.001), main pancreatic duct dilatation (>5 mm) (HR 5.32, 95% CI 2.67–10.60, p=0.001), thickened cystic wall (HR 3.40, 95% CI 1.51–7.63, p=0.003), and elevated CA 19-9 level (>37 unit/mL) (HR 5.25, 95% CI 2.05–13.42, p=0.001) were significantly associated with malignant IPMN. Malignant lesions showed a cyst growth rate >5 mm over 2 years more frequently than benign lesions (60.9 vs 29.7%, p=0.012). The AUC was higher for the 2017 ICG than the 2012 ICG (0.784 vs. 0.746). Conclusion: The new 2017 ICG for IPMN is clinically valid, with a superior diagnostic performance to the 2012 ICG. The inclusion of elevated serum CA 19-9 level and cyst growth rate to the 2017 ICG is appropriate.

Clinical validation of the 2017 international consensus guidelines on intraductal papillary mucinous neoplasm of the pancreas.

PurposeThe 2017 international consensus guidelines (ICG) for intraductal papillary mucinous neoplasm (IPMN) of the pancreas were recently released. Important changes included the addition of worrisome features such as elevated serum CA 19-9 and rapid cyst growth (>5 mm over 2 years). We aimed to clinically validate the 2017 ICG and compare the diagnostic performance between the 2017 and 2012 ICG.MethodsThis was a retrospective cohort study. During January 2000–January 2017, patients who underwent complete surgical resection and had pathologic confirmation of branch-duct or mixed-type IPMN were included. To evaluate diagnostic performance, the areas under the receiver operating curves (AUCs) were evaluated.ResultsA total of 448 patients were included. The presence of mural nodule (hazard ratio [HR], 9.12; 95% confidence interval [CI], 4.60–18.09; P = 0.001), main pancreatic duct dilatation (>5 mm) (HR, 5.32; 95% CI, 2.67–10.60; P = 0.001), thickened cystic wall (HR, 3.40; 95% CI, 1.51–7.63; P = 0.003), and elevated CA 19-9 level (>37 unit/mL) (HR, 5.25; 95% CI, 2.05–13.42; P = 0.001) were significantly associated with malignant IPMN. Malignant lesions showed a cyst growth rate >5 mm over 2 years more frequently than benign lesions (60.9% vs. 29.7%, P = 0.012). The AUC was higher for the 2017 ICG than the 2012 ICG (0.784 vs. 0.746).ConclusionThe new 2017 ICG for IPMN is clinically valid, with a superior diagnostic performance to the 2012 ICG. The inclusion of elevated serum CA 19-9 level and cyst growth rate to the 2017 ICG is appropriate.

Laparoscopic enucleation of Branch Duct IPMN of the head of the pancreas

Background: Enucleation is a sparing parenchyma procedure for benign lesions or low grade malignant tumors of the pancreas, and when performed for lesions on the head of the pancreas it presents the advantage of avoidance of reconstruction of pancreatic or biliary duct. Most of reports on laparoscopic enucleation are of solid tumors or cystic tumors non communicated with the main pancreatic duct. IPMN’s remains controversial in laparoscopic enucleation. Our aim is to show our results in laparoscopic enucleation of BD IPMN of the head of the pancreas. Methods: A retrospective study from 2012 to 2015 was performed recollecting laparoscopic enucleations of BD IPMN. 5 Patients were included. Surgery indication was made according Sendai Criteria. Results: The mean age of patients was 53 years old. Most indications of surgical intervention were increase in size and pancreatitis. All Cysts were located in the head/uncinated. Malignancy was ruled out by CT scan, MRI and EUS. Frozen section was routine. Final pathology showed mild and moderate side-branch IPMNs. Two patients developed pancreatic leaks (grade A and B), and one patient acute pancreatitis with posterior bleeding that required an angiography. No patients had recurrent cysts or adenocarcinoma with a follow up to present day. Conclusion: In our experience laparoscopic enucleation for BD IPMN’s of the head of the pancreas is feasible and safe in selected cases, avoiding large resections with their respective consequences.

Prognostic value of mural nodules and their size in IPMN of the pancreas: high-volume center experience, systematic review and meta-analysis

Background: Mural nodes (MN) are well-established predictors of malignancy in IPMN and are a major indication for surgery for Guidelines. Less is known about whether their size might play a role in risk assessment. Methods: A systematic review of the literature was carried out following the PRISMA statement. A meta-analysis was conducted on selected studies reporting MNs size and final IPMN pathology. The random effect model was adopted and the pooled SMD (standardized mean difference) obtained. The IPMN surgical series of a single high-volume Institution was retrospectively reviewed. Only patients with comprehensive data about MN at MRI were included in the study. Results: The systematic review included 70 studies. Overall, the presence of MN had a positive predictive value for malignancy of 60.1%. The meta-analysis carried out on the 7 studies considered as eligible suggested that the size of MN has a considerable effect in predicting malignancy in IPMNs, with a mean SMD of 0.79. Of 317 resected IPMNs at our Institution, 102 (32.1%) had a preoperative diagnosis of MN. MN is the only independent predictor of malignancy for both branch duct IPMN and for IPMN with main pancreatic duct involvement. Conclusion: The presence MN is a reliable predictor of malignancy in IPMNs. Contrast enhanced endoscopic ultrasound seems to be the best tool in characterizing MNs’ size obtaining the best accuracy in predicting malignancy. Further studies will have the aim to identify potential MN dimensional cut-offs.

Laparoscopic enucleation of Branch Duct IPMN of the head of the pancreas

Background: Enucleation is a sparing parenchyma procedure for benign lesions or low grade malignant tumors of the pancreas, and when performed for lesions on the head of the pancreas it presents the advantage of avoidance of reconstruction of pancreatic or biliary duct. Most of reports on laparoscopic enucleation are of solid tumors or cystic tumors non communicated with the main pancreatic duct. IPMN’s remains controversial in laparoscopic enucleation. Our aim is to show our results in laparoscopic enucleation of BD IPMN of the head of the pancreas. Methods: A retrospective study from 2012 to 2015 was performed recollecting laparoscopic enucleations of BD IPMN. 5 Patients were included. Surgery indication was made according Sendai Criteria. Results: The mean age of patients was 53 years old. Most indications of surgical intervention were increase in size and pancreatitis. All Cysts were located in the head/uncinated. Malignancy was ruled out by CT scan, MRI and EUS. Frozen section was routine. Final pathology showed mild and moderate side-branch IPMNs. Two patients developed pancreatic leaks (grade A and B), and one patient acute pancreatitis with posterior bleeding that required an angiography. No patients had recurrent cysts or adenocarcinoma with a follow up to present day. Conclusion: In our experience laparoscopic enucleation for BD IPMN’s of the head of the pancreas is feasible and safe in selected cases, avoiding large resections with their respective consequences.

Results of First-Round of Surveillance in Individuals at High-Risk of Pancreatic Cancer from the AISP (Italian Association for the Study of the Pancreas) Registry.

Surveillance programs on high-risk individuals (HRIs) can detect pre-malignant lesions or early pancreatic cancer (PC). We report the results of the first screening round of the Italian multicenter program supported by the Italian Association for the study of the Pancreas (AISP). The multicenter surveillance program included asymptomatic HRIs with familial (FPC) or genetic frailty (GS: BRCA1/2, p16/CDKN2A, STK11/LKB1or PRSS1, mutated genes) predisposition to PC. The surveillance program included at least an annual magnetic resonance cholangio pancreatography (MRCP). Endoscopic ultrasound (EUS) was proposed to patients who refused or could not be submitted to MRCP. One-hundreds eighty-seven HRIs underwent a first-round screening examination with MRCP (174; 93.1%) or EUS (13; 6.9%) from September 2015 to March 2018.The mean age was 51 years (range 21-80).One-hundreds sixty-five (88.2%) FPC and 22 (11.8%) GF HRIs were included. MRCP detected 28 (14.9%) presumed branch-duct intraductal papillary mucinous neoplasms (IPMN), 1 invasive carcinoma/IPMN and one low-grade mixed-type IPMN, respectively. EUS detected 4 PC (2.1%): 1 was resected, 1 was found locally advanced intraoperatively, and 2 were metastatic. Age > 50 (OR 3.3, 95%CI 1.4-8), smoking habit (OR 2.8, 95%CI 1.1-7.5), and having > 2 relatives with PC (OR 2.7, 95%CI 1.1-6.4) were independently associated with detection of pre-malignant and malignant lesions. The diagnostic yield for MRCP/EUS was 24% for cystic lesions. The overall rate of surgery was 2.6% with nil mortality. The rate of malignancies found in this cohort was high (2.6%). According to the International Cancer of the Pancreas Screening Consortium the screening goal achievement was high (1%).

Risk of advanced lesions in patients with branch-duct IPMN and relative indications for surgery according to European evidence-based guidelines

BackgroundEuropean evidence-based guidelines proposed surgery for branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) based on the presence of 1–2 relative indications, depending on the comorbidity burden. AimsTo assess the accuracy of the guidelines in patients with relative indications in a surgical cohort of demonstrated BD-IPMNs. MethodsThis report describes a multi-centre, observational, retrospective study. All consecutive patients with relative indications and histologically confirmed BD-IPMN were included. The main outcome was risk of invasive carcinoma in patients with relative indications. ResultsNinety-one patients with BD-IPMN underwent surgery because of absolute (n = 21), relative (n = 60), or no formal indications (n = 10). In total, there were 60 patients (mean age: 66 ± 9, 50% male) with one (n = 35, 58.3%) or ≥2 relative indications (n = 25, 41.7%). The global advanced lesion and invasive carcinoma rates were 40% and 13.3%, respectively. No risk factor was associated with high-grade dysplasia or invasive carcinoma. Patients with one indication had a lower risk of invasive carcinoma than did those with ≥2 relative indications (5.7% vs. 24%, respectively, p = 0.048); however, the advanced lesion rates were comparable (37.1% vs. 44%, p = 0.593). ConclusionsInvasive carcinoma is considerably more frequent in patients with two or more relative indications. The surgical strategy in these selected cases should be decided on an individual basis.

Imaging and Cytopathological Criteria Indicating Malignancy in Mucin-Producing Pancreatic Neoplasms: A Series of 68 Histopathologically Confirmed Cases.

This study aims to evaluate the performance of clinical, imaging, and cytopathological criteria in the identification of high-grade dysplasia/carcinoma (HGD/Ca) in pancreatic mucin-producing cystic neoplasms. Sixty-eight consecutive, histopathologically confirmed mucin-producing cystic neoplasms, evaluated by endoscopic ultrasound-guided fine-needle aspiration, were enrolled; specifically, 39 branch duct intraductal papillary mucinous neoplasms (BD-IPMNs), 21 main duct IPMNs, and 8 mucinous cystic neoplasms. The associations between HGD/Ca in histopathology and findings of endoscopic ultrasound and cytology, demographic, lifestyle, and clinical parameters were evaluated, separately in IPMNs and mucinous cystic neoplasms. Age 65 years or more was associated with HGD/Ca in IPMNs. In BD-IPMNs, cyst diameter 3 cm or greater (sensitivity, 68.8%; specificity, 65.2%), a mural nodule (sensitivity, 56.3%; specificity, 78.3%), main pancreatic duct diameter 5 to 9 mm (sensitivity, 50.0%; specificity, 87.0%), and suspicious cytology (sensitivity, 81.3%; specificity, 100%) signaled the presence of HGD/Ca. Similarly, in main duct IPMNs, suspicious cytology predicted HGD/Ca with high sensitivity (88.9%) and excellent specificity (100%). Regarding cytopathological criteria, in BD-IPMNs, HGD/Ca was associated with a high nuclear/cytoplasmic ratio, background necrosis, presence of papillary structures, hypochromatic nuclei, hyperchromatic nuclei, and major nuclear membrane irregularities (thickening and/or indentations). Clinical, imaging, and cytopathological criteria are useful in the identification of HGD/Ca in IPMNs.

Develop Nomogram to Predict Malignancy of Intraductal Papillary Mucinous Neoplasm.

A nomogram is a useful graphical tool for presenting a risk prediction and prognosis prediction in medical research. Intraductal papillary mucinous neoplasm (IPMN) is the premalignant lesions of the pancreas. Among the IPMN, branch duct (BD) IPMN is hard to determine whether progress to an invasive tumor or not. Surgery on the pancreas part is likely to lower the quality of life of the patient, so avoiding surgery to remove IPMN tissue of the patients with low risk should be carefully decided. In this study, we introduce the process of constructing a nomogram and illustrate it with a prediction model to predict malignancy of IPMN.

The natural history of intraductal papillary mucinous neoplasm of the pancreas: Reappraisal of the indolent precursor of pancreatic cancer

Aim: Aim of the present study is to describe the natural history of IPMNs observed at a high-volume center for thirty years. Methods: Growth rates were analyzed through a linear-mixed model. The development of worrisome features (WF), high-risk stigmata (HRS), pancreatic cancer (PC), survival and risk for surgery were analyzed. Results: From a total of 2189 observed patients, 1529 were included. The overall growth rate was 1mm/year. For about half of cases no dimensional change was documented. The presence of high risk stigmata (HRS), age < 75 years, and cyst size >30mm at diagnosis were associated to a faster growth rate. During follow-up, IPMNs developed WF in 6.5% of cases and HRS in 0.6%. Overall, 3.5% of patients developed PC after a median time of 28 months. Of these PC patients, 72% previously developed HRS/WF. Of 1043 initially observed indolent branch duct (BD) IPMNs, 16 eventually developed PC with 10% occurring after 15 years of follow-up. HRS and growth rate were independent predictors of PC. Growth rate was the only difference between IPMNs developing PC and those remained stable after more than 5 years of follow-up (n=399). The mean estimated disease specific survival (DSS) for the overall population exceeded 19 years. Conclusions: IPMN of the pancreas is the indolent precursor of PDAC that will not show a detectable growth during follow-up in half of the cases. Those rapidly growing (>2.75 mm/year) will likely progress to pancreatic cancer through the development of WF and HRS during the first year of follow-up.

Issue Highlights

Issue Highlights