Management Of Intraductal Papillary Mucinous Neoplasms Research Articles

Intraductal papillary mucinous neoplasms of the pancreas: Uncommon imaging presentation, evolution and comparison of guidelines

Pancreatic cystic lesions are often asymptomatic, incidentally detected and include a range of entities with varying degrees of concern for malignancy. Among these, intraductal papillary mucinous neoplasms (IPMN) are considered premalignant pancreatic lesions, with a broad pathological spectrum ranging from lesions without dysplasia, which can be managed conservatively, to malignant lesions that require surgical resection. The increasing use of CT and MRI has led to increased recognition of this entity incidentally, with branch-duct IPMN representing the most common subtype and the most challenging lesions in terms of patient management. The main imaging modality involved in diagnosis and surveillance of IPMN is MRI. Radiologists play an important role in the management of patients with IPMN, including lesion detection, characterization, follow-up and prognostication, allowing early MRI identification of features that are concerning for malignancy. The main aim of this pictorial review is to illustrate MRI features of IPMN and to discuss risk stratification scores based on different guidelines, with a main focus on branch-duct IPMN. The secondary aims include the presentation of common and uncommon imaging evolution of BD-IPMN as well as the discussion on current controversies on the appropriate management of IPMN.

A Comparison of Single Dimension and Volume Measurements in the Risk Stratification of Pancreatic Cystic Lesions.

The incidence of pancreatic cystic lesions (PCLs) has been rising due to improvements in imaging. Of these, intraductal papillary mucinous neoplasms (IPMNs) are the most common and are thought to contribute to almost 20% of pancreatic adenocarcinomas. All major society guidelines for the management of IPMNs use size defined by maximum diameter as the primary determinant of whether surveillance or surgical resection is recommended. However, there is no consensus on how these measurements should be obtained or whether a single imaging modality is superior. Furthermore, the largest diameter may fail to capture the complexity of PCLs, as most are not perfectly spherical. This article reviews current PCL measurement techniques in CT, MRI, and EUS and posits volume as a possible alternative to the largest diameter.

Circulating Epithelial Cells in Patients with Intraductal Papillary Mucinous Neoplasm of the Pancreas.

Intraductal papillary mucinous neoplasm (IPMN) is the most common pancreatic cyst and a precursor of pancreatic cancer (PDAC). Since PDAC has a devastatingly high mortality rate, the early diagnosis and treatment of any precursor lesion are rational. The safety of the existing guidelines on the clinical management of IPMN has been criticized due to unsatisfactory sensitivity and specificity, showing the need for further markers. Blood obtained from patients with IPMN was therefore subjected to size-based isolation of circulating epithelial cells (CECs). We isolated CECs and evaluated their cytological characteristics. Additionally, we compared Kirsten rat sarcoma viral oncogene homolog (KRAS) mutations in CECs and the primary IPMN tissue, since KRAS mutations are very typical for PDAC. Samples from 27 IPMN patients were analyzed. In 10 (37%) patients, CECs were isolated and showed a hybrid pattern of surface markers involving both epithelial and mesenchymal markers, suggesting a possible EMT process of the cells. Especially, patients with high-grade dysplasia in the main specimen were all CEC-positive. KRAS mutations were also present in CECs but less common than in IPMN tissue. The existence of CEC in IPMN patients offers additional blood-based research possibilities for IMPN biology.

Pancreatic Intraductal Papillary Mucinous Neoplasms: A Narrative Review.

Intraductal papillary mucinous neoplasms (IPMNs) are the most frequent cystic pancreatic neoplasm. They derive from the main pancreatic duct or branch ducts. This narrative review aims to present and compare the current guidelines on the management of IPMNs. We reviewed the most important scientific literature on the management of IPMNs. The clinical presentation of IPMNs is usually nonspecific; common symptoms are abdominal pain, weight loss, and jaundice. There are no sex differences, and the incidence increases with age. It is considered a premalignant lesion associated with synchronous or metachronous carcinomas. Multifocal sites within the pancreas and the presence of solid components, like mural nodules, are predictive factors for developing malignancy. Magnetic resonance imaging (MRI) is the imaging technique of choice. However, computed tomography (CT) and endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) can also contribute to the diagnosis. Resection is the optimal treatment for IPMNs that arise from the main duct, while several indications are suggested for the surgery on IPMNs of branch ducts. The decision on surgery is not always a simple task and should be based on high-risk features of the neoplasm. In any case, re-examination and follow-up are highly recommended.

Risk Perceptions and Risk Thresholds Among Surgeons in the Management of Intraductal Papillary Mucinous Neoplasms.

We aimed to determine whether surgeon variation in management of intraductal papillary mucinous neoplasm (IPMN) is driven by differences in risk perception and quantify surgeons' risk threshold for changing their recommendations. Surgeons vary widely in management of IPMN. We conducted a survey of members of the Americas HepatoPancreatoBiliary Association, presented participants with 2 detailed clinical vignettes and asked them to choose between surgical resection and surveillance. We also asked them to judge the likelihood that the IPMN harbors cancer and that the patient would have a serious complication if surgery was performed. Finally, we asked surgeons to rate the level of cancer risk at which they would change their treatment recommendation. We examined the association between surgeons' treatment recommendations and their risk perception and risk threshold. One hundred fifty surgeons participated in the study. Surgeons varied in their recommendations for surgery [19% for vignette 1 (V1) and 12% for V2] and in their perception of the cancer risk (interquartile range: 2%-10% for V1 and V2) and risk of surgical complications (V1 interquartile range: 10%-20%, V2 20-30%). After adjusting for surgeon characteristics, surgeons who were above the median in cancer risk perception were 22 percentage points (27% vs 5%) more likely to recommend resection than those who were below the median (95% CI: 11%-4%; P <0.001). The median risk threshold at which surgeons would change their recommendation was 15% (V1 and V2). Surgeons who recommended surgery had a lower risk threshold for changing their recommendation than those who recommended surveillance (V1: 10.0 vs 15.0, P =0.06; V2: 7.0 vs 15.0, P =0.05). The treatment that patients receive for IPMNs depends greatly on how their surgeons perceive the risk of cancer in the lesion. Efforts to improve cancer risk prediction for IPMNs may lead to decreased variations in care.

The Influence of Patient Preference on Surgeons' Treatment Recommendations in the Management of Intraductal Papillary Mucinous Neoplasms.

We aimed to determine whether surgeon variation in management of intraductal papillary mucinous neoplasms (IPMN) is driven by differences in risk perception and quantify surgeons' risk threshold for changing their recommendations. Surgeons vary widely in management of IPMN. We conducted a survey of members of the Americas HepatoPancreatoBiliary Association, presented participants with 2 detailed clinical vignettes and asked them to choose between surgical resection and surveillance. We also asked them to judge the likelihood that the IPMN harbors cancer and that the patient would have a serious complication if surgery was performed. Finally, we asked surgeons to rate the level of cancer risk at which they would change their treatment recommendation. We examined the association between surgeons' treatment recommendations and their risk perception and risk threshold. One hundred and fifty surgeons participated in the study. Surgeons varied in their recommendations for surgery [19% for vignette 1 (V1) and 12% for V2] and in their perception of the cancer risk (interquartile range: 2%-10% for V1 and V2) and risk of surgical complications (V1 interquartile range: 10%-20%, V2 20%-30%). After adjusting for surgeon characteristics, surgeons who were above the median in cancer risk perception were 22 percentage points (27% vs. 5%) more likely to recommend resection than those who were below the median (95% CI: 11.34%; P <0.001). The median risk threshold at which surgeons would change their recommendation was 15% (V1 and V2). Surgeons who recommended surgery had a lower risk threshold for changing their recommendation than those who recommended surveillance (V1: 10.0 vs. 15.0, P =0.06; V2: 7.0 vs. 15.0, P =0.05). The treatment that patients receive for IPMNs depends greatly on how their surgeons perceive the risk of cancer in the lesion. Efforts to improve cancer risk prediction for IPMNs may lead to decreased variations in care.

Limitations and prospects in the management of IPMN: a retrospective, single-center observational study

BackgroundWith increasing use and enhanced accuracy of cross-sectional imaging, the diagnosis of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas has increased over the last few decades. The extent to which malignant transformation occurs remains unclear, making the management of IPMNs controversial. The aim of this study was to evaluate the progression rate and outcome of follow-up in patients with IPMNs.MethodsA database of all patients diagnosed with IPMN at the Cantonal Hospital HFR Fribourg, Switzerland, between January 2006 and December 2019 with a follow-up of at least 6 months was analyzed retrospectively. Descriptive statistics were performed on patient demographics, IPMN characteristics, and follow-up data.ResultsA total of 56 patients were included in this study. Ten patients underwent primary surgery, 46 were enrolled in a surveillance program.21.7% (n = 5) of patients under surveillance presented with worrisome features of IPMN; progression rates were significantly higher in these patients (p = 0.043). Most progression occurred in the early follow-up period. Five patients underwent surgery due to progression, of which 2 presented high-grade dysplasia and 2 malignancy on postoperative histology.ConclusionsThe limited predictive value of current guidelines may lead to surgical overtreatment, and the decision to proceed with surgical resection should be made with caution. Further prospective analyses and the development of novel biomarkers are needed to better understand the natural history of IPMN and improve diagnostic precision.

Risk perceptions and risk thresholds in the management of intraductal papillary mucinous neoplasms

Background: Treatment options for intraductal papillary mucinous neoplasms (IPMN) include surgical resection or surveillance. Management is guided primarily by expert opinion and consensus statements and as a result, surgeons vary widely in their treatment decisions. We aimed (1) to determine whether surgeon variation in management of IPMN is driven by differences in risk perception and (2) to quantify surgeons’ risk threshold for changing their treatment recommendations.

MR Prediction of Malignant Switch With the Cyst Fluid's T2 Value in Intraductal Papillary Mucinous Neoplasm of the Pancreas: A Preliminary Study.

We investigated whether the malignant switch of intraductal papillary mucinous neoplasm (IPMN) of the pancreas can be predicted by using the T1ϱ, T2, and apparent diffusion coefficient (ADC) values of cyst fluid. We retrospectively analyzed the magnetic resonance (MR) images of 60 patients (26 males, 34 females, mean age 61 years) with branch-duct type and mixed-type IPMNs. The IPMNs were diagnosed clinically in 39 patients and histologically in 21 patients. The malignant potential was classified by MR imaging based on the international consensus guidelines for the management of IPMN established in 2017. Morphologically, 42 patients had "worrisome features" and three had "high-risk stigmata." Histologically, 14 lesions were diagnosed as low-grade dysplasia and seven as intermediate-grade dysplasia. The T1ϱ, T2, and ADC values of cyst fluid in each patient's largest cyst were measured on the same slice, avoiding solid components. Spearman's rank correlation test was used to determine the correlation between the morphological malignancy and the T1ϱ, T2, and ADC values. These values were also compared between the low-grade and intermediate-grade groups by Mann-Whitney U-test. There was a significant rank-correlation between the morphological classification and T2 value (p=0.04). The T2 value of the intermediate-grade group was significantly higher than that of the low-grade group (p=0.03). No significant correlations were morphologically or histologically obtained regarding T1ϱ and ADC. The T2 value of cyst fluid together with other MR-signs may be useful for predicting the malignant switch in IPMN of the pancreas.

The role of pancreatoscopy in the diagnostic work-up of intraductal papillary mucinous neoplasms: a systematic review and meta-analysis.

Confirming the diagnosis, invasiveness, and disease extent of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas is challenging. The aim of this study was to summarize the literature on the efficacy and safety of peroral pancreatoscopy (POP) in the diagnosis of IPMN, including the impact of pre- and intraoperative POP on the management of IPMN. The EMBASE, Medline Ovid, Web of Science, Cochrane CENTRAL, and Google Scholar databases were systematically searched for articles. Eligible articles investigated cohorts of patients who underwent POP for (suspected) IPMN. 25 articles were identified and included in this review; with 22 of these reporting on the diagnostic yield of POP in IPMN and 11 reporting on the effect of pre- or intraoperative POP on clinical decision-making. Cannulation and observation rates, and overall diagnostic accuracy were high across all studies. Frequently reported visual characteristics of IPMN were intraductal fish-egg-like lesions, hypervascularity, and granular mucosa. Overall, the adverse event rate was 12 %, primarily consisting of post-endoscopic retrograde cholangiopancreatography pancreatitis, with a pooled rate of 10 %, mostly of mild severity. Regarding the impact of POP on clinical decision-making, POP findings altered the surgical approach in 13 %-62 % of patients. POP is technically successful in the vast majority of patients with (suspected) IPMN, has a consistently high diagnostic accuracy, but an adverse event rate of 12 %. Data on intraoperative pancreatoscopy are scarce, but small studies suggest its use can alter surgical management. Future studies are needed to better define the role of POP in the diagnostic work-up of IPMN.

The Use of Intraoperative Frozen Sections in Guiding the Extent of Pancreatic Resections for Intraductal Papillary Mucinous Neoplasms: A Single Institution Experience and Review of the Literature.

The utility of frozen section evaluation of the pancreatic parenchymal resection margin(s) in the surgical management of intraductal papillary mucinous neoplasm (IPMN) remains controversial. We investigated the frequency of its use in IPMN resections and its impact on achievement of negative final parenchymal margin(s). Sixty-two IPMN resections (11 with invasive carcinoma) performed over a 12-year period were studied. Frozen sections of the parenchymal margin(s) were performed on 44 of the 62 resections (71%), 30 (68%) of which had 10 positive and 22 indefinite margins on frozen section. Additional margin resections were performed in 14 of these 30 cases (47%), boosting the complete resection rate from 14% (2 of 14) on the initial margin(s) to 71% (10 of 14) on the final margin(s) (P = 0.002). Overall, negative final parenchymal margin(s) were achieved more frequently when evaluation of the initial margin(s) by frozen section was performed (35 of 44; 80%) than when it was not (11 of 18; 61%) (P = 0.13). In the intraoperative management of IPMN, frozen sections are highly reliable for margin evaluation and are useful for guiding the extent of pancreatic resection.

Number of Worrisome Features Is Associated with Increasing Risk of Malignancy in Intraductal Papillary Mucinous Neoplasm (IPMN)

Background: The 2017 revised IAP guidelines for management of IPMN describe worrisome features (WF) and high-risk stigmata (HRS), recommending resection in the latter and further workup and close surveillance for patients with WF. The effect of multiple WF on the likelihood of malignancy has not been evaluated. Methods: 810 patients who underwent pancreatic resection for IPMN in two tertiary referral centers were identified from prospective institutional databases. Patients were retrospectively categorized into subgroups according to the number of WF or HRS, and presence of malignancy, defined as high-grade dysplasia (HGD) or invasive cancer on final pathology. Results: 379 (47%) patients had HRS, 370 (46%) had one or more WF, and 61 patients (7%) had neither. Malignancy was present in 70% (n=267) of patients with HRS and in 30% (n=127) of those with WF. Only 3/61 patients without WF/HRS had malignancy, and all only in the form of HGD. The risk of malignancy increased in a stepwise fashion with the number of WF, was 22%, 34%, and 59%, with 1, 2, and 3 WF, respectively (p= 0.001), and reached 100% in patients with 4 or more. Although the relative risks differed for particular WF, the AUCs were not statistically different. Conclusion: We confirm that presence of HRS in IPMN is associated with a very high likelihood of malignancy. The presence of a single WF has a malignancy risk of 22%, and additional WF increase this risk significantly. When 3 or more are present, the risk is similar to that of HRS.

Pancreatic intraductal papillary mucinous neoplasms: Current diagnosis and management.

Intraductal papillary mucinous neoplasms (IPMNs) represent approximately 1% of all pancreatic neoplasms and 25% of cystic neoplasms. They are divided into three types: main duct-IPMN (MD-IPPMN), branch duct-IPMN (BD-IPMN), and mixed type-IPMN. In this review, diagnostics, including clinical presentation and radiological investigations, were described. Magnetic resonance imaging is the most useful for most IPMNs. Management depends on the type and radiological features of IPMNs. Surgery is recommended for MD-IPMN. For BD-IPMN, management involves surgery or surveillance depending on the tumor size, cyst growth rate, solid components, main duct dilatation, high-grade dysplasia in cytology, the presence of symptoms (jaundice, new-onset diabetes, pancreatitis), and CA 19.9 serum level. The patient’s age and comorbidities should also be taken into consideration. Currently, there are different guidelines regarding the diagnosis and management of IPMNs. In this review, the following guidelines were presented: Sendai International Association of Pancreatology guidelines (2006), American Gastroenterological Association guidelines, revised international consensus Fukuoka guidelines (2012), revised international consensus Fukuoka guidelines (2017), and European evidence-based guidelines according to the European Study Group on Cystic Tumours of the Pancreas (2018). The Verona Evidence-Based Meeting 2020 was also presented and discussed.

Risk of the Watch-and-Wait Concept in Surgical Treatment of Intraductal Papillary Mucinous Neoplasm

The natural history of intraductal papillary mucinous neoplasms (IPMNs) remains uncertain. The inconsistencies among published guidelines preclude accurate decision-making. The outcomes and potential risks of a conservative watch-and-wait approach vs a surgical approach must be compared. To provide an overview of the surgical management of IPMNs, focusing on the time of resection. This cohort study was conducted in a single referral center; all patients with pathologically proven IPMN who received a pancreatic resection at the institution between October 2001 and December 2019 were analyzed. Preoperatively obtained images and the medical history were scrutinized for signs of progression and/or malignant features. The timeliness of resection was stratified into too early (adenoma and low-grade dysplasia), timely (intermediate-grade dysplasia and in situ carcinoma), and too late (invasive cancer). The perioperative characteristics and outcomes were compared between these groups. Timeliness of resection according to the final pathological findings. The risk of malignant transformation at the final pathology. Of 1439 patients, 438 (30.4%) were assigned to the too early group, 504 (35.1%) to the timely group, and 497 (34.5%) to the too late group. Radiological criteria for malignant conditions were detected in 53 of 382 patients (13.9%), 149 of 432 patients (34.5%), and 341 of 385 patients (88.6%) in the too early, timely, and too late groups, respectively (P < .001). Patients in the too early group underwent more parenchyma-sparing resections (too early group, 123 of 438 [28.1%]; timely group, 40 of 504 [7.9%]; too late group, 5 of 497 [1.0%]; P < .001), while morbidity (too early group, 112 of 438 [25.6%]; timely group, 117 of 504 [23.2%]; too late group, 158 of 497 [31.8%]; P = .002) and mortality (too early group, 4 patients [0.9%]; timely, 4 [0.8%]; too late, 13 [2.6%]; P = .03) were highest in the too late group. Of the 497 patients in the too late group, 124 (24.9%) had a previous history of watch-and-wait care. Until the biology and progression patterns of IPMN are clarified and accurate guidelines established, a watch-and-wait policy should be applied with caution, especially in IPMN bearing a main-duct component. One-third of IPMNs reach the cancer stage before resection. At specialized referral centers, the risks of surgical morbidity and mortality are justifiable.

The Ratio of C-Reactive Protein to Albumin Is an Independent Predictor of Malignant Intraductal Papillary Mucinous Neoplasms of the Pancreas.

There is growing evidence to indicate that inflammatory reactions are involved in cancer progression. The aim of this study is to assess the significance of systemic inflammatory biomarkers, such as the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), the ratio of C-reactive protein to albumin ratio (CAR), the prognostic nutritional index (PNI) and the modified Glasgow prognostic score (mGps) in the diagnosis and prognosis of malignant intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. Data were obtained from a retrospective analysis of patients who underwent pancreatic resection for IPMNs from January 2005 to December 2015. Univariate and multivariate analyses were performed, considering preoperative inflammatory biomarkers, clinicopathological variables, and imaging features. Eighty-three patients with histologically proven IPMNs of the pancreas were included in the study, 37 cases of low-grade or intermediate dysplasia and 46 cases of high-grade dysplasia (HGD) or invasive carcinoma. Univariate analysis showed that obstructive jaundice (p = 0.02) and a CAR of >0.083 (p = 0.001) were predictors of malignancy. On multivariate analysis, only the CAR was a statistically significant independent predictor of HGD or invasive carcinoma in pancreatic IPMNs, identifying a subgroup of patients with a poor prognosis. Combining the CAR with patients’ imaging findings, clinical features and tumor markers can be useful in the clinical management of IPMNs. Their value should be tested in prospective studies.

A tug-of-war in intraductal papillary mucinous neoplasms management: Comparison between 2017 International and 2018 European guidelines

Background2017 International and 2018 European guidelines are the most recent guidelines for intraductal papillary mucinous neoplasms management. Aimto evaluate the diagnostic accuracy of these guidelines in identifying malignant IPMN. Methodsdata from resected patients with IPMN were collected in two referral centers. Features of risk associated to cancerous degeneration described in International and European guidelines were retrospectively applied. Sensitivity, specificity, positive and negative predictive value in detecting malignant disease were calculated. Resultsthe study includes 627 resected patients. European guidelines suggest resection in any patient with at least one feature of moderate-risk. International guidelines suggest that patients with moderate-risk features undergo endoscopic ultrasound before surgery. European guidelines had a higher sensitivity (99.2% vs. 83%) but a lower positive predictive value (59.5% vs. 65.8%) and Specificity (2% vs. 37.5%). European guidelines detected almost all malignancies, but 40% of resected patients had low-grade dysplasia. 297 patients underwent endoscopic ultrasound before surgery. 31/116 (26.7%) tumors radiologically classified as “worrisome features” were reclassified as “high-risk stigmata” by endoscopic ultrasound and 24/31 were malignant IPMN. ConclusionsEuropean and International guidelines have a relatively low diagnostic accuracy, being European guidelines more aggressive. Endoscopic ultrasound can improve guidelines accuracy in patients with moderate-risk features.

Supplemental 18F-FDG-PET/CT for Detection of Malignant Transformation of IPMN-A Model-Based Cost-Effectiveness Analysis.

Simple SummaryThe incidence of IPMN is increasing, mainly attributed to the expanded application of radiological cross-sectional imaging and improvements in image quality. IPMN are the cause of approximately 10% of all pancreatectomies in the USA. A significant number of surgically treated IPMNs do not show high-grade dysplasia or invasive cancer, raising the question of overtreatment, and the need for better diagnostic accuracy. 18F-FDG-PET/CT demonstrated promising diagnostic performance in the detection of malignant transformation of IPMN in comparison to CT and MRI. In this study, the authors analyze whether a supplemental 18F-FDG-PET/CT to the current diagnostic pathway of IPMN could be cost-effective. Results suggest that implementation of 18F-FDG-PET/CT in a preoperative setting could be beneficial from a health care system perspective. It also encourages the research community to investigate if 18F-FDG-PET/CT could be a useful addition in other diagnostic settings within IPMN management.Accurate detection of malignant transformation and risk-stratification of intraductal papillary mucinous neoplasms (IPMN) has remained a diagnostic challenge. Preliminary findings have indicated a promising role of positron emission tomography combined with computed tomography and 18F-fluorodeoxyglucose (18F-FDG-PET/CT) in detecting malignant IPMN. Therefore, the aim of this model-based economic evaluation was to analyze whether supplemental FDG-PET/CT could be cost-effective in patients with IPMN. Decision analysis and Markov modeling were applied to simulate patients’ health states across a time frame of 15 years. CT/MRI based imaging was compared to a strategy with supplemental 18F-FDG-PET/CT. Cumulative costs in US-$ and outcomes in quality-adjusted life years (QALY) were computed based on input parameters extracted from recent literature. The stability of the model was evaluated by deterministic sensitivity analyses. In the base-case scenario, the CT/MRI-strategy resulted in cumulative discounted costs of USD $106,424 and 8.37 QALYs, while the strategy with supplemental FDG-PET/CT resulted in costs of USD $104,842 and a cumulative effectiveness of 8.48 QALYs and hence was cost-saving. A minimum specificity of FDG-PET/CT of 71.5% was required for the model to yield superior net monetary benefits compared to CT/MRI. This model-based economic evaluation indicates that supplemental 18F-FDG-PET/CT could have a favorable economic value in the management of IPMN and could be cost-saving in the chosen setting. Prospective studies with standardized protocols for FDG-PET/CT could help to better determine the value of FDG-PET/CT.

External validation of nomogram for predicting malignant intraductal papillary mucinous neoplasm (IPMN): from the theory to the clinical practice using the decision curve analysis model

The management of IPMNs is a challenging and controversial issue because the risk of malignancy is difficult to predict. The present study aimed to assess the clinical usefulness of two preoperative nomograms for predicting malignancy of IPMNs allowing their proper management. Retrospective study of patients affected by IPMNs. Two nomograms, regarding main (MD) and branch duct (BD) IPMN, respectively, were evaluated. Only patients who underwent pancreatic resection were collected to test the nomograms because a pathological diagnosis was available. The analysis included: 1-logistic regression analysis to calibrate the nomograms; 2-decision curve analysis (DCA) to test the nomograms concerning their clinical usefulness. 98 patients underwent pancreatic resection. The logistic regression showed that, increasing the score of both the MD-IPMN and BD-IPMN nomograms, significantly increases the probability of IPMN high grade or invasive carcinoma (P = 0.029 and P = 0.033, respectively). DCA of MD-IPMN nomogram showed that there were no net benefits with respect to surgical resection in all cases. DCA of BD-IPMN nomogram, showed a net benefit only for threshold probability between 40 and 60%. For these values, useless pancreatic resection should be avoided in 14.8%. The two nomograms allowed a reliable assessment of the malignancy rate. Their clinical usefulness is limited to BD-IPMN with threshold probability of malignancy of 40–60%, in which the patients can be selected better than the “treat all” strategy.

Guidelines on Pancreatic Cystic Neoplasms: Major Inconsistencies With Available Evidence and Clinical Practice— Results From an International Survey

Epidemiologic studies have estimated that between 2% and 45% of the general population harbor a pancreatic cyst.1Mella J.M. Gómez E.J. Omodeo M. et al.Prevalence of incidental clinically relevant pancreatic cysts at diagnosis based on current guidelines.Gastroenterol Hepatol. 2018; 41: 293-301Crossref PubMed Scopus (3) Google Scholar Pancreatic cystic neoplasms (PCNs) encompass a wide spectrum, from benign entities to premalignant conditions.2Nagtegaal I.D. Odze R.D. Klimstra D. et al.The 2019 WHO classification of tumours of the digestive system.Histopathology. 2020; 76: 182-188Crossref PubMed Scopus (525) Google Scholar Surgery offers the possibility of preventing pancreatic cancer or its treatment during an early stage; poor patient selection can expose many individuals to the severe sequelae of a major pancreatic resection.3Andrianello S. Falconi M. Salvia R. Crippa S. Marchegiani G. Surveillance of cystic lesions of the pancreas: whom and how to survey?.Visc Med. 2018; 34: 202-205Crossref PubMed Scopus (3) Google Scholar Despite the efforts of clinical and basic research and several thousands of published studies, management of PCNs remains controversial and is driven by 3 main sets of guidelines: the International Guidelines of the International Association of Pancreatology (IAP)4Tanaka M. Fernández-del Castillo C. Kamisawa T. et al.Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas.Pancreatology. 2017; 17: 738-753Crossref PubMed Scopus (584) Google Scholar published in 2006 and updated in 2012 and 2016, the European evidence-based guidelines5Del Chiaro M. Besselink M.G. Scholten L. et al.European evidence-based guidelines on pancreatic cystic neoplasms.Gut. 2018; 67: 789-804Crossref PubMed Scopus (387) Google Scholar published in 2013 and updated in 2017, and the guidelines of the American Gastroenterological Association (AGA)6Vege S.S. Ziring B. Jain R. Moayyedi P. American Gastroenterological Association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts.Gastroenterology. 2015; 148: 819-822Abstract Full Text Full Text PDF PubMed Scopus (487) Google Scholar published in 2015. These guidelines share some key points, but also have profound differences with respect to patient management. Moreover, they are primarily based on expert opinions or weak scientific evidence stemming from studies burdened by important selection biases. Little is known about the level of circulation and application of the guidelines in clinical practice. Before further updating any of the existing guidelines, it is mandatory to identify and solve these discrepancies by focusing the efforts of the pancreatic community on specific low-evidence areas. The aim of the present study was to assess the dissemination, clinical application, and the perceived reliability of the 3 main sets of guidelines for the management of PCNs based on the available evidence. This project was promoted by the University of Verona Hospital Trust and approved by the Institutional Review Board (approval number 2390CESC, Verona Ethical Committee). Support was engendered from the United European Gastroenterology Society and the European Digestive Surgery Society. We designed a mobile application (iCyst) to disseminate guidelines on PCN management. The app was released on October 2019 and consisted of 2 different sections: a guidelines consultation section where flowcharts of the 3 guidelines can be virtually browsed, and a patient simulation section where the user can simulate a case and obtain the recommendations of the 3 different guidelines based on the clinical and radiologic features. The patient simulation section could be unlocked after completing an online survey about the current application of guidelines for the management of PCNs. Both the survey and the iCyst app were promoted through United European Gastroenterology Society, European Digestive Surgery Society, and major social media. The method of disseminating the survey was specifically designed to obtain a real-world picture of the management of PCNs that is not limited to experts in this field. The 47 questions of the survey were designed to be completed in 12 minutes. The survey was closed after 12 months on September 2020. Only responders with a verified email address were included in the final analysis. PCN classification and definitions of clinical and radiologic features were all derived from the IAP,4Tanaka M. Fernández-del Castillo C. Kamisawa T. et al.Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas.Pancreatology. 2017; 17: 738-753Crossref PubMed Scopus (584) Google Scholar European evidence-based,5Del Chiaro M. Besselink M.G. Scholten L. et al.European evidence-based guidelines on pancreatic cystic neoplasms.Gut. 2018; 67: 789-804Crossref PubMed Scopus (387) Google Scholar and AGA6Vege S.S. Ziring B. Jain R. Moayyedi P. American Gastroenterological Association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts.Gastroenterology. 2015; 148: 819-822Abstract Full Text Full Text PDF PubMed Scopus (487) Google Scholar guidelines. Data were processed and analyzed using Microsoft Excel (Microsoft Corporation, Redmond, WA) and IBM SPSS Statistics (version 24 for Mac, Armonk, NY). All data are reported as frequencies and percentage. Subgroup analysis were performed to compare answers provided by different categories of responders using the χ2 or Fisher exact tests. The survey was completed by 259 international responders. Most responders were from Europe (86%), followed by Asia (8%), and the United States (6%), and practiced in university or teaching hospitals (85%) evaluating >100 patients per year with pancreatic diseases (79% of cases). Only 23% declared evaluating <25 patients per year affected by PCNs, and 47% had <5 years of experience in managing PCNs. Most responders were either surgeons (58%) or gastroenterologists (38%). The best-known guidelines were the European (79%) followed by IAP (69%) and AGA (61%) guidelines. Interestingly, 7% of responders claimed not to be aware of any guidelines. Most diagnostic techniques, including magnetic resonance imaging (MRI), computed tomography scans, endoscopic ultrasound (EUS) examination, and cyst fluid analysis were available for all responders; however, only 41% had access to contrast-enhanced EUS examination. The full text of the case vignettes and distribution of answers are displayed in Table 1.Table 1Case Vignettes and Clinical PracticeQuestionsAnswersn (%)What would you suggest in this case? A 55-year-old man, no relevant comorbidities, chronic diarrhea, first observation, main pancreatic duct 9 mm, no nodules or solid components, no lymphadenopathies.Surgery3/6 months follow-up with MRI12 months follow-up with MRIAdditional evaluation with EUSNone of the previous mentioned28 (11)68 (26)11 (4)147 (57)3 (1)What would you suggest in this case? A 65-year-old man, fit for surgery, first observation, 54 mm cyst in the head, clear connection with the ductal system, no additional features, no symptoms.Surgery3/6 months follow-up with MRIClose surveillance alternating MRI with EUS every 3–6 monthsAdditional evaluation with EUSNone of the previous mentioned89 (34)24 (9)34 (13)108 (42)1 (0.3)Suppose that after completing the workup the cyst remained stable for 12 months, what would you suggest?I still strongly consider surgeryI suggest close surveillance alternating MRI with EUS every 3/6 monthsFollow-up with MRI after additional 12 monthsNone of the previous mentioned89 (34)80 (31)84 (32)2 (0.7)What would you do in this case? A 67-year-old woman, occasional finding of multifocal (largest cyst 15 mm) IPMN with no additional features.SurgerySurveillance with MRI at 6 months, then after additional 12 months if stable.Additional evaluation with EUSSurveillance with ultrasoundsNone of the previous mentioned9 (3)192 (74)46 (18)5 (2)6 (2)Supposing you chose follow-up, 5 years after no changes occurred in cyst’s features, what would you suggest?SurgerySurveillance with MRI every 12 monthsSurveillance with MRI at interval >12 monthsSurveillance with ultrasoundsStop follow-up7 (3)93 (36)94 (36)16 (6)46 (18)Which cyst-related symptoms do you consider as indication for surgery? (Multiple answers allowed)Acute pancreatitisRecurrent acute pancreatitis, no other causesJaundiceAbdominal discomfortDyspepsiaBack painNone of the previous mentionedNo99 (38)199 (77)231 (89)47 (18)20 (8)41 (16)4 (2)91 (35)Do you know the implications of all the different epithelial subtype of IPMNs and of the differentiation of the invasive component?YesNo127 (49)109 (42)Do you think that distinguishing the epithelial subtype and the differentiation of the invasive component could be of clinical importance?YesNoEUSCT scanMRI without contrast enhancement (only MRCP)MRI with contrast enhancement and MRCP205 (79)29 (11)100 (39)36 (14)37 (14)218 (84)CT, computed tomography; EUS, endoscopic ultrasound; IPMN, Intraductal Papillary Mucinous Neoplasms; MPD, main pancreatic duct; MRCP, magnetic resonance cholangiopancreatography; MRI, magnetic resonance imaging. Open table in a new tab CT, computed tomography; EUS, endoscopic ultrasound; IPMN, Intraductal Papillary Mucinous Neoplasms; MPD, main pancreatic duct; MRCP, magnetic resonance cholangiopancreatography; MRI, magnetic resonance imaging. The first case was a young patient without comorbidities presenting with a dilated main pancreatic duct of 9 mm as the sole radiologic feature. European guidelines would have suggested surgery, IAP additional evaluation with EUS, and AGA an MRI in 6 months. However, only 11% of responders recommended surgery, whereas 57% recommended EUS and 26% short-term surveillance in 3–6 months. The second case was a young man without comorbidities presenting with a presumed branch duct (BD)-intraductal papillary mucinous neoplasm (IPMN) of 54 mm as the sole radiologic feature. In this case, most responders (42%) would have followed the IAP guidelines, suggesting EUS examination, and 34% would have suggested surgery. If the same case had remained stable for 12 months, the responders were split equally among 3 discrete positions: surgery (34%), short-term surveillance (31%), and long-term surveillance (32%). In the case of a 67-year-old woman without comorbidities presenting with a multifocal presumed BD-IPMN <15 mm, 74% of physicians would have suggested surveillance with MRI and, in case of stability for 5 years, 72% would have continued versus 18% discontinued surveillance. Physicians were then questioned about the role of symptoms in PCN with multiple answers allowed. A strong agreement to suggest surgery in cases of symptoms was encountered only in case of jaundice (89%) and recurrent acute pancreatitis (77%). Only a few responders would have suggested surgery in the presence of abdominal discomfort (18%), dyspepsia (8%), and back pain (16%). Most responders followed the European guidelines (41%) in their practice, followed by IAP guidelines (36%), and AGA (10%) guidelines. There was a strong agreement (97%) in suggesting surgery for high-risk stigmata, as suggested by the IAP guidelines. However, there was a strong disagreement on worrisome features; 68% would suggest surgery and 27% an additional workup. In the presence of ≥1 relative indication for surgery according to the European guidelines, 36% would have suggested resection only in patients without comorbidities, and 26% would have suggested surgery regardless of their presence. Despite the relevant tendency to choose surgery in the presence of worrisome features/relative indications, approximately 80% of responders would consider surveillance as safe in case of an main pancreatic duct of 5.0–9.9 mm or a cyst size of >30 mm once present as a unique radiologic feature. According to 67% of responders, there was enough evidence to support surgery in the presence of mural nodules, to 82% in case of main pancreatic duct ≥10 mm, to 18% in case of main pancreatic duct 5.0–9.9 mm, to 38% based only on cyst size, to 15% based only on Ca19.9 levels and to 38% based only on cyst growth rate. In the presence of an invasive component on the final pathology, 68% would suggest adjuvant chemotherapy, even if only 31% believed that this choice was supported by evidence. Regarding nonoperatively managed PCNs, only 18% would consider surveillance discontinuation after 5 years of surveillance, in accord with the AGA guidelines. At the same time, 54% believed that there was not enough evidence to recommend lifetime follow-up in case of IPMN without indication for surgery. Moreover, 64% of responders believed that there was not enough evidence to recognize that lifetime follow-up is associated with lower mortality for pancreatic cancer. Regarding the imaging technique for follow-up/surveillance, there was strong agreement (84%) for MRI with cholangiopancreatography, whereas only 6% believed that transabdominal ultrasound examination can be used. There was strong agreement on the use of frozen sections; 83% supported their routine use. However, there was worrying disagreement regarding how to proceed based on the results. Only 51% believed that an additional resection was not required in case of low-grade dysplasia. In the presence of high-grade dysplasia, 66% would proceed with an additional resection, but 27% would directly proceed to total pancreatectomy. In the presence of a denuded epithelium preventing a proper pathological assessment, 57% would proceed with an additional resection, whereas 34% believed that an additional resection is usually not required. Interestingly, 30% of responders would agree to operate on a patient asking for surgery because they were worried about an IPMN, even if it was deemed low risk. Regarding pathological assessment, only 56% usually distinguished between pancreatic cancer arising from an IPMN and a concomitant pancreatic cancer. Moreover, only 49% recognized the implications of the different IPMN epithelial subtypes and invasive component types; of note, 79% believed that knowing these data could be of clinical importance. Despite this survey not being limited to expert pancreatologists, the primary characteristics of responders revealed that most PCNs are still handled by physicians working at university or teaching hospitals with a high volume of pancreatic diseases. This evidence suggests that PCNs are treated as a rare disease, despite several studies demonstrating a high prevalence in the general population, especially among the elderly.1Mella J.M. Gómez E.J. Omodeo M. et al.Prevalence of incidental clinically relevant pancreatic cysts at diagnosis based on current guidelines.Gastroenterol Hepatol. 2018; 41: 293-301Crossref PubMed Scopus (3) Google Scholar,7Laffan T.A. Horton K.M. Klein A.P. et al.Prevalence of unsuspected pancreatic cysts on MDCT.Am J Roentgenol. 2008; 191: 802-807Crossref PubMed Scopus (594) Google Scholar,8Lee K.S. Sekhar A. Rofsky N.M. Pedrosa I. Prevalence of incidental pancreatic cysts in the adult population on MR imaging.Am J Gastroenterol. 2010; 105: 2079-2084Crossref PubMed Scopus (381) Google Scholar Outside the community of pancreatologists, patients are then at higher risk for treatment disparities. Therefore, experts have a duty to improve awareness about PCN and related guidelines in nonspecialist physicians. Guidelines have an adequate level of dissemination among surgeons and gastroenterologists. However, major concerns regarding their actual application in clinical practice immediately emerge due to resource availability. More than half of physicians do not have access to contrast-enhanced EUS examination, preventing the proper application of guidelines in clinical practice. This evidence could represent the tip of the iceberg, because accurate data about the availability of imaging techniques in scenarios other than those explored by the survey are limited. Guidelines should be disseminated to include most of the medical community and should be easily applicable in any health care system to avoid treatment disparities. Through case vignettes and direct and indirect questioning, we identified several low-evidence areas that are likely primarily responsible for the discrepancies between guidelines and clinical practice. Enhancing mural nodules ≥5 mm are considered high-risk stigmata and an absolute indication for surgical resection.4Tanaka M. Fernández-del Castillo C. Kamisawa T. et al.Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas.Pancreatology. 2017; 17: 738-753Crossref PubMed Scopus (584) Google Scholar,5Del Chiaro M. Besselink M.G. Scholten L. et al.European evidence-based guidelines on pancreatic cystic neoplasms.Gut. 2018; 67: 789-804Crossref PubMed Scopus (387) Google Scholar However, >30% of physicians who answered this survey did not believe that there is enough evidence to suggest surgery once present. Mural nodules predict malignancy in surgical series,9Marchegiani G. Andrianello S. Borin A. et al.Systematic review, meta-analysis, and a high-volume center experience supporting the new role of mural nodules proposed by the updated 2017 international guidelines on IPMN of the pancreas.Surg (United States). 2018; 163: 1272-1279Google Scholar but some questions remain unsolved, including their role in patients under surveillance, the correlation between radiologic, and final pathological examination, the optimal size cutoff to best scale the risk of malignancy, and the most accurate imaging technique to obtain optimal characterization.10Kim Y Il Woo S.M. Lee W.J. et al.Appropriate indications of initial endoscopic ultrasound evaluation for detecting mural nodules in branch duct intraductal papillary mucinous neoplasms of the pancreas.Scand J Gastroenterol. 2013; 48: 610-616Crossref PubMed Scopus (8) Google Scholar,11Harima H. Kaino S. Shinoda S. et al.Differential diagnosis of benign and malignant branch duct intraductal papillary mucinous neoplasm using contrast-enhanced endoscopic ultrasonography.World J Gastroenterol. 2015; 21: 6252-6260Crossref PubMed Scopus (45) Google Scholar Despite there being several lines of evidence showing an increased rate of malignancy in resected IPMNs with main pancreatic duct between 5.0 and 9.9 mm,12Del Chiaro M. Beckman R. Ateeb Z. et al.Main duct dilatation is the best predictor of high-grade dysplasia or invasion in intraductal papillary mucinous neoplasms of the pancreas.Ann Surg. 2020; 272: 1118-1124Crossref PubMed Scopus (25) Google Scholar, 13Marchegiani G. Andrianello S. Morbin G. et al.Importance of main pancreatic duct dilatation in IPMN undergoing surveillance.Br J Surg. 2018; 105: 1825-1834Crossref PubMed Scopus (19) Google Scholar, 14Hackert T. Fritz S. Klauss M. et al.Main-duct intraductal papillary mucinous neoplasm: high cancer risk in duct diameter of 5 to 9 mm.Ann Surg. 2015; 262: 875-881Crossref PubMed Scopus (76) Google Scholar this issue still raises many doubts, because >80% of responders believe that there is not enough evidence to suggest surgery based on a moderately dilated main pancreatic duct. The available evidence is not considered adequate, probably because it was retrieved by sole surgical series. Overall, it seems that the presence of a moderate main pancreatic duct dilatation alone does not cause an increased perception of cancer risk among clinicians until prospective observational data on the surveilled cyst become available. Similar concerns can be identified when dealing with cyst size and cyst growth rate, because the available evidence rarely considers their role outside of a surgical series.15Masica D.L. Molin M.D. Wolfgang C.L. et al.A novel approach for selecting combination clinical markers of pathology applied to a large retrospective cohort of surgically resected pancreatic cysts.J Am Med Informatics Assoc. 2017; 24: 145-152Crossref PubMed Scopus (25) Google Scholar, 16Hirono S. Kawai M. Okada K.I. et al.Factors associated with invasive intraductal papillary mucinous carcinoma of the pancreas.JAMA Surg. 2017; 152e165054Crossref PubMed Scopus (21) Google Scholar, 17Marchegiani G. Andrianello S. Pollini T. et al.“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?.Am J Gastroenterol. 2019; 114: 1678-1684Crossref PubMed Scopus (24) Google Scholar Indeed, >60% of responders stated that there is not enough evidence to suggest surgery based on these 2 features. Another important issue involves symptoms. Several guidelines strongly recommend surgery in case of symptoms, but rarely define what constitutes a “symptom.” Apart from a few pancreas-specific signs and symptoms, such as jaundice or severe abdominal pain consistent with acute pancreatitis, patients affected by PCNs usually report many complaints, which are to be considered concomitant to the PCN rather than determined by it.18Marchegiani G. Andrianello S. Miatello C. et al.The actual prevalence of symptoms in pancreatic cystic neoplasms: a prospective propensity matched cohort analysis.Dig Surg. 2019; 36: 522-529Crossref PubMed Scopus (4) Google Scholar, 19Crippa S. Bassi C. Salvia R. et al.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: 495-506Crossref PubMed Scopus (112) Google Scholar, 20Han Y. Lee H. Kang J.S. et al.Progression of pancreatic branch duct intraductal papillary mucinous neoplasm associates with cyst size.Gastroenterology. 2018; 154: 576-584Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Further studies are needed, and guidelines should be more detailed in identifying which patients actually require surgery for the presence of PCN-related symptoms to avoid unnecessary surgery. One of the most vital issues identified likely concerns surveillance discontinuation. For the first time, the AGA guidelines6Vege S.S. Ziring B. Jain R. Moayyedi P. American Gastroenterological Association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts.Gastroenterology. 2015; 148: 819-822Abstract Full Text Full Text PDF PubMed Scopus (487) Google Scholar proposed ceasing surveillance after 5 years in patients with a stable PCN. This recommendation caused perplexity, if not open rejection, in the scientific community, because other guidelines continued to stress the need for a lifetime surveillance, given the evidence showing a lifetime risk of cancer. The present survey shows that the common belief is that there is a real risk of oversurveilling patients, and further studies are urgently needed to identify subsets of cysts suitable for follow-up discontinuation. Only 18% of responders would consider surveillance discontinuation after 5 years, as recommended by the AGA guidelines, but 54% believe there is not enough evidence to recommend lifetime follow-up because this practice is not associated with a decreased mortality for pancreatic cancer. Behind this conviction, there is a greater attention to issues such as health care resources, ethics, and the cost effectiveness of surveillance protocols, which have not yet been shown to decrease pancreatic cancer-related mortality, a fundamental prerequisite of any screening protocol. Further studies evaluating the most cost-effective surveillance protocols and identifying the most suitable population for surveillance discontinuation are mandatory. Another controversial issue concerns the use of adjuvant therapy after surgery for invasive IPMNs. Available evidence is scarce,21Aronsson L. Marinko S. Ansari D. et al.Adjuvant therapy in invasive intraductal papillary mucinous neoplasm (IPMN) of the pancreas: a systematic review.Ann Transl Med. 2019; 7 (689–689)Crossref PubMed Google Scholar, 22Marchegiani G. Andrianello S. Dal Borgo C. et al.Adjuvant chemotherapy is associated with improved postoperative survival in specific subtypes of invasive intraductal papillary mucinous neoplasms (IPMN) of the pancreas: it is time for randomized controlled data.HPB. 2019; 21: 596-603Abstract Full Text Full Text PDF Google Scholar, 23Mungo B. Croce C. Oba A. et al.Controversial role of adjuvant therapy in node-negative invasive intraductal papillary mucinous neoplasm.Ann Surg Oncol. 2020; 28: 1533-1542Crossref PubMed Scopus (4) Google Scholar, 24Rodrigues C. Hank T. Qadan M. et al.Impact of adjuvant therapy in patients with invasive intraductal papillary mucinous neoplasms of the pancreas.Pancreatology. 2020; 20: 722-728Crossref PubMed Scopus (8) Google Scholar often deriving from large national databases where fundamental data for the study of IPMNs is lacking, and recommendations are often derived from those for pancreatic ductal adenocarcinoma. Further studies, including randomized controlled trials, should identify populations that can benefit the most from adjuvant treatment. The current study has several limitations. Most responders were European surgeons and gastroenterologists working in university or teaching hospitals. This factor limited the definition of the picture of PCNs management in smaller settings. However, it is easy to imagine how concerns identified in university or teaching hospitals might be exacerbated in smaller hospitals and among other specialties. An analysis of PCN guidelines application in clinical practice demonstrated that 3 levels of discrepancies exist: among the 3 existing guidelines themselves, between guidelines and available evidence, and between guidelines and clinical practice. Primary low evidence areas are represented by the role of main pancreatic duct dilatation, mural nodules, cyst size and growth rate, cyst-related symptoms, and surveillance discontinuation. The update of the current guidelines, possibly attempting to merge them into a single universally accepted version, should focus on filling the gap of low evidence areas. For this purpose, an international consortium of experts named Verona Evidence-Based-Meeting gathered for the definition of future research lines with the aim of increasing the level of available evidence.

Intraductal papillary mucinous neoplasm of the pancreas: A 10-year experience at a single center

Background: The incidence of intraductal papillary mucinous neoplasm (IPMN) of the pancreas has increased over the past years along with the development of diagnostic imaging tests. Objective: The aim of this study is to describe our experience on long-term management of patients with IPMNs in a reference center. Material and methods: We conducted a retrospective and descriptive analysis of patients with pancreatic neoplasms followed-up at the Department of General Surgery and Hepato-Biliary Surgery, Hospital Universitario Fundación Favaloro, between January 2010 and December 2019. The patients were classified into 2 groups: group A (diagnosis of IPMN made in the outpatient clinic), and group B (diagnosis of IPMN in the pathological examination). Results: Eighty-six patients were analyzed: 79 (90%) in group A and 7 in group B. In group A, a watchful waiting with monitoring (AM) was decided in 57 cases (66%). Of the remaining 22 patients, 18 (29%) patients underwent surgery (AS) and 4 are waiting for surgery. Survival at 5 years was 89% in group AM, 86% in group AS and 43% in group B (Breslow 0.001, log-rank test 0,001 vs. group A). Conclusion: The diagnosis and management of IPMNs is currently standardized. Surgery is indicated in MD-IPMN and mixed type IPMN. Patients with BD-IPMN type should be monitored due to the risk of malignant transformation. When surgery is indicated, long-term survival should be similar to that of the surveillance group.