Nonoperative management of main pancreatic duct-involved intraductal papillary mucinous neoplasm might be indicated in select patients

Alexandra M. Roch, John DeWitt, C. Maximillian Schmidt, Mohammad A. Al-Haddad, C. Schmidt, Eugene P. Ceppa, Michael House, Nicholas Zyromski, Attila Nakeeb

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Abstract

Background Although the natural history of intraductal papillary mucinous neoplasm (IPMN) remains unclear, large surgical series have reported malignancy in 40% to 90% of main pancreatic duct (MPD)-involved IPMN. Accordingly, the 2012 International Consensus Guidelines recommend surgical resection in patients with suspected MPD involvement. We hypothesized that nonoperative management of select patients with suspected MPD-involved IPMN might be indicated. Study Design From 1992 to 2012, 362 patients underwent surgical resection for pathologically confirmed IPMN at a single academic center. A retrospective review of prospectively collected data was performed. Main pancreatic duct involvement was suspected with an MPD diameter 5 mm on preoperative imaging. A multivariate analysis was conducted to assess predictors of malignancy. Results Of 362 patients, 334 had complete data for analysis. Main pancreatic duct involvement was suspected preoperatively in 171 patients. Final pathology revealed 20% high-grade dysplastic and 27% invasive IPMN (47% malignant). Preoperative cytopathology and serum carbohydrate antigen 19-9 independently predicted malignancy (p = 0.003 and p = 0.002, respectively) and invasiveness (p < 0.0001 and p = 0.001, respectively). Patients with both negative preoperative cytopathology and normal serum carbohydrate antigen 19-9 (ie, double negatives) had a lower rate of malignancy and invasiveness (28% and 8% vs 58% and 38%; p < 0.0001). The MPD diameter did not predict malignancy or invasiveness (p = 0.36 and p = 0.46, respectively). Conclusions Patients with suspected MPD-involved IPMN have a highly variable rate of malignancy. Despite recent International Consensus Guidelines recommendations, these data suggest that MPD diameter is not an optimal gauge of malignant risk. Nonoperative management of suspected MPD-involved IPMN in select patients, particularly double negatives, might be indicated. Depending on age and comorbidity, operative risk might outweigh the risk of malignant progression in these patients.

Original languageEnglish
Pages (from-to)122-129
Number of pages8
JournalJournal of the American College of Surgeons
Volume219
Issue number1
DOIs
StatePublished - 2014

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Pancreatic Ducts
Neoplasms
Carbohydrates
Guidelines
Antigens
Serum
Comorbidity
Multivariate Analysis

ASJC Scopus subject areas

  • Surgery

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Nonoperative management of main pancreatic duct-involved intraductal papillary mucinous neoplasm might be indicated in select patients. / Roch, Alexandra M.; DeWitt, John; Schmidt, C. Maximillian; Al-Haddad, Mohammad A.; Schmidt, C.; Ceppa, Eugene P.; House, Michael; Zyromski, Nicholas; Nakeeb, Attila.

In: Journal of the American College of Surgeons, Vol. 219, No. 1, 2014, p. 122-129.

Research output: Contribution to journalArticle

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title = "Nonoperative management of main pancreatic duct-involved intraductal papillary mucinous neoplasm might be indicated in select patients",
abstract = "Background Although the natural history of intraductal papillary mucinous neoplasm (IPMN) remains unclear, large surgical series have reported malignancy in 40{\%} to 90{\%} of main pancreatic duct (MPD)-involved IPMN. Accordingly, the 2012 International Consensus Guidelines recommend surgical resection in patients with suspected MPD involvement. We hypothesized that nonoperative management of select patients with suspected MPD-involved IPMN might be indicated. Study Design From 1992 to 2012, 362 patients underwent surgical resection for pathologically confirmed IPMN at a single academic center. A retrospective review of prospectively collected data was performed. Main pancreatic duct involvement was suspected with an MPD diameter 5 mm on preoperative imaging. A multivariate analysis was conducted to assess predictors of malignancy. Results Of 362 patients, 334 had complete data for analysis. Main pancreatic duct involvement was suspected preoperatively in 171 patients. Final pathology revealed 20{\%} high-grade dysplastic and 27{\%} invasive IPMN (47{\%} malignant). Preoperative cytopathology and serum carbohydrate antigen 19-9 independently predicted malignancy (p = 0.003 and p = 0.002, respectively) and invasiveness (p < 0.0001 and p = 0.001, respectively). Patients with both negative preoperative cytopathology and normal serum carbohydrate antigen 19-9 (ie, double negatives) had a lower rate of malignancy and invasiveness (28{\%} and 8{\%} vs 58{\%} and 38{\%}; p < 0.0001). The MPD diameter did not predict malignancy or invasiveness (p = 0.36 and p = 0.46, respectively). Conclusions Patients with suspected MPD-involved IPMN have a highly variable rate of malignancy. Despite recent International Consensus Guidelines recommendations, these data suggest that MPD diameter is not an optimal gauge of malignant risk. Nonoperative management of suspected MPD-involved IPMN in select patients, particularly double negatives, might be indicated. Depending on age and comorbidity, operative risk might outweigh the risk of malignant progression in these patients.",
author = "Roch, {Alexandra M.} and John DeWitt and Schmidt, {C. Maximillian} and Al-Haddad, {Mohammad A.} and C. Schmidt and Ceppa, {Eugene P.} and Michael House and Nicholas Zyromski and Attila Nakeeb",
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T1 - Nonoperative management of main pancreatic duct-involved intraductal papillary mucinous neoplasm might be indicated in select patients

AU - Roch, Alexandra M.

AU - DeWitt, John

AU - Schmidt, C. Maximillian

AU - Al-Haddad, Mohammad A.

AU - Schmidt, C.

AU - Ceppa, Eugene P.

AU - House, Michael

AU - Zyromski, Nicholas

AU - Nakeeb, Attila

PY - 2014

Y1 - 2014

N2 - Background Although the natural history of intraductal papillary mucinous neoplasm (IPMN) remains unclear, large surgical series have reported malignancy in 40% to 90% of main pancreatic duct (MPD)-involved IPMN. Accordingly, the 2012 International Consensus Guidelines recommend surgical resection in patients with suspected MPD involvement. We hypothesized that nonoperative management of select patients with suspected MPD-involved IPMN might be indicated. Study Design From 1992 to 2012, 362 patients underwent surgical resection for pathologically confirmed IPMN at a single academic center. A retrospective review of prospectively collected data was performed. Main pancreatic duct involvement was suspected with an MPD diameter 5 mm on preoperative imaging. A multivariate analysis was conducted to assess predictors of malignancy. Results Of 362 patients, 334 had complete data for analysis. Main pancreatic duct involvement was suspected preoperatively in 171 patients. Final pathology revealed 20% high-grade dysplastic and 27% invasive IPMN (47% malignant). Preoperative cytopathology and serum carbohydrate antigen 19-9 independently predicted malignancy (p = 0.003 and p = 0.002, respectively) and invasiveness (p < 0.0001 and p = 0.001, respectively). Patients with both negative preoperative cytopathology and normal serum carbohydrate antigen 19-9 (ie, double negatives) had a lower rate of malignancy and invasiveness (28% and 8% vs 58% and 38%; p < 0.0001). The MPD diameter did not predict malignancy or invasiveness (p = 0.36 and p = 0.46, respectively). Conclusions Patients with suspected MPD-involved IPMN have a highly variable rate of malignancy. Despite recent International Consensus Guidelines recommendations, these data suggest that MPD diameter is not an optimal gauge of malignant risk. Nonoperative management of suspected MPD-involved IPMN in select patients, particularly double negatives, might be indicated. Depending on age and comorbidity, operative risk might outweigh the risk of malignant progression in these patients.

AB - Background Although the natural history of intraductal papillary mucinous neoplasm (IPMN) remains unclear, large surgical series have reported malignancy in 40% to 90% of main pancreatic duct (MPD)-involved IPMN. Accordingly, the 2012 International Consensus Guidelines recommend surgical resection in patients with suspected MPD involvement. We hypothesized that nonoperative management of select patients with suspected MPD-involved IPMN might be indicated. Study Design From 1992 to 2012, 362 patients underwent surgical resection for pathologically confirmed IPMN at a single academic center. A retrospective review of prospectively collected data was performed. Main pancreatic duct involvement was suspected with an MPD diameter 5 mm on preoperative imaging. A multivariate analysis was conducted to assess predictors of malignancy. Results Of 362 patients, 334 had complete data for analysis. Main pancreatic duct involvement was suspected preoperatively in 171 patients. Final pathology revealed 20% high-grade dysplastic and 27% invasive IPMN (47% malignant). Preoperative cytopathology and serum carbohydrate antigen 19-9 independently predicted malignancy (p = 0.003 and p = 0.002, respectively) and invasiveness (p < 0.0001 and p = 0.001, respectively). Patients with both negative preoperative cytopathology and normal serum carbohydrate antigen 19-9 (ie, double negatives) had a lower rate of malignancy and invasiveness (28% and 8% vs 58% and 38%; p < 0.0001). The MPD diameter did not predict malignancy or invasiveness (p = 0.36 and p = 0.46, respectively). Conclusions Patients with suspected MPD-involved IPMN have a highly variable rate of malignancy. Despite recent International Consensus Guidelines recommendations, these data suggest that MPD diameter is not an optimal gauge of malignant risk. Nonoperative management of suspected MPD-involved IPMN in select patients, particularly double negatives, might be indicated. Depending on age and comorbidity, operative risk might outweigh the risk of malignant progression in these patients.

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