Intraductal papillary mucinous neoplasm of the pancreas (IPMN): clinico-pathological correlations and surgical indications (original) (raw)
Management of Pancreatic Intraductal Papillary Mucinous Neoplasm in an Academic Hospital (2005–2010)
Pancreas, 2013
Objectives: Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are diagnosed frequently in asymptomatic patients. It is still not clear what follow-up is indicated for patients not undergoing surgical resection. Methods: Review of all reports of magnetic resonance cholangiopancreatography (MRCP) from June 2005 to June 2010, identifying all patients diagnosed with IPMN; subsequent reconstruction of the initial therapeutic decision, indications for and adherence to scheduled follow-up, and IPMN evolution by morphology and by biology. Results: Overall, 4943 MRCP reports were analyzed, identifying 234 patients with IPMN. Although 143 (61.1%) of these were comprised in Sendai criteria for resection, surgical resection was considered in only 42 (17.9%) patients. Of the remainder, 52 were not subjected to any control, 58 to a single short time check, 77 to MRCP-based regular annual followup, and 5 were treated for associated ductal adenocarcinoma. With a median follow-up of 39.5 months (range, 12Y72), 37.6% of 125 patients in follow-up had a morphological evolution, but only 2.4% has developed a malignant IPMN. No deaths were recorded, directly related to IPMN, in all 187 conservatively managed patients. Conclusions: In the analyzed series, fewer patients than expected underwent surgical resection, and only 67.2% undergo regular follow-up, but no more than 2.4% developed malignancy.
Langenbeck's Archives of Surgery, 2012
Purpose The clinical importance of intraductal papillary mucinous neoplasm of the pancreas (IPMN) has been increasing with a large number of newly diagnosed IPMN. This study was designed to explore the characteristics of resected IPMN and to determine the predictive factors for malignant and invasive IPMN. Methods Retrospective review of a prospectively collected database was performed on 187 consecutive patients following IPMN surgery between 1994 and 2008 at a tertiary institute. The main duct type IPMN was radiologically defined as main pancreatic duct dilation >5 mm rather than previously defined ≥10 mm. Results The morphologic types of IPMN included 28 main duct (IPMN-M, 15.0%), 118 branch duct (IPMN-Br, 63.1%), and 41 mixed (IPMN-Mixed, 21.9%) IPMNs. There were 23 patients with adenoma, 106 borderline atypia, 15 carcinoma in situ, and 43 invasive carcinoma. Sixty-nine extrapancreatic malignancies were diagnosed in 61 (32.6%) patients. Based on multivariate analysis, IPMN-M was statistically significant predictor of malignancy/ invasiveness (p=0.013/p=0.028). In patients with IPMN-Br, the presence of mural nodule was a predictive factor for malignancy/invasiveness (p=0.005/p=0.002). In patients with IPMN-Mixed, mural nodule (p=0.038/p=0.047) and wall thickening (>2 mm, p=0.015/p=0.046) were risk factor for malignancy/invasiveness and elevated CA19-9 (p=0.046) for invasiveness. Conclusions The main pancreatic duct diameter (>5 mm) is a significant predictor for malignancy and invasiveness. Therefore, IPMN patients with main pancreatic duct dilatation (>5 mm) should be considered surgical resection. Mural nodule is the indicator of surgery in IPMN-Br and IPMN-Mixed. In case of IPMN-Mixed with wall thickening or elevated serum CA19-9, surgical resection is recommended.
BMC Surgery, 2019
Background: The European Consensus 2018 established a new algorithm with absolute and relative criteria for intraductal papillary mucinous neoplasms of the pancreas (IPMN) management. The aim of this study was to validate these criteria and analyse the outcomes in function of the surgical procedure and IPMN subtype. Methods: Clinical, radiological and surgical data (procedure, morbidity/mortality rates) of patients who underwent surgery for IPMN between 2007 and 2017. The predictive value of the different criteria was analysed. Results: 124 patients (men 67%; mean age 65 years) underwent surgery for IPMN (n = 62 malignant tumours; 50%). Jaundice, cyst ≥4 cm and Wirsung duct size 5-9.9 mm or ≥ 10 mm were significantly associated with malignancy (4.77 < OR < 11.85 p < 0.0001). The positive predictive value of any isolated criterion ranged from 71 to 87%, whereas that of three relative criteria together reached 100%. The mortality and morbidity (grade III-IV complications according to the Dindo-Clavien classification) rates were 3 and 8%, respectively. Morbidity/mortality after duodenopancreatectomy and total pancreatectomy were significantly higher for benign IPMN (p = 0.01). Considering the morbidity associated with extended surgery, particularly for benign IPMN, the results of the present study suggest that high-risk surgery should be considered only in the presence of three relative criteria and including the surgery type in the decision-making algorithm.
Gut, 2002
Background: Although the prognosis in malignant resectable intraductal papillary mucinous tumours of the pancreas (IPMT) is often considered more favourable than for ordinary pancreatic ductal adenocarcinoma, the long term outcome remains ill defined. Aims: To assess prognostic factors in patients with malignant IPMT after surgical resection, and to compare long term survival rates with those of patients surgically treated for ductal adenocarcinoma. Methods: Seventy three patients underwent surgery for malignant IPMT in four French centres. Clinical, biochemical, and pathological features and follow up after resection were recorded. Patients with invasive malignant IPMT were matched with patients with pancreatic ductal adenocarcinoma, according to age and TNM stages; survival rates after resection were compared. Results: Surgical treatment for IPMT were pancreaticoduodenectomy (n=46), distal (n=14), total (n=11), or segmentary (n=2) pancreatectomy. The operative mortality rate was 4%. IPMT corresponded to in situ (n=22) or invasive carcinoma (n=51). In the latter group, 17 had lymph node metastases. Overall median survival was 47 months. Five year survival rates in patients with in situ and invasive carcinoma were 88% and 36%, respectively. On univariate analysis, abdominal pain, preoperative high serum carbohydrate antigen 19.9 concentrations, caudal localisation, invasive carcinoma, lymph node metastases, peripancreatic extension, and malignant relapse were associated with a fatal outcome. Using multivariate analysis, lymph node metastases were the only prognostic factor (OR 7.5; 95% CI: 3.4 to 16.4). Overall five year survival rate was higher in patients with malignant invasive IPMT compared with those with pancreatic ductal carcinoma (36 v 21%, p=0.03), but was similar in the subset of stage II/III tumours. Conclusions: The prognosis of patients with resected in situ/invasive stage I malignant IPMT is excellent. In contrast, prognosis of locally advanced forms is as poor as in patients with pancreatic ductal adenocarcinoma.
Intraductal Papillary Mucinous Neoplasm of the Pancreas: Understanding the Basics and Beyond
Cureus, 2019
Intraductal papillary mucinous neoplasm (IPMN) is a benign cystic lesion that grows in the pancreatic ductal system. While the risk for undergoing malignant transformation is dependent on a number of factors, the risk is certainly present, differentiating it from other cystic lesions of the pancreas. Additionally, IMPN is to be starkly contrasted with adenocarcinoma of the pancreas, which is by nature malignant. There are numerous ways to detect IPMN, which is helpful, as a patient may be initially asymptomatic at presentation. Prognosis varies depending upon the malignant potential of the lesion at hand. Surgical resection is the mainstay of treatment in patients with a high probability of malignancy potential. What once was a very confusing diagnosis is now becoming defined based on new literature. The goal of this manuscript is to compile the literature on IPMNs in a clear and precise way as to educate clinicians as to the nature of this increasingly prevalent disease.
Intraductal papillary mucinous tumors of the pancreas: biology, diagnosis, and treatment
Pancreatic intraductal papillary mucinous neoplasms (IPMNs) rank among the most common cystic tumors of the pancreas. For a long time they were misdiagnosed as mucinous cystadenocarcinoma, ductal adenocarcinoma in situ, or chronic pancreatitis. Only in recent years have IPMNs been fully recognized as clinical and pathological entities, although their origin and molecular pathogenesis remain poorly understood. IPMNs are precursors of invasive carcinomas. When resected in a preinvasive state patient prognosis is excellent, and even when they are already invasive, patient prognosis is more favorable than with ductal adenocarcinomas. Subdivision into macroscopic and microscopic subtypes facilitates further patient risk stratification and directly impacts treatment. There are main duct and branch duct IPMNs, with the main duct type including the intestinal, pancreatobiliary, and oncocytic types and the branch duct type solely harboring the gastric type. Whereas main duct IPMNs have a high risk for malignant progression, demanding their resection, branch duct IPMNs have a much lower risk for harboring malignancy. Patients with small branch duct/gastric-type IPMNs (<2 cm) without symptoms or mural nodules can be managed by periodic surveillance. The Oncologist 2010;
Invasive intraductal papillary mucinous neoplasm versus sporadic pancreatic adenocarcinoma
Cancer, 2010
Introduction-Although invasive intraductal papillary mucinous neoplasms (IPMN) of the pancreas is thought to be more indolent than sporadic pancreatic adenocarcinoma (PAC), the natural history remains poorly defined. We compare survival and identify prognostic factors following resection for invasive IPMN vs. stage-matched PAC. Methods-The Surveillance, Epidemiology, and End Results (SEER) database (1991-2005) was utilized to identify 729 patients with invasive IPMN and 8082 patients with PAC who underwent surgical resection. Results-Patients with resected invasive IPMN experienced improved overall survival when compared to resected PAC (median survival 21mos vs. 14mos, p<0.001). Stratification by nodal status demonstrated no difference in survival among node positive patients, however, median survival of resected, node negative, invasive IPMN was significantly improved compared to node negative PAC (34mos vs. 18mos, p <0.001). On multivariate analysis PAC histology was an adverse predictor of overall survival (HR 1.31, 95% CI 1.15-1.50) compared to invasive IPMN. For patients with invasive IPMN, positive lymph nodes (HR 1.98, 95% CI 1.50-2.60), high tumor grade (HR 1.74, 95% CI 1.31-2.31), tumor size >2cm (HR 1.50, 95% CI 1.04-2.19), and age >66 years (HR 1.33, 95% CI 1.03-1.73) were adverse predictors of survival. Conclusions-Although node negative invasive IPMN shows improved survival following resection compared to node negative PAC, the natural history of node positive invasive IPMN mimics that of node positive PAC. We also identify adverse predictors of survival in invasive IPMN to guide discussions regarding use of adjuvant therapies and prognosis following resection of invasive IPMN.
JOP : Journal of the pancreas, 2013
The Dr. Tolstunov's letter published in the present issue of JOP. Journal of the Pancreas [1] is very interesting, because it pointed out the controversial management approach for the branch-duct intraductal papillary mucinous neoplasms (IPMNs) of the pancreas, even in high volume centers for pancreatic disease. The final questions, "Have I been correct with my decision so far in delaying the surgery?" and "Should my mother have had her surgery a long time ago?" pointed out the real problems both for patients (and her/his relatives) and surgeons.
Surgery, Gastroenterology and Oncology, 2018
Introduction: Pancreatic intraductal papillary mucinous neoplasms (IPMN) are recognized as pre-malignant lesions, corresponding to less than 3% of all pancreatic exocrine neoplasms. The study objectives were: to evaluate the surgical results of our institution, to identify factors predicting malignancy in IPMN and to assess the validity of recently introduced IPMN guidelines in our population. Methods: A single center, retrospective study in patients submitted to surgical resection for IPMN was conducted, between 1/2008-6/2016, to identify predictive factors for malignancy, and to evaluate the surgical results. Results: Thirty-nine patients were submitted to a surgical resection. The median age was 68 years (61.5% females). Adenocarcinoma and high-grade dysplasia were present, in 7 and 4 patients, respectively. A significant association was identified with the phenotype and the degree of atypia (p = 0.001), and duct origin and degree of atypia (p = 0.026). Malignant transformation was associated with intestinal or pancreatic-biliary subtypes. Discussion and Conclusions: Applying the European guidelines, all adenocarcinoma would have undergone surgical resection, but 1 with high-grade dysplasia would not be resected. If we applied the American guidelines, 1 patient with adenocarcinoma and 3 with high-grade dysplasia wouldn´t be submitted to resection. The decision in patients with these lesions requires multidisciplinary teams and a tailored based approach.