Are the Current Guidelines for the Surgical Management of Intraductal Papillary Mucinous Neoplasms of the Pancreas Adequate? A Multi-Institutional Study

Gregory C. Wilson, Shishir K. Maithel, David Bentrem, Daniel E. Abbott, Sharon Weber, Clifford Cho, Robert C.G. Martin, Charles R. Scoggins, Hong Jin Kim, Nipun B. Merchant, David A. Kooby, Michael J. Edwards, Syed A. Ahmad

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Abstract

Background Controversy persists regarding the management of patients with intraductal papillary mucinous neoplasms (IPMN). International consensus guidelines stratify patients into high-risk, worrisome, and low risk categories. Study Design The medical records of 7 institutions were reviewed for patients who underwent surgical management of IPMN between 2000 and 2015. Results There were 324 patients included in the analysis; 60.4% of patients had main-duct/mixed type, and 39.7% had branch-duct IPMN. The median cyst size was 2.65 cm, invasive cancer (IC) or high-grade dysplasia (HGD) was present in 42% (n = 136); 68.9% of patients with high-risk, 40.0% of patients with worrisome, and 24.6% of patients with low risk features exhibited HGD/IC. Multivariate analysis demonstrated that only 1 of 3 high-risk features and 2 of 7 worrisome features predicted the presence of HGD/IC. Positive predictive values for HGD/ IC in patients with obstructive jaundice and lymphadenopathy were 0.83 (95% CI 0.65 to 0.94) and 0.69 (95% CI 0.39 to 0.91), respectively. In the absence of high-risk features, HGD/IC was still present in 57.4% of patients with 2 or more worrisome features. Regression analysis demonstrated that each additional worrisome factor present was additive in predicting HGD/IC in a linear fashion (odds ratio 1.39; 95% CI 1.08 to 1.80; p < 0.01). Conclusions These data demonstrate that the current consensus guidelines for surgical resection of IPMN may not adequately stratify and identify patients at risk for having HGD or invasive cancer. Patients with multiple worrisome features, in the absence of high-risk factors, should be considered for resection.

LanguageEnglish (US)
Pages461-469
Number of pages9
JournalJournal of the American College of Surgeons
Volume224
Issue number4
DOIs
StatePublished - Apr 1 2017

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Pancreatic Neoplasms
Guidelines
Neoplasms
Obstructive Jaundice
Medical Records
Cysts
Multivariate Analysis
Odds Ratio
Regression Analysis

ASJC Scopus subject areas

  • Surgery

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Are the Current Guidelines for the Surgical Management of Intraductal Papillary Mucinous Neoplasms of the Pancreas Adequate? A Multi-Institutional Study. / Wilson, Gregory C.; Maithel, Shishir K.; Bentrem, David; Abbott, Daniel E.; Weber, Sharon; Cho, Clifford; Martin, Robert C.G.; Scoggins, Charles R.; Kim, Hong Jin; Merchant, Nipun B.; Kooby, David A.; Edwards, Michael J.; Ahmad, Syed A.

In: Journal of the American College of Surgeons, Vol. 224, No. 4, 01.04.2017, p. 461-469.

Research output: Contribution to journalArticle

Wilson, GC, Maithel, SK, Bentrem, D, Abbott, DE, Weber, S, Cho, C, Martin, RCG, Scoggins, CR, Kim, HJ, Merchant, NB, Kooby, DA, Edwards, MJ & Ahmad, SA 2017, 'Are the Current Guidelines for the Surgical Management of Intraductal Papillary Mucinous Neoplasms of the Pancreas Adequate? A Multi-Institutional Study' Journal of the American College of Surgeons, vol 224, no. 4, pp. 461-469. DOI: 10.1016/j.jamcollsurg.2016.12.031
Wilson, Gregory C. ; Maithel, Shishir K. ; Bentrem, David ; Abbott, Daniel E. ; Weber, Sharon ; Cho, Clifford ; Martin, Robert C.G. ; Scoggins, Charles R. ; Kim, Hong Jin ; Merchant, Nipun B. ; Kooby, David A. ; Edwards, Michael J. ; Ahmad, Syed A./ Are the Current Guidelines for the Surgical Management of Intraductal Papillary Mucinous Neoplasms of the Pancreas Adequate? A Multi-Institutional Study. In: Journal of the American College of Surgeons. 2017 ; Vol. 224, No. 4. pp. 461-469
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abstract = "Background Controversy persists regarding the management of patients with intraductal papillary mucinous neoplasms (IPMN). International consensus guidelines stratify patients into high-risk, worrisome, and low risk categories. Study Design The medical records of 7 institutions were reviewed for patients who underwent surgical management of IPMN between 2000 and 2015. Results There were 324 patients included in the analysis; 60.4\{%} of patients had main-duct/mixed type, and 39.7\{%} had branch-duct IPMN. The median cyst size was 2.65 cm, invasive cancer (IC) or high-grade dysplasia (HGD) was present in 42\{%} (n = 136); 68.9\{%} of patients with high-risk, 40.0\{%} of patients with worrisome, and 24.6\{%} of patients with low risk features exhibited HGD/IC. Multivariate analysis demonstrated that only 1 of 3 high-risk features and 2 of 7 worrisome features predicted the presence of HGD/IC. Positive predictive values for HGD/ IC in patients with obstructive jaundice and lymphadenopathy were 0.83 (95\{%} CI 0.65 to 0.94) and 0.69 (95\{%} CI 0.39 to 0.91), respectively. In the absence of high-risk features, HGD/IC was still present in 57.4\{%} of patients with 2 or more worrisome features. Regression analysis demonstrated that each additional worrisome factor present was additive in predicting HGD/IC in a linear fashion (odds ratio 1.39; 95\{%} CI 1.08 to 1.80; p < 0.01). Conclusions These data demonstrate that the current consensus guidelines for surgical resection of IPMN may not adequately stratify and identify patients at risk for having HGD or invasive cancer. Patients with multiple worrisome features, in the absence of high-risk factors, should be considered for resection.",
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AU - Maithel,Shishir K.

AU - Bentrem,David

AU - Abbott,Daniel E.

AU - Weber,Sharon

AU - Cho,Clifford

AU - Martin,Robert C.G.

AU - Scoggins,Charles R.

AU - Kim,Hong Jin

AU - Merchant,Nipun B.

AU - Kooby,David A.

AU - Edwards,Michael J.

AU - Ahmad,Syed A.

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N2 - Background Controversy persists regarding the management of patients with intraductal papillary mucinous neoplasms (IPMN). International consensus guidelines stratify patients into high-risk, worrisome, and low risk categories. Study Design The medical records of 7 institutions were reviewed for patients who underwent surgical management of IPMN between 2000 and 2015. Results There were 324 patients included in the analysis; 60.4% of patients had main-duct/mixed type, and 39.7% had branch-duct IPMN. The median cyst size was 2.65 cm, invasive cancer (IC) or high-grade dysplasia (HGD) was present in 42% (n = 136); 68.9% of patients with high-risk, 40.0% of patients with worrisome, and 24.6% of patients with low risk features exhibited HGD/IC. Multivariate analysis demonstrated that only 1 of 3 high-risk features and 2 of 7 worrisome features predicted the presence of HGD/IC. Positive predictive values for HGD/ IC in patients with obstructive jaundice and lymphadenopathy were 0.83 (95% CI 0.65 to 0.94) and 0.69 (95% CI 0.39 to 0.91), respectively. In the absence of high-risk features, HGD/IC was still present in 57.4% of patients with 2 or more worrisome features. Regression analysis demonstrated that each additional worrisome factor present was additive in predicting HGD/IC in a linear fashion (odds ratio 1.39; 95% CI 1.08 to 1.80; p < 0.01). Conclusions These data demonstrate that the current consensus guidelines for surgical resection of IPMN may not adequately stratify and identify patients at risk for having HGD or invasive cancer. Patients with multiple worrisome features, in the absence of high-risk factors, should be considered for resection.

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