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Assessment of a Revised Management Strategy for Patients With Intraductal Papillary Mucinous Neoplasms Involving the Main Pancreatic Duct.
JAMA Surg. 2017 01 18; 152(1):e163349.JS

Abstract

Importance

According to the 2012 International Consensus Guidelines, the diagnostic criterion of intraductal papillary mucinous neoplasms (IPMNs) involving the main duct (MD IPMNs) or the main and branch ducts (mixed IPMNs) of the pancreatic system is a main pancreatic duct (MPD) diameter of 5.0 mm or greater on computed tomography (CT) or magnetic resonance imaging (MRI). However, surgical resection is recommended for patients with an MPD diameter of 10.0 mm or greater, which is characterized as a high-risk stigma. An MPD diameter of 5.0 to 9.0 mm is not an indication for immediate resection.

Objectives

To determine an appropriate cutoff (ie, one with high sensitivity and negative predictive value) of the MPD diameter on CT or MRI as a prognostic factor for malignant disease and to propose a new management algorithm for patients with MD or mixed IPMNs.

Design, Setting, and Participants

This retrospective cohort study included 103 patients who underwent surgical resection for a preoperative diagnosis of MD or mixed IPMN and in whom IPMN was confirmed by surgical pathologic findings at a single institution from July 1, 1996, to December 31, 2015.

Main Outcomes and Measures

Malignant disease was defined as high-grade dysplasia or invasive adenocarcinoma on results of surgical pathologic evaluation. An appropriate MPD diameter on preoperative CT or MRI to predict malignant disease was determined using a receiver operating characteristic curve analysis. The prognostic value of the new management algorithm that incorporated the new MPD diameter cutoff was evaluated.

Results

Among the 103 patients undergoing resection for an MD or mixed IPMN (59 men [57.3%]; 44 women [42.7%]; median [range] age, 71 [48-86] years), 64 (62.1%) had malignant disease. Diagnostic accuracy for malignant neoplasms was highest at an MPD diameter cutoff of 7.2 mm (area under the receiver operating characteristic curve, 0.70; 95% CI, 0.59-0.81). An MPD diameter of 7.2 mm or greater was also an independent prognostic factor for malignant neoplasms (odds ratio, 12.76; 95% CI, 2.43-66.88; P = .003) on logistic regression analysis after controlling for preoperative variables. The new management algorithm, which included an MPD diameter of 7.2 mm or greater as one of the high-risk stigmata, had a higher sensitivity (100%), negative predictive value (100%), and accuracy (66%) for malignant disease than the 2012 version of the International Consensus Guidelines (95%, 57%, and 63%, respectively).

Conclusions and Relevance

In this single-center, retrospective analysis, an MPD diameter of 7.2 mm was identified as an optimal cutoff for a prognostic factor for malignant disease in MD or mixed IPMN. These data support lowering the accepted criteria for MPD diameter when selecting patients for resection vs surveillance so as not to overlook cancer in IPMN.

Authors+Show Affiliations

Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA).Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA).Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA).Division of Digestive Diseases, David Geffen School of Medicine at UCLA.Division of Digestive Diseases, David Geffen School of Medicine at UCLA.Division of Digestive Diseases, David Geffen School of Medicine at UCLA.Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA).Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA.Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA).Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles (UCLA).

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

27829085

Citation

Sugimoto, Motokazu, et al. "Assessment of a Revised Management Strategy for Patients With Intraductal Papillary Mucinous Neoplasms Involving the Main Pancreatic Duct." JAMA Surgery, vol. 152, no. 1, 2017, pp. e163349.
Sugimoto M, Elliott IA, Nguyen AH, et al. Assessment of a Revised Management Strategy for Patients With Intraductal Papillary Mucinous Neoplasms Involving the Main Pancreatic Duct. JAMA Surg. 2017;152(1):e163349.
Sugimoto, M., Elliott, I. A., Nguyen, A. H., Kim, S., Muthusamy, V. R., Watson, R., Hines, O. J., Dawson, D. W., Reber, H. A., & Donahue, T. R. (2017). Assessment of a Revised Management Strategy for Patients With Intraductal Papillary Mucinous Neoplasms Involving the Main Pancreatic Duct. JAMA Surgery, 152(1), e163349. https://doi.org/10.1001/jamasurg.2016.3349
Sugimoto M, et al. Assessment of a Revised Management Strategy for Patients With Intraductal Papillary Mucinous Neoplasms Involving the Main Pancreatic Duct. JAMA Surg. 2017 01 18;152(1):e163349. PubMed PMID: 27829085.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Assessment of a Revised Management Strategy for Patients With Intraductal Papillary Mucinous Neoplasms Involving the Main Pancreatic Duct. AU - Sugimoto,Motokazu, AU - Elliott,Irmina A, AU - Nguyen,Andrew H, AU - Kim,Stephen, AU - Muthusamy,V Raman, AU - Watson,Rabindra, AU - Hines,O Joe, AU - Dawson,David W, AU - Reber,Howard A, AU - Donahue,Timothy R, Y1 - 2017/01/18/ PY - 2016/11/10/pubmed PY - 2017/6/24/medline PY - 2016/11/10/entrez SP - e163349 EP - e163349 JF - JAMA surgery JO - JAMA Surg VL - 152 IS - 1 N2 - Importance: According to the 2012 International Consensus Guidelines, the diagnostic criterion of intraductal papillary mucinous neoplasms (IPMNs) involving the main duct (MD IPMNs) or the main and branch ducts (mixed IPMNs) of the pancreatic system is a main pancreatic duct (MPD) diameter of 5.0 mm or greater on computed tomography (CT) or magnetic resonance imaging (MRI). However, surgical resection is recommended for patients with an MPD diameter of 10.0 mm or greater, which is characterized as a high-risk stigma. An MPD diameter of 5.0 to 9.0 mm is not an indication for immediate resection. Objectives: To determine an appropriate cutoff (ie, one with high sensitivity and negative predictive value) of the MPD diameter on CT or MRI as a prognostic factor for malignant disease and to propose a new management algorithm for patients with MD or mixed IPMNs. Design, Setting, and Participants: This retrospective cohort study included 103 patients who underwent surgical resection for a preoperative diagnosis of MD or mixed IPMN and in whom IPMN was confirmed by surgical pathologic findings at a single institution from July 1, 1996, to December 31, 2015. Main Outcomes and Measures: Malignant disease was defined as high-grade dysplasia or invasive adenocarcinoma on results of surgical pathologic evaluation. An appropriate MPD diameter on preoperative CT or MRI to predict malignant disease was determined using a receiver operating characteristic curve analysis. The prognostic value of the new management algorithm that incorporated the new MPD diameter cutoff was evaluated. Results: Among the 103 patients undergoing resection for an MD or mixed IPMN (59 men [57.3%]; 44 women [42.7%]; median [range] age, 71 [48-86] years), 64 (62.1%) had malignant disease. Diagnostic accuracy for malignant neoplasms was highest at an MPD diameter cutoff of 7.2 mm (area under the receiver operating characteristic curve, 0.70; 95% CI, 0.59-0.81). An MPD diameter of 7.2 mm or greater was also an independent prognostic factor for malignant neoplasms (odds ratio, 12.76; 95% CI, 2.43-66.88; P = .003) on logistic regression analysis after controlling for preoperative variables. The new management algorithm, which included an MPD diameter of 7.2 mm or greater as one of the high-risk stigmata, had a higher sensitivity (100%), negative predictive value (100%), and accuracy (66%) for malignant disease than the 2012 version of the International Consensus Guidelines (95%, 57%, and 63%, respectively). Conclusions and Relevance: In this single-center, retrospective analysis, an MPD diameter of 7.2 mm was identified as an optimal cutoff for a prognostic factor for malignant disease in MD or mixed IPMN. These data support lowering the accepted criteria for MPD diameter when selecting patients for resection vs surveillance so as not to overlook cancer in IPMN. SN - 2168-6262 UR - https://www.unboundmedicine.com/medline/citation/27829085/Assessment_of_a_Revised_Management_Strategy_for_Patients_With_Intraductal_Papillary_Mucinous_Neoplasms_Involving_the_Main_Pancreatic_Duct_ L2 - https://jamanetwork.com/journals/jamasurgery/fullarticle/10.1001/jamasurg.2016.3349 DB - PRIME DP - Unbound Medicine ER -