Do Consensus Indications for Resection in Branch Duct Intraductal Papillary Mucinous Neoplasm Predict Malignancy? A Study of 147 Patients

Peláez-Luna, Mario; Chari, Suresh T.; Smyrk, Thomas C.; Takahashi, Naoki; Clain, Jonathan E.; Levy, Michael J.; Pearson, Randall K.; Petersen, Bret T.; Topazian, Mark D.; Vege, Santhi Swaroop; Kendrick, Michael L.; Farnell, Michael B.

doi:10.1111/j.1572-0241.2007.01224.x

Cited by 247 publications

(150 citation statements)

References 20 publications

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“…Since their publication in 2006, studies have shown the Sendai guidelines to be highly sensitive (approximately 97%), but very nonspecific (approximately 29%) for the detection of a malignant mucinous cyst. [8][9][10] Cyst size and nonspecific patient symptoms have proven to be poor predictors of malignancy. 11,12 Although the majority of patients with cancer were detected, many patients already had invasive cancers at the time of surgical resection.…”

Section: 6mentioning

confidence: 99%

Revised international consensus guidelines for the management of patients with mucinous cysts

Pitman

2012

Cancer Cytopathology

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The management of patients with pancreatic cysts is a significant issue in the health care community. We know from over 30 years of study that mucinous cysts account for a significant percentage of pancreatic cysts, and that mucinous cysts are precursors of pancreatic carcinoma. Based on autopsy studies, approximately 2.6% of the adult population and nearly 8% of elderly patients have a pancreatic cyst.1 How many of these cysts are mucinous and, of those that are mucinous, how many are malignant or sufficiently highgrade to prompt surgical management is a conundrum physicians are facing on an increasingly common basis. 2,3 The detection of mucinous cysts before the development of invasive carcinoma is the goal of management given that invasion is the single most important factor determining patient prognosis. 4Understanding the clinicopathological features of pancreatic cysts is critical in answering the important question of whether surgical management is warranted, and this requires a multidisciplinary approach. 5,6In 2005, an international and multidisciplinary group of physicians met in Sendai, Japan and developed a consensus document to guide physicians in the diagnosis and management of patients with pancreatic mucinous cysts (also known as the ''Sendai guidelines''). 7 In brief, these guidelines called for the conservative management of asymptomatic patients with pancreatic mucinous cysts that were small (< 3 cm), not associated with a dilated main pancreatic duct (MPD) ( 6 mm) or mural nodule by imaging, and without ''positive cytology.'' Since their publication in 2006, studies have shown the Sendai guidelines to be highly sensitive (approximately 97%), but very nonspecific (approximately 29%) for the detection of a malignant mucinous cyst. [8][9][10] Cyst size and nonspecific patient symptoms have proven to be poor predictors of malignancy. 11,12 Although the majority of patients with cancer were detected, many patients already had invasive cancers at the time of surgical resection. In addition, many elderly patients with significant comorbid conditions and mucinous cysts with low-to intermediate-grade (moderate) dysplasia were also undergoing surgical resection, which is riskier than conservative follow-up because the progression to carcinoma would likely take longer than the expected life expectancy of the patient. Most importantly, some asymptomatic patients with carcinoma or high-grade dysplasia but with no high-risk imaging features were being followed conservatively. 12,13In 2010, a new international, multidisciplinary group of physicians (the 8 members of the original group plus 6 new physicians from various specialties) met in Fukuoka, Japan to revisit the Sendai guidelines and to discuss advances in the understanding of the biology, imaging, preoperative testing, and surgical management of patients with mucinous cysts, with the goal of providing a revised management algorithm.14 Because the levels

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Section: 6mentioning

confidence: 99%

Revised international consensus guidelines for the management of patients with mucinous cysts

Pitman

2012

Cancer Cytopathology

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“…While these guidelines had a sensitivity of 100%, multiple studies indicated low specificity ranging from 23%-31%. 10,11 Subsequently, revised Fukuoka guidelines were presented in 2012 with stricter surgical criteria: pancreatic duct ≥ 10 mm, an enhancing solid component, or obstructive jaundice with a pancreatic head cyst. 8 While this resulted in improved specificity, there was a loss in sensitivity to detect advanced neoplasia and no statistical differences when compared to the Sendai guidelines.…”

Section: Guidelines For Screening Pancreatic Cystic Lesionsmentioning

confidence: 99%

An appraisal of pancreatic cyst fluid molecular markers

Modi

Pavurala

Krishna

2017

Int J Gastrointest Interv

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Pancreatic malignancy is the third leading cause of cancer related death in the United States with limited viable screening options. By the end of this decade, cancers are poised to become the leading cause of death with pancreatic cancer projected to be the second leading cause of cancer related mortality. Pancreatic cystic lesions (PCLs) are found in approximately 5%-14% of patients due to the increased utilization of cross-sectional imaging, with approximately 8%-10% of pancreatic cancers originating as PCLs. Current screening guidelines have shown discrepancies between morphologic characteristics of PCLs and identifying advanced pancreatic disease. Molecular analysis has emerged as a novel technology to aid in adequate diagnosis and management decisions of PCLs. Mucinous cysts including intraductal papillary mucinous neoplasms (IPMNs) or mucinous cystic neoplasms have similar oncogenic mutations including KRAS, TP53, SMAD4, PIK3CA, PTEN, or CKDN2A, while GNAS and RNF43 mutations are specific only to IPMNs. Serous cystadenomas have been associated with a loss of tumor suppressor gene VHL, while solid-psuedopapillary neoplasms have an oncogenic mutation CTNNB1. A specific molecular marker to diagnose existing high-grade dysplasia or impending malignant transformation is yet to be identified. Moving forward it is important to advance technology in isolating and identifying high-risk molecular markers from cyst fluid while considering their increased utilization in the evaluation of PCLs.

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“…Communicates with MPD and no MPD dilatation. 12-47 [16][17][18][19][20] Mixed Satisfy criteria for both main duct and branch duct IPMN. 38-65 9,[14][15][16] Mucinous cystic neoplasm Mucinous.…”

Section: -68mentioning

confidence: 99%

Clinical Approach to Incidental Pancreatic Cystic Neoplasm in Outpatient Clinics

Woo

Lee

2017

Korean J Gastroenterol

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Cystic lesions of the pancreas are increasingly observed due to increased use of abdominal images. The malignant rate of pancreas cystic lesion varies widely between various types. Identification of malignant or high-risk lesions is important when determining the appropriate course of management. Using these image findings, including cyst size, presence of solid components, and pancreatic duct involvement, the 2012 International Association of Pancreatology (IAP) and the 2015 American Gastroenterological Association (AGA) guidelines provide a rationale in identifying higher risk patients requiring further workups using an endoscopic ultrasound (EUS). EUS with fine needle aspiration and cytology allows confirmation of the cyst type and determines the risk of malignancy. Small cysts with no suspicious features may undergo the regular imaging study for regular surveillance due to low risk for malignancy. In this review, the differences between the 2012 IAP and 2015 AGA guidelines are presented, In addition to possible recommendations for management and surveillance.

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Do Consensus Indications for Resection in Branch Duct Intraductal Papillary Mucinous Neoplasm Predict Malignancy? A Study of 147 Patients

Abstract: Suggested consensus indications for resection identify all patients with malignancy; however, their specificity is low. In the short term it would be safe to follow patients without these features.

Cited by 247 publications

References 20 publications

Revised international consensus guidelines for the management of patients with mucinous cysts

Revised international consensus guidelines for the management of patients with mucinous cysts

An appraisal of pancreatic cyst fluid molecular markers

Clinical Approach to Incidental Pancreatic Cystic Neoplasm in Outpatient Clinics

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